Selection of outcomes was done by a panel of experts who were part of the ATS guideline committee for the management of MPEĮlectronic literature searches and data extractions were conducted by Doctor Evidence, a medical evidence software and services company, using their proprietary software platform (Doctor Evidence, 2018: DOC Library, DOC Data, version 2.0 Doctor Evidence, LLC). Outcomes: Improvement in dyspnea, survival, mortality, hospital length of stay (LOS) treatment failure as measured by the need for additional pleural interventions (preferred) or radiologic/clinical criteria and adverse events such as cellulitis, pleural infection, and bleeding requiring intervention. We synthesized the best available evidence for the following Population, Intervention, Comparator, and Outcome (PICO) question: As part of the American Thoracic Society (ATS) clinical practice guidelines for malignant pleural effusions, we performed a systematic review and meta-analysis to examine the patient-centered outcomes with the use of tunneled pleural catheter versus chemical pleurodesis as the first-line treatment of MPE ( 6). The publication of several randomized controlled trials (RCTs) comparing IPC with chemical pleurodesis has mandated a reassessment of existing evidence. Indwelling pleural catheters (IPCs) have been successfully used for ongoing control of MPE, especially when survival of months to a few years is expected. Pleurodesis generally requires inpatient hospitalization and when done using thoracoscopy, often necessitates the use of general anesthesia. However, pleurodesis fails within a few months in a substantial proportion of patients ( 4, 5). For several decades, management has focused on chemical pleurodesis using various agents such as doxycycline, talc, and bleomycin ( 1). This has often been interpreted to support the use of the least intrusive intervention that is both effective and has minimal adverse effects. Generally considered a manifestation of terminal malignancy, the main goal of treatment is to palliate and provide symptom relief ( 3). Symptoms of MPE include often debilitating breathlessness, chest pain, and constitutional symptoms such as anorexia and weight loss. The annual incidence of MPE in the United States is estimated to be greater than 150,000, and MPE accounts for 42–77% of all exudative effusions in adults ( 2). Malignant pleural effusions (MPEs) affect a significant proportion of patients with cancer ( 1). Careful assessment of individual patient preferences and costs should be considered when choosing between IPC and pleurodesis. No differences were noted in other adverse events.Ĭonclusions: Compared with chemical pleurodesis, IPC results in shorter hospital length of stay and fewer repeat pleural procedures but carries a higher risk of cellulitis. However, the risk of cellulitis was higher with IPC (RR, 5.83 95% CI, 1.56–21.8). Total hospital length of stay was shorter, and repeat pleural interventions were less common in the IPC group (RR, 0.32 95% CI, 0.18–0.55). No differences in survival or measures of dyspnea were observed in any of the studies. Lack of blinding and the inevitable attrition of patients due to death resulted in an overall high risk of bias among the studies. Results: We identified five randomized trials, involving 545 patients, that compared IPC and pleurodesis. We used risk ratios (RRs) with 95% confidence interval (CI) as the effect measure for dichotomous outcomes and mean differences for continuous outcomes. The meta-analysis was performed with Review Manager software, using a random effects model. Risk of bias was assessed with the Cochrane Risk of Bias tool recommended by the Cochrane Methods Bias Group. We included randomized controlled trials comparing IPC and pleurodesis in adult patients with symptomatic MPE. Methods: We performed literature searches in MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials. Objectives: As part of the American Thoracic Society’s guidelines for management of MPE, we performed a systematic review and a meta-analysis to compare patient-centered outcomes with the use of a tunneled pleural catheter versus chemical pleurodesis for the first-line treatment of malignant pleural effusions. Rationale: Several randomized trials have compared the efficacy of an indwelling pleural catheter (IPC) versus the more traditional chemical pleurodesis in the management of malignant pleural effusion (MPE).
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