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Maree Azzopardi, MBBS; Edward T. H. Fysh, MBBS; Y. C. Gary Lee, MBChB, PhD, FCCP
Author and Funding Information

From Respiratory Medicine, Sir Charles Gairdner Hospital, Western Australia; and Centre for Asthma, Allergy and Respiratory Research and School of Medicine and Pharmacology, The University of Western Australia.

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

FINANCIAL/NONFINANCIAL DISCLOSURES: The authors have reported to CHEST the following conflicts of interest: Dr Fysh received postgraduate scholarships from the National Health and Medical Research Council (NHMRC) and Lung Institute of Western Australia (LIWA) to undertake this work and project funding from the New South Wales Dust Disease Board (DDB) and Cancer Council Western Australia. Dr Lee is a NHMRC Career Development Fellow and receives project grant funding from the NHMRC, DDB, Sir Charles Gairdner Research Advisory Committee, LIWA Westcare grants, and the Cancer Council Western Australia. Dr Lee is on the advisory board of CareFusion and Sequana Medical and was a coinvestigator of the TIME-2 trial in which the indwelling catheters were provided without charge by Rocket Medical plc. Dr Azzopardi has reported that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

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):e233. doi:10.1378/chest.15-0558
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To the Editor:

Malignant pleural effusion (MPE) is a significant health-care burden. However, the care needs of individual patients vary. Some patients have rapid recurring MPEs with significant symptoms requiring definitive therapy (including pleurodesis or indwelling pleural catheter placement); in others, the effusion may recur slowly or not at all. The ability to identify early those patients who need definitive therapy can potentially allow more efficient care. Our study in this issue of CHEST1 found pleural fluid pH, large effusions, age, and mesothelioma to be associated with a greater likelihood of the patient receiving definitive therapy (defined as pleurodesis or indwelling pleural catheter treatment).

We thank Dr Boshuizen and colleagues for sharing their data and are glad to read that they had similar findings in their cohort. Importantly, they also found that only about one-half (45% in their study and 54% in ours) of the patients with MPE underwent definitive treatment, further highlighting the usefulness of a predictive tool. Dr Boshuizen and colleagues also found a higher pleural fluid protein level to be a predictor, similar to our finding on univariate analysis (OR, 1.03; P < .05). Both studies also identified age as a (weak) predictor. Our study identified pleural fluid pH as the most important predictor. Unfortunately, pH was not captured in the study of Dr Boshuizen and colleagues.

Our study did not intend to determine if the decision for definitive treatment was correct, but rather to identify trends in clinical practice that may then help guide physicians in the early initiation of treatment. We agree with Dr Boshuizen and colleagues that improvement in dyspnea following pleural fluid drainage is and should be the main factor influencing the decision to proceed with definitive therapy. Large prospective multinational databases/registries are essential to help answer important management questions in MPE.


Fysh ETH, Bielsa S, Budgeon CA, et al. Predictors of clinical use of pleurodesis and/or indwelling pleural catheter therapy for malignant pleural effusion. Chest. 2015;147(6):1629-1634.




Fysh ETH, Bielsa S, Budgeon CA, et al. Predictors of clinical use of pleurodesis and/or indwelling pleural catheter therapy for malignant pleural effusion. Chest. 2015;147(6):1629-1634.
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