The role of interventional therapy for pleural diseases

Abstract

Pleural diseases encompass a vast and heterogeneous group of diseases that have traditionally received relatively little attention from researchers, resulting in empiric approaches to patient management based largely on expert opinions and anecdotal evidence. Yet, paradoxically, pleural diseases represent a considerable burden for patients, providers, and the healthcare system as a whole, with a rising incidence of malignant pleural effusions and pleural space infections, in increasingly complex patients. Fortunately, the last decade has witnessed unprecedented research efforts from the pleural community, which have resulted in substantial advances in risk-stratification, patient selection, treatment efficacy and the development of evidence-based recommendations ultimately leading to improved patient care. In this review, we will present a summary of the current evidence for the management of pleural diseases with an emphasis on interventional procedures, and highlight the need for future research efforts in the field of malignant pleural effusions, pleural space infections and pneumothorax.

Keywords::

• empyema
• malignant pleural effusion
• pleural disease
• pleural effusion
• pneumothorax

Financial & competing interests disclosure

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending or royalties.

No writing assistance was utilized in the production of this manuscript.

Key issues

• Pleural diseases represent a common problem encountered in clinical practice.

• Several landmark studies have been recently published which challenge the mostly expert opinion-based management strategies for malignant pleural effusions and pleural space infections.

• Talc pleurodesis using graded talc has been shown to be safe in two large prospective studies, arguing against the perceived role of talc in post-pleurodesis acute respiratory distress syndromes.

• Tunneled indwelling pleural catheters appear to represent an effective alternative to talc pleurodesis in malignant pleural effusions, allow for patients to stay out of the hospital and may be cost-effective from a third-party payer standpoint.

• Small bore chest tubes appear as effective as large bore chest tubes for the drainage of pleural space infections, although prospective confirmatory data are needed.

• The combination of intrapleural tissue plasminogen activators and DNAse could represent an effective and less invasive alternative to surgery for the management of empyema.

• Risk-stratification prediction models have been developed which, if validated could inform clinical decisions in the management of patients with empyema.

• Outpatient management of pneumothorax has been shown to be feasible and safe in several prospective studies in selected patients.