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Clinical Investigations: PLEURAL |

Pleurodesis Practice for Malignant Pleural Effusions in Five English-Speaking Countries*: Survey of Pulmonologists FREE TO VIEW

Y. C. Gary Lee; Michael H. Baumann; Nick A. Maskell; Grant W. Waterer; Tam E. Eaton; Robert J. O. Davies; John E. Heffner; Richard W. Light
Author and Funding Information

*From the University of Oxford and Osler Chest Unit (Drs. Lee, Maskell, and Davies), Churchill Hospital, Oxford, UK; St. Thomas Hospital and Vanderbilt University (Dr. Light), Nashville, TN; University of Mississippi Medical Center (Dr. Baumann), Jackson, MS; University of Western Australia (Dr. Waterer), Perth, Australia; Greenlane Hospital (Dr. Eaton), Auckland, New Zealand; Medical University of South Carolina (Dr. Heffner), Charleston, SC.

Correspondence to: Y. C. Gary Lee, MBChB, PhD, FCCP, Wellcome Trust Centre for Human Genetics, University of Oxford, Roosevelt Dr, Oxford OX3 7BN, UK; e-mail: ycgarylee@hotmail.com



Chest. 2003;124(6):2229-2238. doi:10.1378/chest.124.6.2229
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Background: Pleurodesis is important in the management of malignant pleural effusions, but no consensus exists on the optimal agent or methods of pleurodesis. How pleurodesis is practiced worldwide has not been studied.

Objectives: To identify variations in the clinical practice of pleurodesis in major English-speaking countries, and to quantify the experience of pulmonologists on the effectiveness and adverse effects of different pleurodesis agents worldwide.

Methods: Eight hundred fifty-nine pulmonologists practicing in the United States, United Kingdom, Canada, Australia, and New Zealand participated in a Web-based survey.

Results: The respondents collectively perform > 8,300 pleurodesis annually. Talc was the preferred agent by most respondents (slurry, 56%; poudrage, 12%), followed by tetracycline derivatives (26%), and bleomycin (7%). Differences were seen in pleurodesis practice patterns among practitioners among and within the surveyed countries. Physicians’ overall satisfaction with the available pleurodesis agents was modest (5.0 out of 8), and the reported success rate averaged only 66%. Talc (both poudrage and slurry) was perceived as significantly more effective, but was associated with significantly more pain, nausea, and fever (p < 0.05). Respiratory failure occurred more commonly with talc poudrage than with other agents (p < 0.05), and had been observed by 70% and 54% of physicians who used talc poudrage and slurry, respectively.

Conclusions: Significant variations exist in how pleurodesis is performed worldwide. Pleurodesis agents currently available are perceived as suboptimal. Talc poudrage and slurry were perceived to be more effective, but were associated with more complications, including respiratory failure.

Figures in this Article

Pleurodesis is frequently employed worldwide in the management of malignant pleural effusions.13 In the United States alone, an estimated 100,000 patients undergo pleurodesis each year.4 Despite the widespread application of pleurodesis, little is known regarding the optimal method for performing the procedure. Few clinical trials of adequate size have been conducted to establish the preferred pleurodesis agent or the best surgical technique for inducing pleurodesis. Consequently, practice guidelines published by international professional societies were mainly based on expert consensus.56 In the absence of well-designed, high-grade research, clinical practices are usually characterized by marked practice variation. No data exist, however, on worldwide practice patterns for performing pleurodesis.

The existence of widespread practice variation in performing pleurodesis would be of concern because different techniques might vary in their effectiveness, patient risk, and overall costs. For instance, marked differences in effectiveness and the incidence and nature of adverse effects have been reported for the conventional pleurodesis agents.7 Selection of the most appropriate compound for pleurodesis has become especially important with reports811 of acute respiratory failure and death following talc pleurodesis. Also, surgical techniques for performing pleurodesis range widely from intrapleural instillation of a chemical agent through a small- or large-bore catheter to more invasive approaches by thoracoscopy or thoracotomy. In addition, there are no standard recommendations for the optimal time to perform pleurodesis after insertion of a chest tube, or for the need of rotation of patients and clamping of chest tubes after instillation of a pleurodesis agent. Widespread practice variation in performing pleurodesis would underscore the importance of appropriate clinical trials to determine the best clinical practices in performing pleurodesis.

This study surveyed practicing pulmonologists in five English-speaking countries about their practice of pleurodesis for malignant pleural effusions. We aimed to identify the key areas of differences in the clinical practice of pleurodesis in order to direct future research efforts. We hypothesized that (1) significant differences exist in the way pleurodesis is performed worldwide, and (2) the perceived success rates and complications of pleurodesis vary with the pleurodesis agent and with the methods employed for pleurodesis.

Survey Questionnaire

A survey questionnaire comprised of 30 questions on various aspects of pleurodesis for malignant pleural effusions was developed by the study investigators. A list of questions was first distributed to investigators for initial review and revision. The questions were designed to collect demographic information on the surveyed practitioners, agents and techniques used for pleurodesis, experience of physicians who performed pleurodesis, estimates of success rates for pleurodesis, frequency and nature of adverse reactions, and overall practitioner satisfaction with the available techniques for pleurodesis. Some questions used a 9-point Likert scale12 to grade responses. Investigators reiteratively revised the survey until final consensus was achieved. The survey was tested for reliability and validated by examining the responses of 10 pulmonologists who completed the survey instrument twice 2 to 4 weeks apart. The survey was posted on the Internet for online completion (http://fmp2.musc.edu/Pleurodesis_Survey/default.htm), and responses were entered into a dynamic database (Filemaker v 5.5; Filemaker; Santa Clara, CA).

Participants

The study was designed to assess the experience and opinions of qualified specialist physicians in pulmonary and/or critical care medicine with primary practices in the United States, United Kingdom, Canada, Australia, and New Zealand. E-mail addresses of the US and Canadian members of the American College of Chest Physicians (ACCP), all members of the British Thoracic Society (BTS), and all members of the Thoracic Society of Australia and New Zealand (TSANZ) were obtained from these professional societies. It was possible to select from the ACCP list only those members registered as pulmonologists and/or critical care physicians, whereas the BTS and TSANZ membership lists included all registered members with e-mail addresses on file.

An e-mail message with a hyperlink to the survey Web site was sent between July 1 and September 1, 2001, to invite society members to participate in the survey. A follow-up message was sent within 4 weeks to initial nonrespondents. Because of good responses from the initial follow-up message to the ACCP members, two further reminders were sent to nonrespondents of this group.

Statistical Analysis

All data were analyzed using a computer software program (SPSS for Windows; SPSS; Chicago, IL). Data were presented as mean ± SD. Comparisons of the differences among groups were performed using one-way analysis of variance or Kruskal-Wallis one-way analysis of variance on ranks (for parametric and nonparametric data, respectively). Differences of the subgroups were analyzed with the Dunnett test. Comparisons between two groups were performed using Student t test. Correlation between physicians’ satisfaction rating and success rate was measured by a Spearman ranked-order coefficient; p < 0.05 was considered significant.

Survey Responses

Messages were sent via e-mail to 3,196 ACCP members, 1,800 BTS members, and 358 TSANZ members. Of these, 634 were undeliverable due to invalid e-mail addresses and five physicians replied that they had retired. Altogether, 929 responses were registered: 736 were from ACCP (694 from the United States and 42 from Canada), 96 were from the BTS, and 97 were TSANZ members (71 from Australia and 26 from New Zealand). Of these, 859 responses (92.5%) were considered valid. Seventy replies were excluded: 30 were duplicated entries, 29 were from physicians of specialties other than pulmonary or critical care or from other health-care professionals, and 11 were from pulmonologists practicing outside the targeted countries.

Demographics of Respondents

The majority of the 859 respondents practiced in the United States (77%), followed by the United Kingdom (9%), Australia (7%), Canada (5%), and New Zealand (3%). The respondents were mainly male (87%), and the most common age range (39%) was from 41 to 50 years. Twenty-nine percent practiced in university medical centers, and 38% practiced in private community hospitals (Table 1 ).

Participating physicians estimated that they performed 8,330 pleurodesis procedures each year. The respondents (42%) most commonly performed 6 to 12 pleurodeses each year. Pleurodesis was performed predominantly as an inpatient procedure (96% of all replies), irrespective of the country of practice.

Pleurodesis Agents
Choice of Agents:

Wide variation was evident in the choice of pleurodesis agents used by the responding pulmonologists (Table 2 ). Talc slurry was the preferred agent of 56% of the respondents. Talc poudrage (12%), tetracycline derivatives (26%) [tetracycline, 7%; doxycycline, 19%] and bleomycin (7%) were the other commonly employed agents. Twelve respondents did not state which agents they used, 3 respondents used other agents (erythromycin, minocycline, and methylprednisolone), and 1 respondent used a combination of talc with tetracycline. These 16 replies were not included in the comparison of the complication rates of pleurodesis agents.

Pulmonologists in the United States, Canada, and Australia were most likely to use talc slurry, whereas a higher portion of the respondents from the United Kingdom and New Zealand preferred tetracycline or doxycycline. Talc slurry remained the most preferred pleurodesis agent when the respondents were stratified by age or gender (Table 2) .

Variations in the Clinical Practice of Pleurodesis
Common Pleurodesis Practices:

Pleurodesis was performed via a chest tube by 75% of the respondents, while others preferred using either video-assisted (17%) or medical thoracoscopy (8%) [Table 3 ] . The preferred size of chest tube for pleurodesis varied from < 14F to > 32F. A 28 to 32F chest tube was the size of catheters preferred by the highest number of respondents (45%) for pleurodesis, although 24 to 28F and 14 to 18F ones were preferred by 34% and 14% of the respondents, respectively.

In the United States, more than half of the respondents reported that, in their practice, surgeons usually inserted the chest tubes for pleurodesis. This contrasted with all other surveyed countries, where pulmonologists (or their junior staff) most often inserted intercostal catheters. In the United Kingdom, Australia, and New Zealand, pulmonary fellows (registrars) or interns were more often responsible for catheter insertion than attending consultants.

Overall in the surveyed countries, pulmonologists most commonly supervised pleurodesis. In the United States, Australia, and Canada, however, a significant proportion of the respondents (30%, 41%, and 26%, respectively) reported that they referred patients requiring pleurodesis to thoracic surgeons. In contrast, pleurodesis was seldom performed by thoracic surgeons in the United Kingdom and New Zealand (3% and 8%, respectively).

Procedural Practice of Pleurodesis
When to Perform Pleurodesis:

Widespread variations existed in most of the technical steps used for pleurodesis (Table 4 ). Timing of pleurodesis varied: 8% of respondents performed pleurodesis as soon as a malignant effusion was diagnosed, 14% would wait until the effusion became symptomatic, 54% would delay pleurodesis until after at least one symptomatic recurrence, and 28% after at least two symptomatic occurrences. The reported success rates were similar among physicians who perform pleurodesis when patients were symptomatic (69.3 ± 16.1%), those who perform pleurodesis at diagnosis (68.2 ± 22.5%), those who pleurodese after first recurrence of the effusions (66.6 ± 17.6%), or those who pleurodese after the second recurrence of the effusions (64.1 ± 18.7%).

While 67% of the respondents would delay instillation of pleurodesis agents until chest tube fluid drainage decreased to less than 150 mL/d, 23% would perform pleurodesis when the lung was fully re-expanded on chest radiographs regardless of the rate of chest tube drainage. The remainder of respondents would perform pleurodesis at an established time after insertion of the chest tube regardless of the rate of fluid drainage.

Management of Chest Tubes:

No accepted practice was found regarding the practice of rotating patients or clamping of a chest tube after instillation of a pleurodesis agent. In the United Kingdom, 91% of the respondents routinely instilled lignocaine along with the pleurodesis agent, whereas only 68 to 74% of respondents from other countries used lignocaine. The criteria used for chest tube removal also varied among physicians of different countries.

Success Rates and Satisfaction With Pleurodesis Agents:

Pulmonologists were asked to estimate the success rate of pleurodesis for patients with malignant effusions in their practice (Fig 1 ). Success was defined in the questionnaire as “satisfactory improvement of dyspnea and no re-accumulation of pleural fluid to a degree that requires additional pleural fluid drainage.” Overall, the success rate of pleurodesis was estimated to be 66 ± 18%. Physicians who used talc poudrage reported a significantly higher success rate (73 ± 17%) of pleurodesis than did those who used talc slurry (68 ± 17%), tetracycline or its derivatives (61 ± 19%), or bleomycin (62 ± 16%), (p < 0.05, p < 0.001, and p < 0.001, respectively). Those who used talc slurry in turn reported a higher success rate than respondents using tetracycline derivatives (p < 0.05) and bleomycin. There were no significant differences in the reported success rates when physicians were categorized by the number of pleurodesis procedures they performed each year.

Respondents were asked to rate their satisfaction with the pleurodesis agents they used most often from 0 (extremely dissatisfied) to 8 (extremely satisfied). Overall, the respondents were only “somewhat satisfied” (5.0 ± 1.5). This score was uniform among the physicians from different surveyed countries. Physicians’ satisfaction rating with pleurodesis correlated with their estimated pleurodesis success rate (r = 0.49, p < 0.0001).

Pulmonologists who employed video-assisted thoracoscopic surgery and medical thoracoscopy reported a significantly higher success rate (73 ± 17% and 72 ± 17%, respectively) compared with those who performed pleurodesis via chest tubes (64 ± 18%) [p < 0.05 for both]. There were no significant association between the physicians’ reported success rate in relation to their preferred chest tube size, timing of performing pleurodesis, use of patient rotation, or the criteria for removal of chest tubes (p = not significant for all of the above).

Complications:

Pulmonologists were asked to rate the frequency of complications they experienced with their preferred pleurodesis agent on a Likert-scale: 0 = never occurs, 1 = rarely occurs, 2 = seldom occurs, 3 = occasionally occurs, 4 = occurs, 5 = often occurs, 6 = regularly occurs, 7 = frequently occurs, 8 = always occurs (Fig 2 , Table 5 ). Talc (both poudrage and slurry) was associated with significantly more adverse effects, especially fever and nausea, than tetracycline derivatives or bleomycin.

Fever and pain were the most frequently reported complications. Fever (> 38°C) was significantly more common with both talc poudrage (2.3 ± 1.6) and slurry (2.0 ± 1.6) than with tetracycline derivatives (1.4 ± 1.3) and bleomycin (1.2 ± 1.3) [p < 0.001 for each of these comparisons; Fig 2 , top left, a]. Pain (of any degree) was more common with the talc poudrage (4.7 ± 1.8), talc slurry (4.5 ± 1.9), and tetracycline groups (4.6 ± 1.9) than bleomycin (3.6 ± 2.0) [p < 0.05; Fig 2 , top right, b]. The same findings were observed when only severe pain (defined as pain requiring narcotic analgesia) was considered (Fig 2 , center left, c). There were no associations between the incidence of pain and the physicians’ preferred size of chest tube or whether intrapleural lignocaine was used. In addition, nausea was also significantly more common with talc (either poudrage or slurry) than with the other agents (p < 0.05; Fig 2 , center right, d).

Respiratory failure and death in relation to pleurodesis, though rare, were reported by 51% of respondents (n = 437) [Table 5] . The majority of physicians (58%, n = 323) who used talc have observed respiratory failure as a complication. Only 29% of the physicians who used talc poudrage, and 44% of those using talc slurry reported that respiratory failure “never occurred” in their experience. Respiratory failure was also reported by 46% of respondents to have occurred, though rarely, with the use of tetracycline, doxycycline, and bleomycin (Table 5) . The reported incidence of respiratory failure was significantly higher with talc (irrespective of poudrage or slurry) than with tetracycline derivatives or bleomycin (Fig 2 , bottom left, e).

While 646 respondents (76%) reported that death following pleurodesis had never occurred in their practice, 184 respondents (24%) categorized death as occurring “rarely” (n = 174, 20% of respondents), “seldom” (n = 14, 1.6% of respondents), or “occasionally/sometimes/often” (n = 6, 0.6% of respondents). Physicians were then asked to quantify the incidence of death after pleurodesis on the Likert scoring scale of 0 to 8. A higher association with death was reported with talc poudrage than with bleomycin (Likert scale grading, 0.37 ± 0.60 vs 0.15 ± 0.36; p = 0.02) [Fig 2 , bottom right, f]. A similar trend was also seen when talc poudrage was compared with tetracycline derivatives (Likert scale grading, 0.37 ± 0.60 vs 0.20 ± 0.52; p = 0.08), although the differences did not reach statistical significance. There was no relation in any of the complication rates with the number of pleurodesis procedures the physicians performed annually.

The present study is the largest survey of worldwide pleurodesis practices. While the results should not be interpreted as indications for preferred practice of pleurodesis—which will require clinical trials—the data revealed from this study provide important information on the current state of clinical practice and the physicians’ opinions of pleurodesis in various countries. Our results demonstrated considerable practice variations in the selection of agents and techniques for performing pleurodesis. Surveyed pulmonologists reported that talc was the most commonly used agent, but tetracycline derivatives and bleomycin were common alternatives. Respondents worldwide were only “somewhat satisfied” with the pleurodesis agent they used, and reported success rates were substantially lower than published data. Talc was perceived as more effective than other agents, but was associated with significantly more complications, including respiratory failure. Many physicians, however, reported that they have observed respiratory failure and death (46% and 16% of respondents, respectively) following pleurodesis with agents other than talc.

The respondents of this study collectively perform 8,330 pleurodeses each year. This large experience provides an opportunity to capture data on the effectiveness and risks of pleurodesis otherwise not readily obtainable. We uncovered wide practice variations observed among pulmonologists, not only between different countries but also within each country assessed. This is most likely explained by the lack of adequately powered randomized trials on how pleurodesis should be conducted, and hence a reliance on physicians’ individual practice experiences in performing the procedure.

Differences in the Practice of Pleurodesis

Our data revealed differences in all key aspects of pleurodesis practice among physicians within and among the surveyed countries. While most pulmonologists (75%) performed pleurodesis via chest tubes, 25% preferred thoracoscopic pleurodesis, reflecting the lack of conclusive data in the literature.1315 The survey revealed that larger size chest tubes were more popular in the United States and Canada compared with the United Kingdom and New Zealand. This may be related to the fact that surgeons, rather than pulmonologists, are more likely to be responsible for chest tube insertion in the United States. Although nonrandomized trials3 report reasonable pleurodesis success with small-bore catheters, there are no randomized trials on the effect of chest tube size on the outcome of pleurodesis for malignant pleural effusions. We found no difference in the reported success rates between physicians who used larger tubes than those using smaller catheters.

The majority of pulmonologists (93%) clamped the chest tubes, but for varying durations up to 4 hours. Despite existing information suggesting that rotation does not influence the outcome of pleurodesis with tetracycline derivatives16 or talc slurry,17 63% of the respondents routinely rotate their patients. Also, 73% of respondents used intrapleural lignocaine as an analgesic, despite no human or animal data supporting its efficacy. These common practices differed from the guidelines of the American Thoracic Society,6 which recommended clamping of chest tubes for 1 h, no rotation of patients (except after talc slurry), and did not suggest the use of lignocaine.

The timing of pleurodesis also varied. While some authorities recommend that pleurodesis be performed as early as possible when a malignant effusion is diagnosed,1819 the majority of the physicians waited until at least one, and some after two, symptomatic recurrences of the effusion before conducting pleurodesis. Whether this delay affects the likelihood of successful pleurodesis requires future investigations.

Pleurodesis Agents

Pulmonologists who used talc poudrage reported higher success rates than other groups. Those who used talc slurry in turn reported higher success rates than respondents using tetracycline derivatives. The overall success rate reported by the respondents (66%) was considerably lower than data cited in the literature (often > 90%). This discrepancy is most likely explained by the strict exclusion criteria in clinical studies (eg, of patients with trapped lungs), whereas those reported by the survey participants would more closely represent the success rates seen in everyday clinical practice.

Our data also showed that talc (poudrage and slurry alike) were associated with significantly more side effects, such as fever, pain, and nausea, than the other agents. This would be in keeping with laboratory evidence that talc induces significant release of pro-inflammatory cytokines resulting in pleural inflammation, which produce fever and chest pain.2021 Although talc is cheap and universally available, there has been controversy over its safety.8,2223 ARDS and deaths have been reported in several series911,24 following talc pleurodesis, irrespective of doses and routes of administration; however, other large studies25 have reported no cases of ARDS.

Our study confirmed that talc-induced respiratory failure is a real entity and had been observed by the majority (70%) of physicians who used talc poudrage. Indeed, the incidence of respiratory failure was significantly higher with talc poudrage than with bleomycin. A higher incidence of respiratory failure was also shown when talc poudrage was compared with tetracycline derivatives, though the differences did not reach statistical significance (p = 0.08). Talc poudrage was also associated with a higher risk of death, although this was rare.

However, respiratory failure was not limited to talc pleurodesis, but was also reported to occur, though rarely, by physicians who preferred tetracycline derivatives or bleomycin. This is an important observation not previously reported, and warrants further investigations. Similarly, a sizeable number of respondents, irrespective of their preferred agents, reported that they have observed death as a complication of pleurodesis. These data highlight that pleurodesis is not entirely benign, but carries definite (though uncommon) risks of serious complications. There is an urgent need to refine current agents or to develop new ones with a better efficacy and safety profile.

Overall, the respondents were only “somewhat satisfied” with their preferred pleurodesis agent, which is not surprising given their complications and suboptimal success rates. This relatively low satisfaction with available pleurodesis agents may well influence the readiness of physicians to subject patients with malignant effusions to pleurodesis over alternatives (eg, regular thoracenteses or long-term indwelling catheters). This may also explain why many pulmonologists delayed pleurodesis until after two (or more) symptomatic recurrences of the effusion. Despite the higher complication risks, pulmonologists who used talc poudrage and slurry both reported a higher satisfaction rating than those who employed other agents.

Potential Limitations of the Study

As in any survey, data supplied by individual physicians can be influenced by recollection bias, and the respondents can potentially represent a biased group over the nonrespondents. Conducting the survey via e-mail allowed us to sample a large number of pulmonologists, but could potentially introduce a selection bias toward those who have Internet access and competency. To avoid ambiguity in translation, we have restricted our survey to five English-speaking countries. Whether the results can be extrapolated to other nations need confirmation. In the study, the success and complication rates of the pleurodesis agents were estimates, rather than actual figures from clinical audits, supplied by the participants. Likewise, the terms used in the Likert scale (such as “seldom,” “rare,” etc) to describe incidences of complications were not defined in exact numbers, and was left to the physicians’ subjective interpretation. However, in the presence of the large number of participants, any potential bias in the interpretation should balance out among the groups.

Whether complications, especially respiratory failure or death, were related to pleurodesis, rather than concurrent illnesses, was based on physicians’ clinical judgment. There is also no uniformly accepted definition for respiratory failure following pleurodesis, and we have left it to the physicians’ discretion. It is accepted that the cause of death in patients with pleural malignancies can be difficult to establish with certainty, and we relied on the physicians to determine if the deaths were related to pleurodesis. Nonetheless, the data are important because physicians’ own experiences are often the most influential factor toward the way they practice, and on how they educate future generations of pulmonologists.

As in any survey, we have to strike a balance between keeping the questions simple and obtaining adequate details to make the study meaningful. Certain factors that may alter the outcome in pleurodesis were not studied. For example, the dose or size of talc particles used (which has been postulated to affect the incidence of complications in talc pleurodesis23 ), the type and extent of pleural tumor, or pleural fluid biochemical parameters (eg, pH),,26 were not singled out in the questionnaire. Withstanding all the above limitations, this study is the largest to date on pleurodesis and served to highlight the key areas of disparity in pleurodesis practice.

Summary

Practicing pulmonologists worldwide perceived that none of the available pleurodesis agents are ideal. Talc, tetracyclines, and bleomycin were the compounds most commonly used, but no consensus existed on a preferred agent. Talc poudrage and slurry were reported to produce higher success rates but caused more adverse effects and higher risks of respiratory failure. Significant variations were found in the way pleurodesis is performed within and among different countries. Large, multicenter, clinical trials are urgently needed to determine the optimal pleurodesis practice, in order to achieve the best outcome for the many patients who undergo the procedure worldwide.

Abbreviations: ACCP = American College of Chest Physicians; BTS = British Thoracic Society; TSANZ = Thoracic Society of Australia and New Zealand

Dr. Light has a patent on the use of a cytokine, transforming growth factor-β, for pleurodesis. To date, transforming growth factor-β has only been used on animal studies (rabbits, mice, and sheep).

Support was provided by St. Thomas Foundation, Nashville, TN (Dr. Light).

Dr. Lee is a Wellcome Trust Research Fellow and a Graham Aitken Nuffeld Medical Postgraduate Traveling Scholar.

Table Graphic Jump Location
Table 1. Demographics of the Respondents as Classified by the Country of Practice
* 

Represents mode of each group.

Table Graphic Jump Location
Table 2. Agents Most Commonly Used for Pleurodesis by the Respondents’ Country of Practice, Gender, and Age
* 

Represents the mode of each group.

Table Graphic Jump Location
Table 3. Common Practice of Pleurodesis for Malignant Pleural Effusions by the Respondents as Classified by the Country of Practice
* 

Represents the mode of the group.

Table Graphic Jump Location
Table 4. Procedural Practice of Pleurodesis for Malignant Pleural Effusions by the Respondents by the Country of Practice*
* 

Represents the mode of each group. ICT = intercostal tube; CRX = chest radiograph.

Figure Jump LinkFigure 1. Physicians’ reported (left, a) success rate (percentage) of pleurodesis and (right, b) satisfaction ratings with the pleurodesis agent they used most often: 0 = extremely dissatisfied, 1 = very dissatisfied, 2 = quite dissatisfied, 3 = somewhat dissatisfied, 4 = not dissatisfied or satisfied, 5 = somewhat satisfied, 6 = quite satisfied, 7 = very satisfied, 8 = extremely satisfied. TCN = tetracycline; Doxy = doxycycline; Bleo = bleomycin. *p < 0.05; **p < 0.01; ***p < 0.001.Grahic Jump Location
Figure Jump LinkFigure 2. Physicians’ reported experience of significant complications following pleurodesis: fever > 38°C (top left, a); pain of any degree (top right, b); severe pain requiring narcotic analgesia (center left, c); nausea (center right, d); respiratory failure (bottom left, e); and death (bottom right, f). 0 = never occurs, 1 = rarely occurs, 2 = seldom occurs, 3 = occasionally occurs, 4 = occurs, 5 = often occurs, 6 = regularly occurs, 7 = frequently occurs, 8 = always occurs. See Figure 1 legend for expansion of abbreviations. *p < 0.05; **p < 0.01; ***p < 0.001.Grahic Jump Location
Table Graphic Jump Location
Table 5. Physicians’ Reported Experience of Significant Complications Following Instillation of Pleurodesis Agents*
* 

Data are presented as No. (%) unless otherwise indicated.

The authors thank the ACCP, the BTS, and the TSANZ for their assistance. In particular, the authors would express their appreciation to Ms. Lynne Marcus (ACCP), Ms. Moon (BTS), Ms. Beattie Pearlman (TSANZ), and Dr. Colin Wong (New Zealand Thoracic Society) for their assistance in distributing the e-mails to their society members.

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Sahn, SA Talc should be used for pleurodesis.Am J Respir Crit Care Med2000;162,2023-2024. [PubMed]
 
Light, RW Talc for pleurodesis?Chest2002;122,1506-1508. [CrossRef] [PubMed]
 
de Campos, JR, Vargas, FS, Werebe, E, et al Thoracoscopy talc poudrage: a 15-year experience.Chest2001;119,801-806. [CrossRef] [PubMed]
 
Viallat, JR, Rey, F, Astoul, P, et al Thoracoscopic talc poudrage pleurodesis for malignant effusions: a review of 360 cases.Chest1996;110,1387-1393. [CrossRef] [PubMed]
 
Heffner, JE, Nietert, PJ, Barbieri, C Pleural fluid pH as a predictor of pleurodesis failure.Chest2000;117,87-95. [CrossRef] [PubMed]
 

Figures

Figure Jump LinkFigure 1. Physicians’ reported (left, a) success rate (percentage) of pleurodesis and (right, b) satisfaction ratings with the pleurodesis agent they used most often: 0 = extremely dissatisfied, 1 = very dissatisfied, 2 = quite dissatisfied, 3 = somewhat dissatisfied, 4 = not dissatisfied or satisfied, 5 = somewhat satisfied, 6 = quite satisfied, 7 = very satisfied, 8 = extremely satisfied. TCN = tetracycline; Doxy = doxycycline; Bleo = bleomycin. *p < 0.05; **p < 0.01; ***p < 0.001.Grahic Jump Location
Figure Jump LinkFigure 2. Physicians’ reported experience of significant complications following pleurodesis: fever > 38°C (top left, a); pain of any degree (top right, b); severe pain requiring narcotic analgesia (center left, c); nausea (center right, d); respiratory failure (bottom left, e); and death (bottom right, f). 0 = never occurs, 1 = rarely occurs, 2 = seldom occurs, 3 = occasionally occurs, 4 = occurs, 5 = often occurs, 6 = regularly occurs, 7 = frequently occurs, 8 = always occurs. See Figure 1 legend for expansion of abbreviations. *p < 0.05; **p < 0.01; ***p < 0.001.Grahic Jump Location

Tables

Table Graphic Jump Location
Table 1. Demographics of the Respondents as Classified by the Country of Practice
* 

Represents mode of each group.

Table Graphic Jump Location
Table 2. Agents Most Commonly Used for Pleurodesis by the Respondents’ Country of Practice, Gender, and Age
* 

Represents the mode of each group.

Table Graphic Jump Location
Table 3. Common Practice of Pleurodesis for Malignant Pleural Effusions by the Respondents as Classified by the Country of Practice
* 

Represents the mode of the group.

Table Graphic Jump Location
Table 4. Procedural Practice of Pleurodesis for Malignant Pleural Effusions by the Respondents by the Country of Practice*
* 

Represents the mode of each group. ICT = intercostal tube; CRX = chest radiograph.

Table Graphic Jump Location
Table 5. Physicians’ Reported Experience of Significant Complications Following Instillation of Pleurodesis Agents*
* 

Data are presented as No. (%) unless otherwise indicated.

References

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Sahn, SA Talc should be used for pleurodesis.Am J Respir Crit Care Med2000;162,2023-2024. [PubMed]
 
Light, RW Talc for pleurodesis?Chest2002;122,1506-1508. [CrossRef] [PubMed]
 
de Campos, JR, Vargas, FS, Werebe, E, et al Thoracoscopy talc poudrage: a 15-year experience.Chest2001;119,801-806. [CrossRef] [PubMed]
 
Viallat, JR, Rey, F, Astoul, P, et al Thoracoscopic talc poudrage pleurodesis for malignant effusions: a review of 360 cases.Chest1996;110,1387-1393. [CrossRef] [PubMed]
 
Heffner, JE, Nietert, PJ, Barbieri, C Pleural fluid pH as a predictor of pleurodesis failure.Chest2000;117,87-95. [CrossRef] [PubMed]
 
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