PURPOSE: Pleural disease is a common medical problem. It forms a significant caseload for respiratory physicians. There are few randomized controlled trial data supporting commonly used therapeutic interventions. We wished to document current stanadards of practice for pleural disease in Canada.
METHODS: A case-based questionnaire with multiple management options was distributed to respiratory physicians in Canada and responses collated.
RESULTS: 331 questionnaires were distributed with 114 responses. Of the respondents, 79% were physicians practicing >5 years and 66% in university/tertiary hospitals. 33.3% had not inserted a chest tube (CTs) in the past year, of those 26.3% used only local analgesia, and 34.2% connected all drains to suction. Ultrasound-guidance was requested in small, loculated, or failed attempts to aspirate the pleural effusion in 71%, 83.3% and 89.4%, respectively. Only 55.2% would order CXRs before and after aspiration. 88.5% would drain parapneumonic effusions with CT if purulent, 74.5% if gram stain or culture were positive, 62.3% when pH <7.2 and 74.5%. 44.7% are still using intra-pleural fibrinolytics when pH<7.1 and CT is blocked. In malignant pleural effusions, 33.3% would use medium size CT; 61.4% initially drain 1-1.5 litre and 57% would not use fibrinolytics. Talc was the most common agent for pleurodesis 90.4%. Semi-permanent catheters were only available to 37%. 16.6% would order a thoracic CT for routine evaluation of spontaneous pneumothorax (PTX). Majority of CT insertions for PTX were for secondary spontaneous PTX whether small 56.1% or large 68.4%. 26.3% performed simple aspiration, whereas 69.3% observed and administered oxygen in small asymptomatic primary PTX. 48.2% inserted small bore catheters, while 38.6% medium sized CT.
CONCLUSION: There exists variation in practice among respiratory physicians in Canada with respect to the management of pleural disease.
CLINICAL IMPLICATIONS: Randomized controlled trials are essential to address the common clinical questions posed in the questionnaire. In the few cases where high level evidence does exist, better strategies for implementation of the results into clinical practice are necessary.
DISCLOSURE: Mubarak Alajmi, None.