CHEST Guidelines-Management-of-Recurrent-Malignant-Pleural-Effusion

Management-of-Recurrent-Malignant-Pleural-Effusion_20

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This article discusses the debate between the efficacy and safety of thoracoscopic talc pleurodesis (TTP) versus indwelling pleural catheters for managing recurrent malignant pleural effusions. Dr. Maldonado and Dr. Astoul argue in favor of TTP, noting its advantages such as debridement and lysis of adhesions for optimal pleurodesis, which are not possible with a blind talc application through a chest tube. They mention that TTP is typically done with local anesthesia or conscious sedation in outpatient settings, potentially offering improved outcomes.<br /><br />The authors acknowledge Dr. Lee's assertion that TTP offers better results when there is proper pleural apposition. However, they criticize the complications reported in a study by Dresler et al., stating that such negative outcomes (including blood transfusions, respiratory failure, and deaths) do not generally align with international data, which supports the safety of talc pleurodesis as confirmed by two European studies.<br /><br />They argue that regional variations in healthcare delivery influence the management more than efficacy and safety data. Cost-effectiveness analysis, a cornerstone of U.S. healthcare decisions, may not be valid globally, particularly since the talc used elsewhere is both cost-effective and safe.<br /><br />In response, a letter highlights the benefits of TTP for cases with limited lung expansion due to pleural loculations and large tumor burdens, scenarios wherein thoracoscopic adhesiolysis could promote better outcomes. A European-African trial with large-particle talc reported lower thirty-day mortality rates, reinforcing the safety of TTP when executed correctly with suitable talc types.<br /><br />Overall, the discussion suggests a preference for TTP due to its potential benefits and manageable risks, provided advanced techniques and appropriate talc types are employed.

Keywords

thoracoscopic talc pleurodesis

indwelling pleural catheters

malignant pleural effusions

pleurodesis efficacy

pleural apposition

talc safety

healthcare variations

cost-effectiveness

thoracoscopic adhesiolysis

large-particle talc