ATS guideline for managing patients with malignant pleural effusion

Reference

Feller-Kopman DJ, Reddy CB, DeCamp MM, et al. Management of malignant pleural effusions. An official ATS/STS/STR clinical practice guideline. Am J Respir Crit Care Med 2018;198(7):839-849.

Synopsis

The American Thoracic Society assembled a multidisciplinary group that included clinicians experienced in managing patients with malignant pleural effusion and guideline methodologists. They also had 2 patients with malignant pleural effusion and their primary caregivers provide insight about patient-oriented outcomes and review the manuscript. The guideline development process began with a delineation of the explicit questions to be addressed, followed by a systematic review of various databases, assessment of the underlying quality of the research, and a synthesis of the relevant evidence. Based on observational studies only, the team found the pooled rate of pneumothorax was 4% in patients with ultrasound-guided thoracentesis compared with 9% in those treated without ultrasound. Overall, approximately one-third of patients with a pneumothorax required chest tubes. The reviewers found 2 studies of patients with asymptomatic malignant pleural effusion, neither of which provided evidence that treating asymptomatic effusions improved patient outcomes. The team found no studies that directly compared large-volume thoracentesis and pleural manometry for guiding treatment, but recommended using large-volume thoracentesis to determine if the fluid volume is the cause of symptoms. They found 10 studies (observational studies and clinical trials) including 1279 patients that showed comparable outcomes for chemical pleurodesis and indwelling pleural catheters (IPCs). The single observational study of patients with nonexpandable lungs found that patients treated with IPCs had shorter hospitalizations. For patients who develop IPC-related infections, the team found 6 case series studies, none of which provided any data suggesting that IPC removal was better or worse than keeping it.