Use of small-bore vs. large-bore chest tubes for treatment of malignant pleural effusions.

Use of small-bore vs. large-bore chest tubes for treatment of malignant pleural effusions. Parulekar W, Di Primio G, Matzinger F, Dennie C, Bociek G. Chest 2001;120:19–25. National Cancer Institute of Canada Clinical Trials Group, Queen's University, Kingston, Ontario; and the Department of Radiology University of Ottawa, Ontario, Canada; and the Department of Internal Medicine, Section of Hematology/Oncology, University of Nebraska Medical Center, Omaha, Nebraska, U.S.A. Comments: This retrospective review evaluated the efficacy of small-bore (12-Fr van Sonnenberg) catheters compared with standard large-bore chest tubes in the drainage and sclerotherapy of malignant pleural effusions in 102 adult patients with documented malignant pleural effusions. Outcome as defined by recurrence of effusion was determined by masked examination of all postpleurodesis chest radiographs. There were 58 cases of malignant pleural effusion in which small-bore catheters (with ultrasound-guided guidance) were used, and 44 in which large-bore chest tubes were used. After drainage, pleurodesis was performed. The causes of pleural effusion were breast cancer in 56 (55%) and lung cancer in 29 (28%). Cytologic analysis evaluation was performed on 70 patients and was positive in 56 patients (80%). The median age of patients was 65 years. Prior systemic chemotherapy was received by 67 patients (66%), and 59 patients (58%) were receiving ongoing chemotherapy at the time of pleurodesis. The following sclerosing agents were used: talc, 27 (26%); tetracycline, 72 (70%); bleomycin, 2 (2%); and interferon, 1 (1%). Talc was administered in the form of a slurry to patients treated with small-bore catheters and via insufflation to patients treated with large-bore chest tubes. The results revealed that the actuarial probabilities of recurrence at 6 weeks and 4 months were 45% and 53% for the small tubes vs. 45% and 51% for the large tubes. Univariate and multivariate analyses failed to demonstrate that tube size had any influence on the rate of recurrence. The median survival for the group receiving the large tube was 4.43 months and for the group receiving the small tube was 3.17 months. The 12-and 24-month survival rates for each group were 23% and 15% for the large-tube group, and 20% and 7% for the small-tube group. A comparison of overall survival between the two groups revealed no significant difference. The authors conclude that they were unable to detect any major differences in outcomes with the use of either size of chest tube, and that their study suggests that small-bore catheters may be effective in the treatment of malignant pleural effusions and deserve further evaluation in prospectively designed trials. When clinicians encounter malignant pleural effusion, the dilemma is always to determine which of the available treatment methods is best as a palliative measure. Repeated thoracentesis sometime offers the only option if surgical and other methods are not available or cannot be performed. This technique is associated with a high rate of reaccumulation of fluid. The most common mode of therapy is to insert a chest tube for drainage of as much fluid as possible and then consider instillation of a pleurodesing agent, such as specific sclerosing agents such as talc, tetracycline, and bleomycin. Thoracoscopic pleurodesis is also frequently considered. As noted in the current study by Parulekar et al., the use of small-bore catheters in lieu of larger, standard-bore chest tubes has been in existence for many years. The published data suggest that the use of small-bore catheters is effective, safe, and well tolerated. Ultrasonic guidance to place the small-bore catheter ensures that the tube is placed just above the diaphragm to maximize drainage of the effusion, assess presence of loculations, and optimize catheter placement and potential fluid drainage. Although complications such as failure to drain, kinking, and blockage of tube by debris and clots may occur more often with small-bore catheters, ultrasound-guided placement of small-bore catheters appears to be a safe technique to manage malignant pleural effusions.