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Point and Counterpoint |

Rebuttal From Drs Lee and Feller-KopmanRebuttal From Drs Lee and Feller-Kopman FREE TO VIEW

Hans J. Lee, MD, FCCP; David J. Feller-Kopman, MD, FCCP
Author and Funding Information

From the Section of Interventional Pulmonology, Division Pulmonary and Critical Care, Johns Hopkins University.

CORRESPONDENCE TO: Hans J. Lee, MD, FCCP, The Johns Hopkins Hospital, 1800 Orleans St, Zayed Bldg 7125L, Baltimore, MD 21287; e-mail: hlee171@jhmi.edu


FINANCIAL/NONFINANCIAL DISCLOSURES: The authors have reported to CHEST the following conflicts: Dr Feller-Kopman has received consulting fees from CareFusion Inc. This editorial reflects Dr Feller-Kopman’s independent thoughts regarding the use of small-bore catheters in the treatment of pleural effusions. Dr Lee reports 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):13-14. doi:10.1378/chest.15-0425
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We compliment Drs Gillespie and DeCamp1 on their insightful thoughts on the topic of small- vs large-bore catheters for the management of malignant pleural effusions. Although their criticism of the existing literature in support of small-bore catheters is fair, there has been no mention of citations supporting large-bore catheters. Assuming no difference in benefit between catheter sizes, which would we choose as a patient if both are equally effective? Our personal opinion would be the smaller catheter, which requires the smallest incision and is functional. Although there are no large, prospective, head-to-head comparative studies, there are data from large prospective trials using small-bore catheters for chemical pleurodesis (including talc).2,3 In one prospective study using 12F catheters, 52 patients had talc pleurodesis with no reports of failure of the procedure due to catheter occlusion.3 Additionally, Drs Gillespie and DeCamp1 make a distinction saying that tunneled pleural catheters should be considered large bore because most of the literature defines small bore as ≤ 14F. Although this may be true, it does not get to the intent of the differentiation between large and small, and we would argue that the 0.48-mm difference in the diameter between a 14F and 15.5F catheter is clinically irrelevant.

Although Drs Gillespie and DeCamp1 nicely summarize the limitations of the studies leading to the British Thoracic Society recommendations for the use of small-bore tubes, they are missing the forest for the trees. As they point out, the fact is that no data suggest inferiority with the most commonly used sizes of small-bore tubes (12F-15.5F), and no data suggest superiority with larger-bore tubes.

A common theme in the argument of Drs Gillespie and DeCamp1 is that one size may not fit all situations, a general truth in medicine. However, a singular goal is palliation for the management of malignant pleural effusion. The basic understanding that a smaller incision and less tissue dissection is more comfortable than a larger incision and more tissue dissection is clear without a large clinical trial. But all therapies do not need a randomized controlled trial to illustrate their efficacy. This point may have been best illustrated satirically by the fact that there has never been a comparative study on the efficacy of parachutes when leaping from a plane.4 Multiple observational studies using small-bore catheters have shown their efficacy in draining effusions and chemical pleurodesis. When both of us showed the picture in Figure 1 to our sons (aged 7 and 11 years) and asked, “If Daddy had to put one of these tubes in between your ribs, which would you want,” both chose the small-bore tube. We would ask the same question to Drs Gillespie and DeCamp.

Figure Jump LinkFigure 1 –  Small-bore (14F) pigtail and large-bore (24F) chest tubes.Grahic Jump Location

References

Gillespie CT, DeCamp MM. Counterpoint: should small-bore pleural catheter placement be the preferred initial management for malignant pleural effusions? No. Chest. 2015;148(1):11-13.
 
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]
 
Agarwal R, Paul AS, Aggarwal AN, Gupta D, Jindal SK. A randomized controlled trial of the efficacy of cosmetic talc compared with iodopovidone for chemical pleurodesis. Respirology. 2011;16(7):1064-1069. [CrossRef] [PubMed]
 
Smith GC, Pell JP. Parachute use to prevent death and major trauma related to gravitational challenge: systematic review of randomised controlled trials. BMJ. 2003;327(7429):1459-1461. [CrossRef] [PubMed]
 

Figures

Figure Jump LinkFigure 1 –  Small-bore (14F) pigtail and large-bore (24F) chest tubes.Grahic Jump Location

Tables

References

Gillespie CT, DeCamp MM. Counterpoint: should small-bore pleural catheter placement be the preferred initial management for malignant pleural effusions? No. Chest. 2015;148(1):11-13.
 
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]
 
Agarwal R, Paul AS, Aggarwal AN, Gupta D, Jindal SK. A randomized controlled trial of the efficacy of cosmetic talc compared with iodopovidone for chemical pleurodesis. Respirology. 2011;16(7):1064-1069. [CrossRef] [PubMed]
 
Smith GC, Pell JP. Parachute use to prevent death and major trauma related to gravitational challenge: systematic review of randomised controlled trials. BMJ. 2003;327(7429):1459-1461. [CrossRef] [PubMed]
 
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