Thoracic Ultrasound for guiding pleurodesis in malignant pleural effusion: a randomised trial

Introduction: Pleurodesis is a treatment for symptomatic recurrent malignant pleural effusion (MPE) that requires hospital admission. This trial investigated if the use of thoracic ultrasound (TUS) in pleurodesis guidance could shorten length of hospital stay (LOS) in MPE patients undergoing pleurodesis. Methods: Patients were randomized to TUS-guided care or standard care in 1:1 ratio. In intervention arm, daily TUS examination of pleural sliding in nine regions was conducted to derive an ‘adherence score’ (min: 9, sliding present; max: 27, complete absence of sliding), and chest tube was removed if score was >20. In standard care arm tube removal was based on daily output volume. Primary outcome was LOS and secondary outcomes were pleurodesis failure at 3 months, time to tube removal and cost-effectiveness of TUS. Results: 313 patients were recruited; 159 randomised to TUS and 154 to standard care. The median [IQR] LOS was significantly shorter in the TUS arm (2 [2-4] days) compared to standard care (3 [2-5] days, difference 1 day, p<0.001). TUS was non-inferior to standard care in terms of pleurodesis failure at 3 months which occurred in 34.6% of patients (37/107) in the TUS arm vs 32.2% of patients (37/115) in the standard care arm (risk dif. 3.2%; 95% CI -6.1% to 12.6%, non-inferiority margin 15%). Mean (SD) time to chest tube removal in the TUS arm was 2.4 (2.5) days vs. 3.1 (2.0) days in the standard arm (mean dif. -0.72 days, p=0.006). TUS was found to be highly cost-effective. Conclusion: TUS-guided care for pleurodesis in patients with MPE results in shorter hospital stay without reducing pleurodesis success. The data support standard use of TUS in MPE patients undergoing pleurodesis.