23 Dec Malignant Chest Fluid Drainage: Optimal Tube Size and Pain Control Studied
MedicalResearch.com Interview with:
Dr Najib Rahman D Phil MSc MRCP
Consultant and Senior Lecturer
Lead for Pleural Diseases
Oxford Centre for Respiratory Medicine
Clinical Director, Oxford Respiratory Trials Unit
Tutor in Clinical Medicine
University College, Oxford
Medical Research: What is the background for this study?
Dr. Rahman : Up to TIME1, the evidence base behind optimal pleurodesis for malignant pleural effusion in terms of tube size and analgesia was poor. Optimal pleurodesis in this context is one which is successful (i.e. the patient needs no further pleural interventions for that malignant effusion), but occurs with the minimum discomfort. This is particularly important as the treatment intent in malignant effusion pleurodesis is palliative.
This is the first adequately powered randomized trial to address two important issues in pleurodesis for malignant pleural effusion – that of whether NSAIDs reduce pleurodesis efficacy, and if smaller chest tubes (12F) are “as good as” larger chest tubes (24F) for pleurodesis success and in terms of pain.
Medical Research: What are the main findings?
Dr. Rahman : The main and somewhat surprising findings are that:
- NSAIDs given short term but at high dose do not impair pleurodesis – they are no better than morphine for pain control (in fact, they needed modestly more rescue medication), but can be freely used during malignant effusion pleurodesis with no fear of reducing pleurodesis success.
- Smaller tubes were marginally less painful than larger tubes – but this difference was not clinically very relevant
- Smaller tubes cannot now be said to be “as good as” larger tubes for malignant effusion pleurodesis. Our data shows that they failed in non-inferiority to larger tubes for pleurodesis success at 3 months.
- Smaller tubes resulted in higher fall our rates, a higher incidence of not being able to administer talc and were associated with more complications during insertion .
Medical Research: What should clinicians and patients take away from your report?
Dr. Rahman : This data provides the first evidence base for the rational selection of analgesia and chest tube size in malignant pleural effusion pleurodesis. On the basis of our results, either NSAIDs or opiate, with additional rescue medication, can be used for pain control for the few days during pleurodesis. Our data suggest that larger tubes (24F) are more efficacious in terms of pleurodesis by an estimated margin of 10%, and are associated with less complications during insertion, less failure to give talc and a lower proportion of falling out. This is only one study and we should be cautious about changing practice on this basis (although the largest to be specifically powered to address this question), but our results suggest that larger tubes should be used for pleurodesis in malignant pleural effusion for maximum pleurodesis efficacy.
Medical Research: What recommendations do you have for future research as a result of this study?
Dr. Rahma : In my view, talc pleurodesis will remain an important treatment option for many patients in the future, although there is an increasing interest in the use of indwelling pleural catheter based management. Optimizing talc or other intrapleural agent pleurodesis efficacy is therefore a clinical priority.
The NSAID data to me demonstrate that the animal models used for pleurodesis need to be questioned.
The results of TIME1 need replication to demonstrate that smaller sized tubes are truly not as good as larger tubes. We cannot using the TIME1 data know whether the modest increase in pain seen with larger tubes was due to the size or the insertion technique, as all large tubes were inserted with the blunt dissection technique. I think the next study will need to address the tube size question, and also the insertion technique question.