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Original Research: Pulmonary Procedures |

Predictors of Clinical Use of Pleurodesis and/or Indwelling Pleural Catheter Therapy for Malignant Pleural EffusionPredicting Therapy in Malignant Pleural Effusion FREE TO VIEW

Edward T. H. Fysh, MBBS; Silvia Bielsa, MD; Charley A. Budgeon, BSc (Hons); Catherine A. Read, RGN, BSc (Hons); Jose M. Porcel, MD, FCCP; Nick A. Maskell, DM, FCCP; Y. C. Gary Lee, MBChB, PhD, FCCP
Author and Funding Information

From Respiratory Medicine (Drs Fysh and Lee), Sir Charles Gairdner Hospital, Government of Western Australia, Perth, WA, Australia; Centre for Asthma, Allergy and Respiratory Research (Drs Fysh and Lee and Ms Read) and School of Medicine and Pharmacology (Drs Fysh and Lee), The University of Western Australia, Perth, WA, Australia; Pleural Diseases Unit (Drs Bielsa and Porcel), University Hospital Arnau de Vilanova, Lleida, Spain; Centre for Applied Statistics (Ms Budgeon), The University of Western Australia, Perth, WA, Australia; Department of Research (Ms Budgeon), Sir Charles Gairdner Hospital, Government of Western Australia, Perth, WA, Australia; and North Bristol Lung Centre (Dr Maskell), Southmead Hospital, Bristol University, Bristol, England.

CORRESPONDENCE TO: Y. C. Gary Lee, MBChB, PhD, FCCP, School of Medicine, The University of Western Australia, 533 Harry Perkins Bldg, QE II Medical Centre, Perth, WA 6009, Australia; e-mail: gary.lee@uwa.edu.au


FUNDING/SUPPORT: Dr Lee is a National Health and Medical Research Council (NHMRC) Career Development Fellow and receives project grant funding from the NHMRC, New South Wales Dust Disease Board (DDB), Sir Charles Gairdner Research Advisory Committee, Lung Institute of Western Australia (LIWA) Westcare grants, and the Cancer Council Western Australia. Dr Fysh received postgraduate scholarships from the NHMRC and LIWA to undertake this work and project funding from the DDB and Cancer Council Western Australia.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2015;147(6):1629-1634. doi:10.1378/chest.14-1701
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BACKGROUND:  The clinical course of patients with malignant pleural effusions (MPEs) varies. The decision to undertake “definitive therapy” (pleurodesis, indwelling pleural catheter [IPC], or both) for MPEs is decided on a case-by-case basis. Identifying factors that predict definitive therapy may help guide early initiation of treatment. The aim of the study was to identify clinical, laboratory, and radiologic predictors associated with clinicians’ prescription of definitive therapy for patients with MPE.

METHODS:  A multicenter, observational study was conducted over 55 months involving tertiary centers in Perth, Western Australia, Australia, and Lleida, Spain. Demographic, clinical, radiologic, biochemical, and histologic data and the treatments received were recorded. Logistic regression was performed to determine the variables useful for predicting definitive therapy.

RESULTS:  Data of 540 patients (365 from Perth and 184 from Lleida) were analyzed; 537 fulfilled the criteria of an MPE. Definitive therapy was used in 288 patients (53.6%): 199 received a pleurodesis and 89 an IPC. Univariate analysis of the combined cohort revealed that definitive therapy was more likely if the effusion has low pH, either as a continuous variable (OR, 30.30; P < .01) or with a pH cutoff of < 7.2 (OR, 2.09; P = .03); was large (> 50% of hemithorax) (OR, 2.75; P < .01); or was associated with mesothelioma (OR, 1.83; P < .01). Following multivariate analysis, low pleural pH (OR, 37.04; P < .01), large effusions (OR, 3.31; P < .01), and increasing age (OR 1.02, P = .01) were associated with the use of definitive therapy.

CONCLUSIONS:  Patients with MPE with an effusion of low pleural fluid pH and large size on radiographs at first presentation are more likely to be treated with pleurodesis and/or IPC.

Figures in this Article

Malignant pleural effusions (MPEs) are common and affect as many as 15% of patients with cancer.1 MPEs cause considerable symptoms, especially breathlessness, and morbidity. Many patients require inpatient and/or outpatient pleural procedures for fluid evacuation for symptom relief, with significant associated health-care costs.

The rate of recurrence of MPE is very variable, with some patients never requiring any fluid removal, to those needing frequent (even daily) drainages.2 For patients whose effusion recurs slowly or whose life expectancy is limited, simple thoracentesis is recommended. However, “definitive therapy” is recommended for those who would otherwise require frequent pleural drainages to control their symptoms.

Pleurodesis (usually using talc) and placement of a tunneled indwelling pleural catheter (IPC) are the most commonly used definitive therapy for MPE.37 The principles of both treatments are the same: to minimize pleural interventions and the associated costs, discomfort, and risks of procedural complications in patients with MPE who often have a limited lifespan. Pleurodesis is the conventional method to obliterate the pleural cavity and prevent fluid accumulation. IPCs facilitate fluid drainage and provide symptom control in an ambulatory setting. Both pleurodesis and IPCs offer comparable improvement in symptom and quality-of-life measurements when used as first-line management of MPE.3,4 Nonetheless, pleurodesis and IPCs carry their own costs and risks, and should only be used in patients whose effusions recur and cause symptoms.

At the time of diagnosis, identifying which of the patients with MPE will need definitive therapy and distinguishing them from those in whom observation and/or simple thoracentesis would suffice is notoriously difficult. Delay in definitive therapy can expose the patient with recurrent MPEs to prolonged symptoms, extra drainage interventions, and cumulative procedural complication risks. On the other hand, a blanket strategy of early definitive therapy at diagnosis for all patients with MPE will mean subjecting many to unnecessary interventions.

No studies have specifically examined predictors of need for definitive therapy at the time of diagnosis to guide clinical care. As such, physicians often treat patients on a case-by-case basis. In this study, we interrogated databases of patients with MPE to identify those offered definitive therapy by their attending clinicians. We aim to identify predictors that are associated with the eventual need of definitive therapy. This can potentially allow early selection of suitable patients and avoid repeated pleural procedures. Examining the identified predictors may also provide insight into the biology of the clinical course of MPE.

Data from the MPE databases at Sir Charles Gairdner Hospital (which also include patients from Fremantle and Royal Perth Hospitals, Perth, Western Australia, Australia) and at University Hospital Arnau de Villanova (Lleida, Spain) were interrogated. Respective local ethics committees have approved longitudinal studies on the clinical outcomes of MPE; all patients gave informed consent. Data of patients presenting with an MPE were prospectively collected.

Clinical, pathologic, radiologic, and biochemical variables of interest in predicting the need for intervention in patients with MPE were determined a priori (Table 1). These data were recorded in each local database at the time of diagnosis of MPE from August 2009 to July 2013 in Western Australia and between December 2007 and April 2012 for the Spain cohort. Size of effusion was graded on the initial preprocedure chest radiograph using a previously described system5: grade 0 referred to no radiographic evidence of pleural fluid; grade 1 = blunting of the costophrenic angle; grade 2 to 5 referred to fluid occupying < 25%, 25% to 50%, 51% to 75%, and > 75% of the hemithorax, respectively.

Table Graphic Jump Location
TABLE 1 ]  Variables Studied

Patients were diagnosed as having an MPE if they had (1) histologic or cytologic confirmation or both of malignant cells from pleural tissue biopsy or pleural fluid cytology or (2) an exudative pleural effusion by Light’s criteria6 in the setting of histocytologically proven extrapleural malignancy with no obvious alternative diagnosis of their effusion. The latter mainly referred to individuals who were too frail for or declined further invasive testing.

Patients were followed until death (n = 426, 78.9%) or for a minimum of 6 months. Pleural interventions were recorded prospectively.

Comorbidity was recorded. Pleural effusion was considered loculated if there was evidence of septations on ultrasonography or if drainage was incomplete and the remaining fluid did not collect as expected according to gravity on postprocedure radiography. Nonexpandable lung referred to radiographic evidence that the lung had not fully reexpanded following evacuation of the pleural effusion. Renal failure was defined as an estimated glomerular filtration rate of < 50 mL/min. Significant ischemic heart disease was defined by prior myocardial infarction, coronary artery intervention (balloon angioplasty, stent placement, and/or bypass surgery), or both. Left ventricular failure was defined by echocardiographic findings of moderate or severe left ventricular failure. Patient’s home location was classed as metropolitan if they lived within a defined metropolitan area according to the local government definition. COPD and asthma were defined according to the World Health Organization (WHO) definition of these diseases, and patients had to be currently receiving inhaled or other therapy for these conditions.

Predefined variables from the data of Western Australia and Lleida were analyzed separately using univariate and multivariate logistic regression. Then, a combined analysis of all variables with data that were > 90% complete and the pleural pH was performed. Pleural pH was included despite being only 74% complete because of its very strong statistical significance in all the univariate analyses compared with the other variables as well as its clinical and biologic importance. Univariate and multivariate binary logistic regressions were conducted on the combined cohort. Two multivariate analyses were performed; the first included pleural pH as a continuous variable and the second used a pH cutoff of 7.2. Variables that were significant at a 5% significance level were retained in the final models. Adjusted ORs and 95% CIs were calculated for the final models. Data were analyzed using R: a language and environment for statistical computing.7

Demographics

The 540 patients with MPE recruited included 356 (65.9%) from Western Australia and 184 from Lleida: 407 (75.8%) had histocytologic confirmation of an MPE, and 130 had known metastatic cancer with an exudative pleural effusion without other discernible cause(s). Three patients were excluded: All had metastatic malignancies but without histocytologic confirmation of an MPE—one had a chylous effusion and two had large bilateral effusions.

The baseline characteristics were largely similar between the Western Australia and Lleida cohorts (Table 2). However, Western Australia is known to have one of the highest incidences of malignant mesothelioma in the world. Hence, the Western Australia cohort consisted of more patients with mesothelioma and, accordingly, had a male predominance (66% vs 51%, respectively) and was younger (median age, 69 years vs 74 years, respectively) than the Lleida patients.

Table Graphic Jump Location
TABLE 2 ]  Baseline Demographics and Distribution of Most Common Malignancies for Each Country

The χ2 test was used to analyze for all variables except age, which was analyzed by Mann-Whitney rank sum test.

Definitive therapy was used in 53.6% (n = 288) of the overall cohort. Of those who received definitive therapy, 199 (69.1%) had a pleurodesis and 89 had an IPC. The other 249 patients (46.4%) received no more aggressive treatment than thoracentesis, either because of poor prognosis, lack of symptomatic relief, or patient choice (Fig 1).

Figure Jump LinkFigure 1 –  Flowchart showing breakdown of interventions. IPC = indwelling pleural catheter; MPE = malignant pleural effusion.Grahic Jump Location
Univariate Analyses

Definitive therapy was more commonly used in the Western Australia subgroup (57.8% vs 45.7%). Univariate analyses were performed first by country and then combined, which revealed very similar predictors. The Western Australia data revealed that the lower the pH the more likely the patient would eventually receive definitive therapy (OR, 10.64; P < .01). A diagnosis of mesothelioma (OR, 1.69; P = .02), a large effusion > 50% of hemithorax on radiographs (OR, 1.59; P = .04), and higher pleural fluid protein level (OR, 1.03; P < .05) were also associated with the likelihood of receiving definitive therapy.

Univariate analysis of the Lleida cohort showed strikingly similar results compared with the Western Australia data. Decreasing pleural fluid pH (OR, 33.3; P < .01), a large effusion (OR, 11.81; P < .01), and higher pleural protein levels (OR, 1.91; P < .01) were associated with the use of definitive therapy.

The presence of COPD (OR, 0.37; P = .01) or renal failure (OR, 0.16; P = .02) was associated with a lower likelihood of receiving definitive therapy in the Western Australia but not the Lleida subgroup. Conversely, age was marginally significant (OR, 1.03; P = .01) in the Lleida but not the Western Australia cohort. Patients on diuretic therapy showed a lower likelihood of receiving definitive therapy in the Western Australia group, although this did not achieve significance (OR, 0.46; P = .07).

Both cohorts were then combined and univariate analyses performed. Decreasing pleural fluid pH (OR, 30.30; P < .01), a large effusion (OR, 2.75; P < .01), and underlying mesothelioma (OR, 1.83; P < .01) were significantly associated with the prescription of definitive therapy for MPE management.

Multivariate Analyses

Multivariate analyses were performed on the separate cohorts and then the combined cohort (Table 3). In the Western Australia cohort, decreasing pleural fluid pH (OR, 13.70; P < .01), and effusions larger than 50% of the hemithorax size (OR, 1.59; P < .04) were again significantly associated with increased rates of definitive therapy. Patients on diuretic treatment were less likely to receive definitive therapy (OR, 0.27; P = .01). Multivariate analysis of the Lleida cohort also confirmed that low pleural fluid pH (OR, 41.67; P = .02) and larger effusions (OR, 14.95; P < .01) were significant predictors of definitive therapy.

Table Graphic Jump Location
TABLE 3 ]  Univariate and Multivariate Results of the Combined Cohorts Are Presented

Pleural fluid pH was analyzed as a continuous variable in multivariate analysis 1 and as a dichotomized variable (cutoff at 7.20) in multivariate analysis 2. NA = excluded from analysis; NS = not significant.

Multivariate analysis of the combined cohort reiterated an association between decreasing pleural pH (continuous variable: OR, 37.04; P < .01), larger effusions (OR, 3.31; P < .01), and use of definitive therapy. Increasing age was also statistically significant, although with a marginal OR of 1.02 (P = .01). If the pH was analyzed as a dichotomized variable at a cutoff of 7.2, the pH was no longer significant; instead, mesothelioma was related to increased rates of definitive therapy (OR, 2.05; P < .01), echoing the findings of the univariate results.

To our knowledge, this is the first study of predictors of the likelihood of receiving pleurodesis or IPC in patients diagnosed with MPE. Patients with effusions of lower pleural fluid pH and large sizes were significantly more likely to receive definitive therapy, as confirmed in two separate cohorts.

Our prospective data showed that only 53.6% of patients with MPE received definitive therapy. This is in contrast to the common belief that most MPEs will recur and all patients should be offered early definitive therapy.8 The latter approach would have seen almost one-half of the patients in our cohort be subjected to unnecessary invasive procedures (and the associated risks and costs). Serious adverse events, including puncture of vital organs and death, complicates about 1% of chest drain insertions, which can amount to a significant number of patients given the high prevalence of MPEs worldwide.911 Finding predictors that identify the appropriate about 50% of patients will allow clinicians to initiate definitive therapy early and avoid repeated/unnecessary thoracenteses before embarking on pleurodesis or IPC placement. Our study specifically only included patients presenting for the first pleural procedure to avoid selection bias, as patients referred to tertiary centers after failing initial drainages are more likely to require definitive therapy. This may in part explain the higher percentage of patients (46.4%) who did not require definitive therapy.

This pragmatic study examined the real-life prescription behavior of clinicians regarding definitive therapy. It could not establish whether the decisions were “appropriate,” in part as there are no universally accepted rules for these decisions. The factors uncovered are those associated with a higher likelihood that pleurodesis or IPC placement was eventually used, based on clinical judgment.

Lower pleural pH strongly predicted subsequent need for definitive therapy in both the Australian and the Spanish populations, when analyzed separately or together. Several investigators have suggested that low pleural pH signifies greater disease burden and metabolic activities in the pleural space which may determine the likelihood and rapidity of reaccumulation of malignant effusions.12,13 This may explain why low pH was strongly and independently associated with definitive procedures in our study. Previous research has shown that lower pleural pH was associated with poorer prognosis1416 and higher failure rate of pleurodesis.1721 However, the largest study concluded that low pH could not be used as a contraindication for pleurodesis as 68% of patients with pH below 7.3 still had “successful” pleurodesis.18 Further prospective studies are needed to establish whether using pleural pH as part of a treatment decision algorithm can improve patient selection and, if so, what is the best cutoff value for decision-making. These studies need to assess the outcomes of pleurodesis as well as the impact on symptoms, quality of life, and hospital admissions.

The finding that larger effusions were more likely to be treated with definitive procedures is not surprising. These patients are more likely to have significant symptoms, and a large effusion likely represents a faster rate of fluid synthesis and recurrence of the pleural effusion, hence the employment of definitive therapy. Clinicians may perceive that larger effusions present lower risks of procedural complications as well.

MPEs occur in a highly heterogeneous group of patients with varying underlying malignancies, comorbidities, available chemotherapy regimes, and prognoses. The Australian cohort consisted of significantly more patients with mesothelioma (40.2% vs 2.7% in the Spanish subgroup) who have a relatively better median survival (about 12 months) compared with metastatic lung cancer and thus a higher risk of recurrence of the effusion during their lifetime. It may explain the higher need, and thus rates, of definitive therapy (57.8% vs 45.7%) used in the Australian subgroup. Mesothelioma and pH appeared to be confounding. Mesothelioma was significantly associated with the use of definitive therapy when a binary cutoff pH value of 7.2 was used. Low pleural pH levels are well recognized in mesothelioma, and likely reflect a high local tumor burden and metabolic rate.22

There are limitations of this study. As a longitudinal observation study, there were missing data not recorded by referring physicians, and this precluded the inclusion of other potential predictors, for example, trapped lung. Nonetheless, to our knowledge, our data provided for the first time important variables that warrant validation in future large prospective studies. Heterogeneity exists between the two centers. However, the involvement of more than one cohort offered a higher level of confidence in our findings. The fact that decreasing pleural pH was highly significant in all univariate and multivariate analyses performed in both cohorts, separately or together, confirmed that it is a robust predictor despite the limitations. In conclusion, patients with low pleural pH and large effusions at first presentation after an initial diagnosis of MPE are more likely to be treated with pleurodesis or IPC placement subsequently.

Author contributions: Y. C. G. L. is the guarantor. E. T. H. F., J. M. P., N. A. M., and Y. C. G. L. contributed to study conception and design; E. T. H. F., S. B., and C. A. R. were center coordinators and contributed to data collection; C. A. B. performed statistical analyses; E. T. H. F. and Y .C. G. L. contributed to the drafting of the manuscript; and all authors contributed to manuscript revision and final approval.

Financial/nonfinancial disclosures: The authors have reported to CHEST the following conflicts of interest: Drs Maskell and Lee are on the advisory boards of CareFusion Corporation and Sequana Medical. They were co-investigators of the TIME-2 trial in which the indwelling catheters were provided without charge by Rocket Medical plc. Drs Fysh, Bielsa, and Porcel and Mss Budgeon and Read have reported that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Role of sponsors: The sponsors had no role in the design of the study, the collection and analysis of the data, or the preparation of the manuscript.

IPC

indwelling pleural catheter

MPE

malignant pleural effusion

Sahn SA. Pleural diseases related to metastatic malignancies. Eur Respir J. 1997;10(8):1907-1913. [CrossRef] [PubMed]
 
Bennett R, Maskell N. Management of malignant pleural effusions. Curr Opin Pulm Med. 2005;11(4):296-300. [PubMed]
 
Davies HE, Mishra EK, Kahan BC, et al. Effect of an indwelling pleural catheter vs chest tube and talc pleurodesis for relieving dyspnea in patients with malignant pleural effusion: the TIME2 randomized controlled trial. JAMA. 2012;307(22):2383-2389. [CrossRef] [PubMed]
 
Putnam JB Jr, Light RW, Rodriguez RM, et al. A randomized comparison of indwelling pleural catheter and doxycycline pleurodesis in the management of malignant pleural effusions. Cancer. 1999;86(10):1992-1999. [CrossRef] [PubMed]
 
Light RW, Rogers JT, Cheng D, Rodriguez RM. Large pleural effusions occurring after coronary artery bypass grafting. Cardiovascular Surgery Associates PC. Ann Intern Med. 1999;130(11):891-896. [CrossRef] [PubMed]
 
Light RW, Macgregor MI, Luchsinger PC, Ball WC Jr. Pleural effusions: the diagnostic separation of transudates and exudates. Ann Intern Med. 1972;77(4):507-513. [CrossRef] [PubMed]
 
R Core Team. R: a language and environment for statistical computing. Vienna, Austria: R Foundation for Statistical Computing. 2013. http://www.R-project.org. Accessed July 2014.
 
Reddy C, Ernst A, Lamb C, Feller-Kopman D. Rapid pleurodesis for malignant pleural effusions: a pilot study. Chest. 2011;139(6):1419-1423. [CrossRef] [PubMed]
 
Wrightson JM, Fysh E, Maskell NA, Lee YCG. Risk reduction in pleural procedures: sonography, simulation and supervision. Curr Opin Pulm Med. 2010;16(4):340-350. [CrossRef] [PubMed]
 
Dresler CM, Olak J, Herndon JE II, et al; Cooperative Groups Cancer and Leukemia Group B; Eastern Cooperative Oncology Group; North Central Cooperative Oncology Group; Radiation Therapy Oncology Group. Phase III intergroup study of talc poudrage vs talc slurry sclerosis for malignant pleural effusion. Chest. 2005;127(3):909-915. [CrossRef] [PubMed]
 
Fysh ET, Smith NA, Lee YCG. Optimal chest drain size: the rise of the small-bore pleural catheter. Semin Respir Crit Care Med. 2010;31(6):760-768. [CrossRef] [PubMed]
 
Rodriguez-Panadero F, Lopez-Mejias J. Survival time of patients with pleural metastatic carcinoma predicted by glucose and pH studies. Chest. 1989;95(2):320-324. [CrossRef] [PubMed]
 
Good JT Jr, Taryle DA, Sahn SA. The pathogenesis of low glucose, low pH malignant effusions. Am Rev Respir Dis. 1985;131(5):737-741. [PubMed]
 
Sahn SA, Good JT Jr. Pleural fluid pH in malignant effusions. Diagnostic, prognostic, and therapeutic implications. Ann Intern Med. 1988;108(3):345-349. [CrossRef] [PubMed]
 
Rodríguez-Panadero F, López Mejías J. Low glucose and pH levels in malignant pleural effusions. Diagnostic significance and prognostic value in respect to pleurodesis. Am Rev Respir Dis. 1989;139(3):663-667. [CrossRef] [PubMed]
 
Bielsa S, Salud A, Martínez M, et al. Prognostic significance of pleural fluid data in patients with malignant effusion. Eur J Intern Med. 2008;19(5):334-339. [CrossRef] [PubMed]
 
Heffner JE, Heffner JN, Brown LK. Multilevel and continuous pleural fluid pH likelihood ratios for evaluating malignant pleural effusions. Chest. 2003;123(6):1887-1894. [CrossRef] [PubMed]
 
Heffner JE, Nietert PJ, Barbieri C. Pleural fluid pH as a predictor of pleurodesis failure: analysis of primary data. Chest. 2000;117(1):87-95. [CrossRef] [PubMed]
 
Sanchez-Armengol A, Rodriguez-Panadero F. Survival and talc pleurodesis in metastatic pleural carcinoma, revisited. Report of 125 cases. Chest. 1993;104(5):1482-1485. [CrossRef] [PubMed]
 
Heffner JE, Nietert PJ, Barbieri C. Pleural fluid pH as a predictor of survival for patients with malignant pleural effusions. Chest. 2000;117(1):79-86. [CrossRef] [PubMed]
 
Burrows CM, Mathews WC, Colt HG. Predicting survival in patients with recurrent symptomatic malignant pleural effusions: an assessment of the prognostic values of physiologic, morphologic, and quality of life measures of extent of disease. Chest. 2000;117(1):73-78. [CrossRef] [PubMed]
 
Gottehrer A, Taryle DA, Reed CE, Sahn SA. Pleural fluid analysis in malignant mesothelioma. Prognostic implications. Chest. 1991;100(4):1003-1006. [CrossRef] [PubMed]
 

Figures

Figure Jump LinkFigure 1 –  Flowchart showing breakdown of interventions. IPC = indwelling pleural catheter; MPE = malignant pleural effusion.Grahic Jump Location

Tables

Table Graphic Jump Location
TABLE 1 ]  Variables Studied
Table Graphic Jump Location
TABLE 2 ]  Baseline Demographics and Distribution of Most Common Malignancies for Each Country

The χ2 test was used to analyze for all variables except age, which was analyzed by Mann-Whitney rank sum test.

Table Graphic Jump Location
TABLE 3 ]  Univariate and Multivariate Results of the Combined Cohorts Are Presented

Pleural fluid pH was analyzed as a continuous variable in multivariate analysis 1 and as a dichotomized variable (cutoff at 7.20) in multivariate analysis 2. NA = excluded from analysis; NS = not significant.

References

Sahn SA. Pleural diseases related to metastatic malignancies. Eur Respir J. 1997;10(8):1907-1913. [CrossRef] [PubMed]
 
Bennett R, Maskell N. Management of malignant pleural effusions. Curr Opin Pulm Med. 2005;11(4):296-300. [PubMed]
 
Davies HE, Mishra EK, Kahan BC, et al. Effect of an indwelling pleural catheter vs chest tube and talc pleurodesis for relieving dyspnea in patients with malignant pleural effusion: the TIME2 randomized controlled trial. JAMA. 2012;307(22):2383-2389. [CrossRef] [PubMed]
 
Putnam JB Jr, Light RW, Rodriguez RM, et al. A randomized comparison of indwelling pleural catheter and doxycycline pleurodesis in the management of malignant pleural effusions. Cancer. 1999;86(10):1992-1999. [CrossRef] [PubMed]
 
Light RW, Rogers JT, Cheng D, Rodriguez RM. Large pleural effusions occurring after coronary artery bypass grafting. Cardiovascular Surgery Associates PC. Ann Intern Med. 1999;130(11):891-896. [CrossRef] [PubMed]
 
Light RW, Macgregor MI, Luchsinger PC, Ball WC Jr. Pleural effusions: the diagnostic separation of transudates and exudates. Ann Intern Med. 1972;77(4):507-513. [CrossRef] [PubMed]
 
R Core Team. R: a language and environment for statistical computing. Vienna, Austria: R Foundation for Statistical Computing. 2013. http://www.R-project.org. Accessed July 2014.
 
Reddy C, Ernst A, Lamb C, Feller-Kopman D. Rapid pleurodesis for malignant pleural effusions: a pilot study. Chest. 2011;139(6):1419-1423. [CrossRef] [PubMed]
 
Wrightson JM, Fysh E, Maskell NA, Lee YCG. Risk reduction in pleural procedures: sonography, simulation and supervision. Curr Opin Pulm Med. 2010;16(4):340-350. [CrossRef] [PubMed]
 
Dresler CM, Olak J, Herndon JE II, et al; Cooperative Groups Cancer and Leukemia Group B; Eastern Cooperative Oncology Group; North Central Cooperative Oncology Group; Radiation Therapy Oncology Group. Phase III intergroup study of talc poudrage vs talc slurry sclerosis for malignant pleural effusion. Chest. 2005;127(3):909-915. [CrossRef] [PubMed]
 
Fysh ET, Smith NA, Lee YCG. Optimal chest drain size: the rise of the small-bore pleural catheter. Semin Respir Crit Care Med. 2010;31(6):760-768. [CrossRef] [PubMed]
 
Rodriguez-Panadero F, Lopez-Mejias J. Survival time of patients with pleural metastatic carcinoma predicted by glucose and pH studies. Chest. 1989;95(2):320-324. [CrossRef] [PubMed]
 
Good JT Jr, Taryle DA, Sahn SA. The pathogenesis of low glucose, low pH malignant effusions. Am Rev Respir Dis. 1985;131(5):737-741. [PubMed]
 
Sahn SA, Good JT Jr. Pleural fluid pH in malignant effusions. Diagnostic, prognostic, and therapeutic implications. Ann Intern Med. 1988;108(3):345-349. [CrossRef] [PubMed]
 
Rodríguez-Panadero F, López Mejías J. Low glucose and pH levels in malignant pleural effusions. Diagnostic significance and prognostic value in respect to pleurodesis. Am Rev Respir Dis. 1989;139(3):663-667. [CrossRef] [PubMed]
 
Bielsa S, Salud A, Martínez M, et al. Prognostic significance of pleural fluid data in patients with malignant effusion. Eur J Intern Med. 2008;19(5):334-339. [CrossRef] [PubMed]
 
Heffner JE, Heffner JN, Brown LK. Multilevel and continuous pleural fluid pH likelihood ratios for evaluating malignant pleural effusions. Chest. 2003;123(6):1887-1894. [CrossRef] [PubMed]
 
Heffner JE, Nietert PJ, Barbieri C. Pleural fluid pH as a predictor of pleurodesis failure: analysis of primary data. Chest. 2000;117(1):87-95. [CrossRef] [PubMed]
 
Sanchez-Armengol A, Rodriguez-Panadero F. Survival and talc pleurodesis in metastatic pleural carcinoma, revisited. Report of 125 cases. Chest. 1993;104(5):1482-1485. [CrossRef] [PubMed]
 
Heffner JE, Nietert PJ, Barbieri C. Pleural fluid pH as a predictor of survival for patients with malignant pleural effusions. Chest. 2000;117(1):79-86. [CrossRef] [PubMed]
 
Burrows CM, Mathews WC, Colt HG. Predicting survival in patients with recurrent symptomatic malignant pleural effusions: an assessment of the prognostic values of physiologic, morphologic, and quality of life measures of extent of disease. Chest. 2000;117(1):73-78. [CrossRef] [PubMed]
 
Gottehrer A, Taryle DA, Reed CE, Sahn SA. Pleural fluid analysis in malignant mesothelioma. Prognostic implications. Chest. 1991;100(4):1003-1006. [CrossRef] [PubMed]
 
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