Can a malignant pleural effusion be drained?

Management of Malignant Pleural Effusions

Yes, malignant pleural effusions should be drained to provide symptomatic relief, but the approach must be tailored based on patient factors, effusion characteristics, and expected survival. 1

Initial Assessment and Management Options

• Observation is recommended if the patient is asymptomatic or has no recurrence of symptoms after initial thoracentesis 1, 2
• For symptomatic patients with recurrent malignant pleural effusions, consultation with a thoracic malignancy multidisciplinary team is recommended 1
• Therapeutic pleural aspiration provides transient relief of breathlessness and is appropriate for patients with very short life expectancy or poor performance status 1, 2
• Drainage volume should be guided by patient symptoms and generally limited to 1-1.5 L at a single time to reduce the risk of re-expansion pulmonary edema 1, 3
• Aspiration should be discontinued if the patient develops chest discomfort, persistent cough, or vasovagal symptoms 1, 3

Definitive Management Approaches

1. Chemical Pleurodesis

• Talc is the most effective pleurodesis agent with success rates approaching 90% 1
• Small bore tubes (10-14 F) should be considered initially for drainage of malignant effusions due to reduced patient discomfort and comparable success rates to large bore tubes 1, 3
• Once effusion drainage and lung re-expansion have been radiographically confirmed, pleurodesis should not be delayed 1
• Premedication with intrapleural lignocaine (3 mg/kg; maximum 250 mg) should be administered just prior to sclerosant administration 1

2. Indwelling Pleural Catheters (IPCs)

• IPCs are an effective alternative for controlling recurrent and symptomatic malignant effusions, particularly in patients with trapped lung or failed pleurodesis 1
• IPCs reduce hospitalization time compared to chemical pleurodesis (0-1 days versus 4-6.5 days) 1
• Daily IPC drainage increases pleurodesis rates when compared with alternate drainage or symptom-based drainage regimes 1
• Patients should be advised that they do not require daily drainage to control symptoms of breathlessness and chest pain if they wish to opt for a less intensive regime 1

3. Thoracoscopy

• Thoracoscopy should be considered for both diagnosis of suspected but unproven malignant pleural effusion and for control of recurrent malignant pleural effusion 1
• Talc poudrage via thoracoscopy has high success rates (90%) and is a safe procedure with low complication rates 1
• The role of surgical thoracoscopy in patients with trapped lung is less clear but can facilitate breaking up of loculations and release of adhesions 1

Special Considerations

• In patients where only partial pleural apposition can be achieved, chemical pleurodesis should still be attempted and may provide symptomatic relief 1
• For loculated malignant pleural effusions, intrapleural fibrinolytic treatment may decrease pleurodesis failure rate and improve breathlessness compared to no treatment 1
• Pleuroperitoneal shunts are an alternative and effective option in patients with a trapped lung or failed pleurodesis 1
• Repeat pleural aspiration has a recurrence rate close to 100% at 1 month and should only be used for palliation in patients with very limited life expectancy 1

Complications and Their Management

• Re-expansion pulmonary edema is a rare but potentially life-threatening complication following rapid evacuation of large amounts of pleural fluid 1, 3
• Complication rates are higher with IPCs (14-30%) compared to talc pleurodesis, with local cellulitis being most common 1
• Suction is usually unnecessary for pleural drainage but if applied, a high volume, low pressure system is recommended with gradual increment in pressure to about -20 cm H₂O 1, 3

Decision Algorithm

1. Assess patient symptoms and life expectancy:

   • Asymptomatic → Observation 1
   • Very short life expectancy → Therapeutic pleural aspiration 1
   • Symptomatic with longer life expectancy → Proceed to definitive management 1

2. Evaluate for trapped lung:

   • If trapped lung present → Consider IPC or pleuroperitoneal shunt 1
   • If no trapped lung → Consider chemical pleurodesis or IPC based on patient preference 1

3. Consider patient mobility and support system:

   • Good support system and preference for outpatient management → IPC 1
   • Limited support or preference for inpatient procedure → Chemical pleurodesis 1