Pathway to Definitive Palliation of Malignant Pleural Effusions

SESSION TITLE: Impact of Pleural Disorders SESSION TYPE: Original Investigation Slide PRESENTED ON: Monday, October 24, 2016 at 07:30 AM - 08:30 AM PURPOSE: Malignant pleural effusions (MPE) are a common clinical problem. Definitive management strategies for symptomatic patients include chemical pleurodesis and indwelling pleural catheters. The clinical pathway that patients with symptomatic MPE experience prior to definitive palliation, including all procedures and hospital admissions, has not been systematically examined. METHODS: This was a retrospective study. Thoracoscopic talc insufflation and indwelling pleural catheter placement are performed at the Montreal Chest Institute for definitive palliation of patients with symptomatic MPE. The charts of all patients referred over a 2-year period were reviewed, with attention to the clinical course preceding definitive MPE palliation. The number of thoracenteses and chest tube insertions performed, ER visits and hospital admissions were tabulated over the interval from initial symptomatic MPE presentation to definitive palliation. RESULTS: Over a 2-year period, 99 patients underwent definitive interventions for MPE. Data on the clinical course leading to definitive palliation was available in 69 patients, who underwent 72 definitive procedures (68 indwelling pleural catheter insertions and 4 thoracoscopic talc insufflations). The clinical course leading to definitive palliation was considered “ideal” in 36/72 (50%) cases, with patients undergoing ≤ 2 therapeutic thoracenteses, no chest tube insertions, ≤ 1 ER visit, and no hospital admissions. In the remaining patients, a mean of 2.4 (SD 1.65) pleural procedures were performed during the period leading to definitive palliation. Tube thoracostomy (without pleurodesis) was performed in 27/72 (38%) cases, with the chest tubes remaining in place for an average of 3.7 days (SD 3.0). Hospitalization for symptomatic MPE preceded definitive palliative intervention in 28/72 (39%) cases. Patients who initially presented to the ER with symptomatic MPE were more likely to undergo chest tube insertion and hospital admission. CONCLUSIONS: There is significant variability in the clinical pathway of patients with symptomatic MPE, prior to definitive palliation. Half of the patients in this series underwent potentially avoidable procedures and/or hospital admissions. CLINICAL IMPLICATIONS: Increased awareness and accelerated referral for definitive palliation may avoid unnecessary pleural procedures and hospitalizations. DISCLOSURE: The following authors have nothing to disclose: Benjamin Shieh, Stephane Beaudoin, Anne Gonzalez No Product/Research Disclosure Information