Pleural Diseases

Pleural effusion:

Light RW, MacGregor MI, Luchsinger PC, et al. Pleural effusions: the diagnostic separation of transudates and exudates. Ann Intern Med 1972;77:507-13. This paper is the basis for using pleural fluid LDH and protein to classify effusions as transudative or exudative.
PMID: 4642731

Lentz RJ, Lerner AD, Pannu JK, et al. Routine monitoring with pleural manometry during therapeutic large-volume thoracentesis to prevent pleural-pressure-related complications: a multicentre, single-blind randomised controlled trial. Lancet Respir Med. 2019; 7:447-455. This study randomized 124 patients with free-flowing effusions with estimated volume > 500 ml (63% with malignant effusion) to thoracentesis drainage based on symptoms alone vs. symptoms plus pleural manometry. There was no significant difference in chest discomfort, volume of fluid drained, proportion of patients with complete lung expansion, or clinically significant complications. Of note, the mean volume of fluid drained was 1,100 ml (SD 500 ml) and patients with known re-expandable lung, such as those with a large hepatic hydrothorax, were excluded.
PMID: 30772283

Pleural infection:

Rahman NM, Maskell NA, West A et al. Intrapleural use of tissue plasminogen activator and DNase in pleural infection. N Engl J Med. 2011;365:518-26. Randomized double blinded trial of 210 patients found an 8% greater reduction in the proportion of the hemithorax occupied by pleural fluid on chest radiograph with tissue plasminogen activator (TPA) and DNAse administered intrapleurally compared to placebo. TPA and DNAse used in isolation did not differ from placebo. Patients receiving placebo were more likely to be referred to surgery than the TPA-DNAse group, but the rate of surgical intervention and mortality did not differ.
PMID: 21830966
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Malignant pleural effusion:

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; 198:839-849.
PMID: 30272503
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Thomas R, Fysh ETH, Smith NA, et al. Effect of an indwelling pleural catheter vs talc pleurodesis on hospitalization days in patients with malignant pleural effusion: The AMPLE randomized clinical trial. JAMA. 2017; 318:1903-1912. Trial of 146 patients with symptomatic malignant pleural effusion randomized to either indwelling pleural catheters (IPC) or talc pleurodesis and followed for up to 12 months. The IPC group spent significantly fewer days in hospital than the pleurodesis group (10.0 vs 12.0; P = .03) but without significant differences in improvements in breathlessness or quality of life.
PMID: 29164255
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Bhatnagar R, Piotrowska H, Laskawiec-Szkonter M, et al. Effect of thoracoscopic talc poudrage vs talc slurry via chest tube on pleurodesis failure rate among patients with malignant pleural effusions: a randomized clinical trial. JAMA 2020; 323:60-69. Open label clinical trial randomized 330 patients with malignant pleural effusion to receive talc poudrage during thoracoscopy versus bedside chest tube insertion followed by talc slurry. At 90 days, pleurodesis failure occurred in 22% of talc poudrage group versus 24% in talc slurry group (p=0.74).
PMID: 31804680
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Spontaneous pneumothorax:

MacDuff A, Arnold A, Harvey J for the British Thoracic Society Pleural Disease Guideline Group. Management of spontaneous pneumothorax: British Thoracic Society pleural disease guideline 2010. Thorax 2010;65(Suppl 2):ii18-ii31
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Hallifax RJ, McKeown E, Sivakumar P, et al. Ambulatory management of primary spontaneous pneumothorax: an open-label, randomised controlled trial. Lancet. 2020; 396:39-49. This study randomized 236 patients with primary spontaneous pneumothorax to either placement of an 8F catheter attached to a one-way valve followed by discharge if there was insufficient lung re-expansion vs. management based on BTS guidelines above. Enrollment criteria included pneumothorax > 2 cm from chest wall at the level of the hilum and/or significant symptoms. Although 12% of the ambulatory group subsequently required admission for a serious adverse event, this group overall had a lower median number of hospital days (0 days [IQR 0 – 3] vs. 4 days [IQR 0 -8]; p<0.0001).
PMID 32622394
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Brown SGA, Ball EL, Perrin K, et al. Conservative versus interventional treatment for spontaneous pneumothorax. N Engl J Med. 2020; 382:405-415. This trial randomized 316 patients with primary spontaneous pneumothorax > 32% of the hemithorax and without severe distress to conservative vs. interventional management. Conservative management entailed discharge if symptoms, pneumothorax size, and room air oxygen saturations were stable after 4 hours of observation. The intervention group received a small-bore catheter and were admitted unless the tube could be removed after 4 hours based on full lung re-expansion and absence of an air leak. In the conservative group, 85% did not require an intervention and, if excluding the 19% of patients lost to follow-up, conservative was non-inferior to interventional management (94.4% vs. 98.5% complete reexpansion at 8 weeks, respectively, p = 0.02).
PMID: 31995689