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Point and Counterpoint |

COUNTERPOINT: Should Small-Bore Pleural Catheter Placement Be the Preferred Initial Management for Malignant Pleural Effusions? NoSmall Pleural Catheter First Choice to Manage? No FREE TO VIEW

Colin T. Gillespie, MD; Malcolm M. DeCamp, MD, FCCP
Author and Funding Information

From the Division of Pulmonary and Critical Care Medicine (Dr Gillespie), Division of Thoracic Surgery (Dr DeCamp), and Robert H. Lurie Comprehensive Cancer Center (Dr DeCamp), Northwestern University Feinberg School of Medicine.

CORRESPONDENCE TO: Malcolm M. DeCamp, MD, FCCP, Division of Thoracic Surgery, Northwestern Memorial Hospital, 676 N St Clair St, Ste 650, Chicago, IL 60611; e-mail: mdecamp@nmh.org


FINANCIAL/NONFINANCIAL DISCLOSURES: The authors have reported to CHEST 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;148(1):11-13. doi:10.1378/chest.15-0426
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The question posed by the editorial staff at CHEST seems simple and straightforward, but unfortunately, its answer is complex. If a discreet dichotomous response is required, then our answer would be no. The essence of the question is small- vs large-bore chest tubes in the management of malignant pleural effusion (MPE). We contend that MPE represents a heterogeneous problem without a one-size-fits-all approach. Not all malignant effusions or the patients with them are the same, and much work needs to be done to sort out optimal management.

The role of tunneled pleural catheters is not going to be addressed here because that debate has already been conducted in this Journal.1,2 Furthermore, as a 15.5F tube, the tunneled pleural catheter would not qualify as a small-bore chest tube (SBCT), which is typically defined at ≤ 14F.

For most of the past 80 years, the treatment of MPEs has been static, with management focused on how best to ablate the pleural space to prevent the reaccumulation of pleural fluid.3 Large-bore chest tube drainage has been a cornerstone of management strategies throughout this time.4 Frustration with the inertia that has defined MPE management is understandable, but the burgeoning enthusiasm for newer approaches should be tempered by an honest assessment of the literature and continued well-designed clinical investigation.

The diversity of chest drains is increasing, with various sizes, shapes (straight and pigtailed), and insertion techniques (the classic blunt dissection, trocar, and Seldinger). In the early 1990s, a university-based health-care system identified 7% of chest tubes placed to be small bore.5 The ease of insertion of many of these tubes and familiarity with Seldinger technique-based procedures has fostered an increased interest among pulmonologists, interventional radiologists, and hospital-based physicians with increasing use and broad application. Seldinger-placed small-bore tubes have become the most common mode of chest drain insertion in the United Kingdom.6 Despite this popularity, there is a paucity of quality data looking at specific tube characteristics and their effect on disease management.

The British Thoracic Society (BTS) guidelines on the management of MPE published in 2010 represent the most comprehensive review of the subject currently in print.7 Its recommendation advocates for preferential use of small-bore tubes in MPE. Three studies are cited as the primary data behind this recommendation and are described as randomized controlled trials investigating the difference in efficacy between large- and small-bore tubes. These guidelines and the three referenced sources subsequently have been cited by multiple reviews of topics related to the subject.8-10 On close review, each source article referenced in the BTS guidelines has notable limitations, which should give pause to this recommendation. Each is worth reviewing here.

The first and most notable oversight is the study by Parulekar et al,11 which was the largest of the studies presented as evidence (N = 102) for the BTS recommendation. In the BTS guideline, this study was noted to be a randomized trial. However, on review, it is clearly nothing of the sort. The abstract of the article plainly classifies it as a retrospective review, not as a randomized trial. Only patients on whom complete records could be identified were included in the analysis and article. To further confound the difficulties and inherent selection bias of a study like this, only 55% of the patients with MPE included actually had cytologic confirmation of MPE. The other 45% were included on the basis of the absence of some other identifiable etiology for the effusion.

The remaining two studies,12,13 and the only actual prospective randomized trials, compared small- and large-bore tubes in a total of 64 patients. The trial by Caglayan et al12 compared 32F chest tubes with an 8F catheter and their performance during iodopovidone pleurodesis. The study ultimately comprised 41 patients; the response rate at 3 months was 90% in the large-bore group and 86.9% in the small-bore group. This study defined success as a combination of dyspneic and radiographic improvements. Overall, no significant difference was found in the two groups, including pain, an often-cited advantage to SBCTs.

The study by Clementsen et al13 started with 21 patients, of whom 18 were included in the final analysis with nine in each group. The patients who received the large-bore tubes had them inserted as part of medical thoracoscopy, whereas the small-bore tubes were inserted directly. Tetracycline was the sclerosant used in this trial. No radiographic difference was found in the two groups after tetracycline pleurodesis. An approximate 70% success rate was noted.

Part of the problem in reconciling the question debated here is the scope of the management process for MPE and transitioning from therapeutic aspiration to pleurodesis for symptomatic effusions. The thoracentesis literature demonstrates that very-small-bore devices can successfully drain even large effusions with improvement in dyspnea, so fluid removal is not the problem.14 Therefore, the crux of the issue behind this debate between large- and small-bore chest tubes is how the tube is used to achieve long-term palliation of the patient’s symptoms, and that leads us to the thorny issue of pleurodesis. “The principle of pleurodesis by chemical irritation…seems well established, even though there is as yet no agreement about the most suitable agent for this purpose.”15 This quote, taken from a paper written in 1948, continues to resonate today.

As in 1948, the intrapleural instillation of some sclerosant remains the most common maneuver in an effort to obliterate the pleural space. The available combinations of various sclerosing agents and tube sizes are dizzying. A Cochrane review on the subject supported talc as the sclerosant, with the most evidence behind its use.16 Neither of the randomized controlled trials selected for the BTS recommendation advocating small-bore chest tube management of MPE used talc. The diversity of agents, with the majority of SBCT pleurodesis studies using sclerosants other than talc, renders comparison with historic larger-bore chest drain experiences difficult.

In 1999, Marom et al17 presented their prospective series of SBCTs followed by talc pleurodesis. The results, although provocative, leave much to be desired. The absence of reaccumulation of pleural fluid defined a successful pleurodesis in this study. No assessment of dyspnea was performed. The final analysis was limited by the 32% mortality within the 30-day postpleurodesis follow-up window and the additional 15% of enrolled patients lost to follow-up and not included in the analysis. Catheter clogging is another concern with talc pleurodesis through SBCTs, and this was anticipated in the Methods section of the study by Marom et al,17 which mandated flushing of the catheter tid. Unfortunately, this issue was never mentioned in the Results or Discussion sections. How often is catheter occlusion a problem?

Management of MPE is a problem now receiving considerable attention compared with historical precedent. Although the quality of investigation focused on MPE has improved with more prospective randomized trials published in the past 10 years than the prior 70, the optimal approach for MPE treatment remains unclear. Our recommendation fits with the current theme of personalized medicine that permeates thoracic oncology practice today. Multiple options from large- and small-bore tube pleurodesis to multiple sclerosants, indwelling pleural catheters, and thoracoscopy are available. Treatment strategies should consider and address performance status, survival expectations, extent of dyspnea, quality of life, availability of social supports, cost, and patient preference. The literature does not support any one approach as optimal. Further well-designed studies will be crucial to define best practices, create appropriate treatment algorithms, and where possible, standardize care for this difficult problem.

References

Lee P. Point: should thoracoscopic talc pleurodesis be the first choice management for malignant effusion? Yes. Chest. 2012;142(1):15-17. [PubMed]
 
Light RW. Counterpoint: should thoracoscopic talc pleurodesis be the first choice management for malignant pleural effusion? No. Chest. 2012;142(1):17-19. [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]
 
Parker LA, Charnock GC, Delany DJ. Small bore catheter drainage and sclerotherapy for malignant pleural effusions. Cancer. 1989;64(6):1218-1221. [CrossRef] [PubMed]
 
Collop NA, Kim S, Sahn SA. Analysis of tube thoracostomy performed by pulmonologists at a teaching hospital. Chest. 1997;112(3):709-713. [CrossRef] [PubMed]
 
Havelock T, Teoh R, Laws D, Gleeson F; BTS Pleural Disease Guideline Group. Pleural procedures and thoracic ultrasound: British Thoracic Society pleural disease guideline 2010. Thorax. 2010;65(suppl 2):ii61-ii76. [CrossRef] [PubMed]
 
Roberts ME, Neville E, Berrisford RG, Antunes G, Ali NJ; BTS Pleural Disease Guideline Group. Management of a malignant pleural effusion: British Thoracic Society pleural disease guideline 2010. Thorax. 2010;65(suppl 2):ii32-ii40. [CrossRef] [PubMed]
 
Mahmood K, Wahidi MM. Straightening out chest tubes: what size, what type, and when. Clin Chest Med. 2013;34(1):63-71. [CrossRef] [PubMed]
 
Light RW. Pleural controversy: optimal chest tube size for drainage. Respirology. 2011;16(2):244-248. [CrossRef] [PubMed]
 
Thomas R, Francis R, Davies HE, Lee YC. Interventional therapies for malignant pleural effusions: the present and the future. Respirology. 2014;19(6):809-822. [CrossRef] [PubMed]
 
Parulekar W, Di Primio G, Matzinger F, Dennie C, Bociek G. Use of small-bore vs large-bore chest tubes for treatment of malignant pleural effusions. Chest. 2001;120(1):19-25. [CrossRef] [PubMed]
 
Caglayan B, Torun E, Turan D, et al. Efficacy of iodopovidone pleurodesis and comparison of small-bore catheter versus large-bore chest tube. Ann Surg Oncol. 2008;15(9):2594-2599. [CrossRef] [PubMed]
 
Clementsen P, Evald T, Grode G, Hansen M, Krag Jacobsen G, Faurschou P. Treatment of malignant pleural effusion: pleurodesis using a small percutaneous catheter. A prospective randomized study. Respir Med. 1998;92(3):593-596. [CrossRef] [PubMed]
 
Feller-Kopman D, Berkowitz D, Boiselle P, Ernst A. Large-volume thoracentesis and the risk of reexpansion pulmonary edema. Ann Thorac Surg. 2007;84(5):1656-1661. [CrossRef] [PubMed]
 
Spontaneous pneumothorax. Br Med J. 1948;2(4585);:908-909. [CrossRef] [PubMed]
 
Shaw P, Agarwal R. Pleurodesis for malignant pleural effusions. Cochrane Database Syst Rev. 2004;;(1):CD002916.
 
Marom EM, Patz EF Jr, Erasmus JJ, McAdams HP, Goodman PC, Herndon JE. Malignant pleural effusions: treatment with small-bore-catheter thoracostomy and talc pleurodesis. Radiology. 1999;210(1):277-281. [CrossRef] [PubMed]
 

Figures

Tables

References

Lee P. Point: should thoracoscopic talc pleurodesis be the first choice management for malignant effusion? Yes. Chest. 2012;142(1):15-17. [PubMed]
 
Light RW. Counterpoint: should thoracoscopic talc pleurodesis be the first choice management for malignant pleural effusion? No. Chest. 2012;142(1):17-19. [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]
 
Parker LA, Charnock GC, Delany DJ. Small bore catheter drainage and sclerotherapy for malignant pleural effusions. Cancer. 1989;64(6):1218-1221. [CrossRef] [PubMed]
 
Collop NA, Kim S, Sahn SA. Analysis of tube thoracostomy performed by pulmonologists at a teaching hospital. Chest. 1997;112(3):709-713. [CrossRef] [PubMed]
 
Havelock T, Teoh R, Laws D, Gleeson F; BTS Pleural Disease Guideline Group. Pleural procedures and thoracic ultrasound: British Thoracic Society pleural disease guideline 2010. Thorax. 2010;65(suppl 2):ii61-ii76. [CrossRef] [PubMed]
 
Roberts ME, Neville E, Berrisford RG, Antunes G, Ali NJ; BTS Pleural Disease Guideline Group. Management of a malignant pleural effusion: British Thoracic Society pleural disease guideline 2010. Thorax. 2010;65(suppl 2):ii32-ii40. [CrossRef] [PubMed]
 
Mahmood K, Wahidi MM. Straightening out chest tubes: what size, what type, and when. Clin Chest Med. 2013;34(1):63-71. [CrossRef] [PubMed]
 
Light RW. Pleural controversy: optimal chest tube size for drainage. Respirology. 2011;16(2):244-248. [CrossRef] [PubMed]
 
Thomas R, Francis R, Davies HE, Lee YC. Interventional therapies for malignant pleural effusions: the present and the future. Respirology. 2014;19(6):809-822. [CrossRef] [PubMed]
 
Parulekar W, Di Primio G, Matzinger F, Dennie C, Bociek G. Use of small-bore vs large-bore chest tubes for treatment of malignant pleural effusions. Chest. 2001;120(1):19-25. [CrossRef] [PubMed]
 
Caglayan B, Torun E, Turan D, et al. Efficacy of iodopovidone pleurodesis and comparison of small-bore catheter versus large-bore chest tube. Ann Surg Oncol. 2008;15(9):2594-2599. [CrossRef] [PubMed]
 
Clementsen P, Evald T, Grode G, Hansen M, Krag Jacobsen G, Faurschou P. Treatment of malignant pleural effusion: pleurodesis using a small percutaneous catheter. A prospective randomized study. Respir Med. 1998;92(3):593-596. [CrossRef] [PubMed]
 
Feller-Kopman D, Berkowitz D, Boiselle P, Ernst A. Large-volume thoracentesis and the risk of reexpansion pulmonary edema. Ann Thorac Surg. 2007;84(5):1656-1661. [CrossRef] [PubMed]
 
Spontaneous pneumothorax. Br Med J. 1948;2(4585);:908-909. [CrossRef] [PubMed]
 
Shaw P, Agarwal R. Pleurodesis for malignant pleural effusions. Cochrane Database Syst Rev. 2004;;(1):CD002916.
 
Marom EM, Patz EF Jr, Erasmus JJ, McAdams HP, Goodman PC, Herndon JE. Malignant pleural effusions: treatment with small-bore-catheter thoracostomy and talc pleurodesis. Radiology. 1999;210(1):277-281. [CrossRef] [PubMed]
 
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