AMERICAN THORACIC SOCIETY DOCUMENTS Management of Malignant Pleural Effusions An Official ATS/STS/STR Clinical Practice Guideline David J. Feller-Kopman*, Chakravarthy B. Reddy*, Malcolm M. DeCamp, Rebecca L. Diekemper, Michael K. Gould, Travis Henry, Narayan P. Iyer, Y. C. Gary Lee, Sandra Z. Lewis, Nick A. Maskell, Najib M. Rahman, Daniel H. Sterman, Momen M. Wahidi, and Alex A. Balekian; on behalf of the American Thoracic Society, Society of Thoracic Surgeons, and Society of Thoracic Radiology THIS OFFICIAL CLINICAL PRACTICE GUIDELINE WAS APPROVED BY THE AMERICAN THORACIC SOCIETY OCTOBER 2018, THE SOCIETY OF THORACIC SURGEONS JUNE 2018, AND THE SOCIETY OF THORACIC RADIOLOGY JULY 2018 Background: This Guideline, a collaborative effort from the MPE; 3) using either an indwelling pleural catheter (IPC) or American Thoracic Society, Society of Thoracic Surgeons, and chemical pleurodesis in symptomatic patients with MPE and Society of Thoracic Radiology, aims to provide evidence-based suspected expandable lung; 4) performing large-volume recommendations to guide contemporary management of patients thoracentesis to assess symptomatic response and lung expansion; with a malignant pleural effusion (MPE). 5) using either talc poudrage or talc slurry for chemical pleurodesis; 6) using IPC instead of chemical pleurodesis in patients with Methods: A multidisciplinary panel developed seven questions nonexpandable lung or failed pleurodesis; and 7) treating using the PICO (Population, Intervention, Comparator, and IPC-associated infections with antibiotics and not removing the Outcomes) format. The GRADE (Grading of Recommendations, catheter. Assessment, Development and Evaluation) approach and the Evidence to Decision framework was applied to each question. Recommendations Conclusions: These recommendations, based on the best available were formulated, discussed, and approved by the entire panel. evidence, can guide management of patients with MPE and improve patient outcomes. Results: The panel made weak recommendations in favor of: 1) using ultrasound to guide pleural interventions; 2)not Keywords: pleural effusion; malignant; palliation; pleurodesis; performing pleural interventions in asymptomatic patients with pleural catheter Contents PICO 2: In Patients with Known PICO 4: In Patients with Methods or Suspected MPE Who Are Symptomatic MPE with Recommendations for Specific Asymptomatic, Should Pleural Known or Suspected Treatment Questions Drainage Be Performed? Expandable Lung and No PICO 1: In Patients with Known PICO 3: Should the Management Prior Definitive Therapy, or Suspected MPE, Should of Patients with Symptomatic Should IPCs or Chemical Thoracic Ultrasound Be Known or Suspected MPE Be Pleurodesis Be Used as Used to Guide Pleural Guided by Large-Volume First-Line Definitive Pleural Interventions? Thoracentesis and Pleural Intervention for Management Manometry? of Dyspnea? *Co–first authors. ORCID IDs: 0000-0002-9008-3617 (D.J.F.-K.); 0000-0003-3589-0018 (N.P.I.); 0000-0002-0036-511X (Y.C.G.L.); 0000-0003-3934-4452 (S.Z.L.); 0000-0002-1276-6500 (N.A.M.); 0000-0003-1195-1680 (N.M.R.); 0000-0003-1249-0804 (D.H.S.). Correspondence and requests for reprints should be addressed to David J. Feller-Kopman, M.D., Section of Interventional Pulmonology, Division of Pulmonary and Critical Care Medicine, Johns Hopkins Hospital, 1800 Orleans Street, Suite 7-125, Baltimore, MD 21287. E-mail: [email protected]. This article has an online supplement, which is accessible from this issue’s table of contents at www.atsjournals.org. Am J Respir Crit Care Med Vol 198, Iss 7, pp 839–849, Oct 1, 2018 Copyright © 2018 by the American Thoracic Society DOI: 10.1164/rccm.201807-1415ST Internet address: www.atsjournals.org American Thoracic Society Documents 839 AMERICAN THORACIC SOCIETY DOCUMENTS PICO 5: In Patients with Nonexpandable Lung, Failed Tunnel Infection, or Pleural Symptomatic MPE Undergoing Pleurodesis, or Loculated Infection), Should Medical Talc Pleurodesis, Should Talc Effusion, Should an IPC or Therapy Alone or Medical Poudrage or Talc Slurry Be Chemical Pleurodesis Be Therapy and Catheter Removal Used? Used? Be Used? PICO 6: In Patients with PICO 7: In Patients with IPC- Discussion Symptomatic MPE with associated Infection (Cellulitis, Malignant pleural effusions (MPEs) are beyond the scope of a single document, of pneumothorax after thoracentesis for the second leading cause (next to this panel opted to narrow the focus of any/all causes of pleural effusions has been parapneumonic effusions) of exudative the guidelines to key issues that are reported to be as high as 39% (12), although effusions, accounting for greater than of the most relevance to clinicians and more recent and larger studies have shown 125,000 hospital admissions per year in the patients/caregivers. substantially lower rates of pneumothorax United States and estimated inpatient in all cases, but especially when ultrasound charges of greater than $5 billion per year guidance is used (13, 14). The use of (1). Though some patients are initially Methods ultrasound guidance for thoracentesis has asymptomatic, the majority will eventually also been shown to reduce the rates of develop dyspnea at rest. Likewise, as MPE is We used the GRADE (Grading of “dry taps” and less common complications, associated with an average survival of 4–7 Recommendations, Assessment, such as solid organ puncture or hemothorax months (2), treatment should aim to relieve Development, and Evaluation) approach (12, 15). dyspnea in a minimally invasive manner, (10, 11) to formulate clinical questions in Although the largest studies in and ideally minimize repeated procedures PICO (Patient, Intervention, Comparator, the literature have assessed the use of and interaction with the healthcare system and Outcome) format, summarize relevant ultrasound for thoracentesis in all types of (i.e., to provide a definitive pleural evidence, and develop recommendations pleural effusions, this question appraised the for clinical practice. To identify the best intervention) (3). With increasing focus on fi evidence for whether ultrasound is superior patient-centered outcomes, many of these available evidence, we identi ed existing for guiding pleural interventions specifically techniques, including thoracoscopy and systematic reviews and performed for MPE. placement of indwelling pleural catheters additional systematic reviews, including Summary of the evidence. The search (IPCs), can be performed in the outpatient a systematic review for PICO4 that will strategy for this question obtained one setting (4–6). The American Thoracic be published separately. Full methodologic retrospective observational study that Society published the first guidelines for details and tables supporting the specifically assessed complication rates management of MPE in 2000 (7), followed recommendations here can be found in for thoracentesis in MPE with or by the British Thoracic Society guidelines, theonlinesupplement. without ultrasound guidance (16). Three published in 2010 (8). Both were based on retrospective observational studies assessed the consensus of a group of international safety and efficacy for ultrasound guidance experts in the field who reviewed the Recommendations for of pleural effusions, including, but not available literature at that time. However, Specific Treatment limited to, MPE were also included in recent data suggest that these guidelines Questions the initial review (17–19). In addition, are followed less than 50% of the time two studies comprised of larger patient (9). Since publication of the British PICO 1: In Patients with Known or populations, including a meta-analysis Thoracic Society guidelines, there Suspected MPE, Should Thoracic (13) and large retrospective cohort (14) have been several large, multicenter, Ultrasound Be Used to Guide Pleural that reviewed complication rates after randomized trials, as well as other well- Interventions? thoracentesis for all causes of pleural conducted studies that have substantially effusion were included to help formulate impacted the way patients with MPE Background. Pleural interventions (e.g., the recommendation. are evaluated and treated. A recent thoracentesis, pleural drainage catheter The outcomes of pneumothorax, and survey by the European Society of insertion) are frequently performed for pneumothorax requiring chest tube Thoracic Surgeons found a majority of diagnostic or therapeutic purposes in placement, were considered critical. No respondents who were aware of existing patients with MPE. These procedures may studies assessed other complication rates guidelines suggested that they are in be performed with or without imaging (i.e., hemothorax, pain at site) or procedural need of updating/revisions (9). guidance, in both inpatient and outpatient success specifically for malignant effusions. This document aims to provide settings. The use of ultrasound guidance practicing clinicians with the synthesis of Iatrogenic pneumothorax is the most reduced the risk of pneumothorax after latest evidence along with recommendations common complication of thoracentesis, thoracentesis for malignant effusions (1.0% to improve patient centered outcomes. and, in a minority of cases, requires chest vs. 8.9%, relative risk [RR] = 0.10, 95% Because the clinical questions surrounding tube placement, which can necessitate or confidence interval [CI] = 0.03–0.37) (16). the management of MPEs can be broad and lengthen hospital stay. Historically, the rate There were no chest tubes placed