What is the preferred treatment for recurrent or large pleural effusions, pleural catheter or thoracentesis?

From the Guidelines

For recurrent or large pleural effusions, indwelling pleural catheters are generally preferred over repeated thoracentesis, as they provide continuous drainage, better symptom control, and fewer hospital visits. This recommendation is based on the most recent and highest quality study, which suggests that either an indwelling pleural catheter (IPC) or chemical pleurodesis be used as first-line definitive pleural intervention for management of dyspnea in patients with symptomatic malignant pleural effusions (MPE) with known or likely suspected expandable lung, and no prior definitive therapy 1.

Key Considerations

• Indwelling pleural catheters allow patients to manage drainage at home, improving quality of life and reducing healthcare utilization.
• They are particularly beneficial for malignant effusions where pleurodesis may not be successful or in patients with trapped lung.
• Thoracentesis remains useful for initial diagnosis and symptom relief but is less suitable as a long-term management strategy due to the risks associated with repeated procedures, including pneumothorax, bleeding, and infection.
• The choice between these options should consider the underlying cause of the effusion, patient's life expectancy, functional status, and preferences.

Patient Education and Care

• Patients with pleural catheters should be educated about proper care, drainage techniques, and signs of complications such as infection or catheter blockage.
• Regular follow-up is necessary to monitor the patient's condition and adjust the treatment plan as needed.

Evidence Summary

The American Thoracic Society (ATS) and Society of Thoracic Surgeons (STS) clinical practice guideline recommends the use of IPCs over chemical pleurodesis in patients with symptomatic malignant pleural effusions with nonexpandable lung, failed pleurodesis, or loculated effusion 1. Additionally, a study published in the Journal of Clinical Oncology suggests that pleurodesis is most effective with a sclerosing agent, and that talc is the most effective sclerosing agent 1. However, the most recent guideline from the ATS/STS/STR takes precedence in guiding clinical practice 1.

From the Research

Pleural Catheter versus Thoracentesis

The treatment of recurrent or large pleural effusions can be managed with either a pleural catheter or thoracentesis. The choice between these two options depends on various factors, including the patient's condition, the underlying cause of the pleural effusion, and the patient's quality of life.

Advantages of Pleural Catheter

• A pleural catheter, such as the PleurX catheter, provides a simple and effective way to manage recurrent malignant pleural effusions, allowing for drainage of the pleural fluid at home 2, 3, 4.
• The use of a pleural catheter has been shown to improve the quality of life of patients with malignant pleural effusions, reducing the need for repeated hospital visits and thoracenteses 2, 3.
• Pleural catheters can also be used to treat non-malignant pleural effusions, providing a viable alternative to repeated thoracenteses 4.

Complications and Limitations

• The use of a pleural catheter is not without complications, including infection, dislocation of the catheter, and blockage of the catheter 2, 5, 3.
• The insertion of a pleural catheter may be contraindicated in patients with certain medical conditions, such as pleural infection 5.

Comparison with Thoracentesis

• Thoracentesis is a procedure that involves the removal of pleural fluid using a needle or catheter, and is often used to diagnose and treat pleural effusions 6.
• While thoracentesis can provide temporary relief, it may not be as effective as a pleural catheter in managing recurrent pleural effusions, particularly in patients with malignant pleural effusions 2, 6.
• The use of a small percutaneous catheter, such as the Cystofix catheter, has been shown to be effective in performing pleurodesis, with less discomfort for the patient compared to a large-bore chest tube 6.

Clinical Evidence

• Studies have demonstrated the efficacy and safety of pleural catheters in the treatment of recurrent pleural effusions, with complication rates ranging from 12% to 19% 2, 3.
• The use of pleural catheters has been shown to improve the quality of life of patients with malignant pleural effusions, with mean survival times ranging from 2.3 to 25 weeks after catheter insertion 2, 3.