Interventions for the management of fluid around the lungs ( | Figure 1

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Interventions for the management of fluid around the lungs (pleural fluid) caused by cancer

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Review question

We reviewed the evidence on the effectiveness of different methods to manage a build‐up of fluid around the lungs in people where this is caused by cancer.

Background

Malignant pleural effusion (MPE) is a condition that affects people with cancer of the lining of the lung. This can cause fluid to build up in the space between the outside of the lungs and rib cage (pleural cavity), often resulting in breathlessness. Treatment options focus on controlling symptoms. These include removal of the fluid using a temporary chest drain, a camera examination of the pleural cavity (thoracoscopy) or a semi‐permanent chest drain tunnelled under the skin (an indwelling pleural catheter). Introducing a chemical into the pleural cavity can also be used to prevent the fluid coming back (pleurodesis). We wanted to find out which method was the most effective for preventing fluid re‐accumulation (pleurodesis failure) and which was best in terms of side effects (including pain and fever) and other important outcomes such as breathlessness and quality of life.

Study characteristics

We collected and analysed relevant studies to answer this question. We were interested in high quality research, so only searched for randomised controlled trials (in which participants are randomly allocated to the treatments being tested). We analysed most data using 'network meta‐analysis', which allows lots of different interventions to be compared in one analysis. This analysis ranks the interventions in order of their effectiveness.

Certainty of the evidence

We rated the certainty of the evidence from studies using four levels: very low, low, moderate or high. Very low‐certainty evidence means that we are very uncertain about the results. High‐certainty evidence means that we are very confident in the results. Many of the studies were of low quality and the individual studies were quite different to each other. This made it difficult to reach definite conclusions.

Key results

From our searches in June 2019, we found 80 studies (18 new) involving 5507 participants (2079 new).

In the network meta‐analysis, we found that giving talc through a chest tube after draining the fluid (talc slurry) resulted in fewer pleurodesis failures than other commonly used methods, such as the medicines doxycycline or bleomycin through a chest tube (low certainty). Using a thoracoscopy procedure to remove the fluid and blow talc into the chest (talc poudrage) is likely to be as effective as talc slurry (moderate certainty).

We had a low level of certainty that the risk of having a fever is similar between treatments. There may be little difference between treatments in the chance of having pain (low certainty for bleomycin, IPCs and doxycycline; very‐low certainty for talc poudrage).

Using an IPC, which allows intermittent drainage of fluid at home, may relieve breathlessness as much as a talc slurry procedure (low certainty).

There may be little difference in the risk of death between treatments when compared to talc slurry (low certainty for bleomycin and IPC without daily drainage; very low certainty for talc poudrage and doxycycline).

The chance of needing another invasive procedure to remove fluid was lower after having an IPC than after talc slurry pleurodesis (moderate certainty).

Conclusions

The available evidence shows that talc poudrage and talc slurry are effective ways of managing MPEs, with lower pleurodesis failure rates than a number of other commonly used methods. However, it is also important to consider global experience of these agents and knowledge of their safety and side effects when selecting the most appropriate pleurodesis method.

IPCs are less likely to prevent pleural fluid from re‐accumulating than talc slurry, but may be as good at helping breathlessness. People who have an IPC are less likely to need another invasive procedure in the future to manage the pleural effusion.

Further research is required to look at particular patient groups and explore outcomes such as breathlessness and quality of life in more detail. Ideally a fuller understanding of the potential harms of the treatments from the patients' perspective would also be beneficial.

Read the full Cochrane Review here

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