Malignant pleural effusion
(MPE) is the second leading cause of death after MPE
pneumonia
Beside the effusion. Approximately 125,000 people are hospitalized every day in the United States because of MPE, at an estimated cost of more than $5 billion.
Although some MPE patients may be asymptomatic at first, most eventually experience difficulty breathing even when at rest. Because MPE has a poor prognosis, with a median survival of only 4 to 7 months, treatment is aimed at alleviating or eliminating dyspnea with minimal trauma. At present, the method that can offer a choice basically has two kinds, it is bury tube drainage, 2 it is talc powder immobilize art, can choose among them one or both amalgamative use.
The American Thoracic Society (ATS) published the first edition of its guidelines for the management of MPE in 2000, and the British Thoracic Society (BTS) has updated it a decade later. The above two guidelines have had a certain age and are no longer suitable for today's clinical practice. In fact, less than 50% of doctors in Europe manage MPE according to these guidelines. Recently, ATS published an updated version of its guidelines for the treatment of MPE, making new recommendations based on new evidence in recent years. This article interprets the guidelines as follows.
The new ATS guidelines address clinical issues in a PICO (Patient, Intervention, Comparison and Outcome) format using a recommendation, assessment, development and evaluation grading model, outlining relevant evidence and providing recommendations to guide clinical practice. Here are the new guidelines' recommendations for seven PICO questions.
PICO Question 1: Should ultrasound-guided thoracic surgery be performed in MPE with known primary cause or highly suspected?
Recommendation: Although no randomized controlled trials of MPE have confirmed that ultrasound guidance is beneficial for reduction
pneumothorax
And bleeding, but because ultrasound is not harmful to the human body, the new guidelines recommend thoracopuncture (thoracopuncture) or pleura for management of MPE
A biopsy
Such operations should be carried out under the guidance of ultrasound. Of course, this procedure is not absolutely necessary, depending on the doctor's experience, local conditions, and the availability of ultrasound machines.
PICO Question 2: Should pleural puncture drainage be performed for asymptomatic MPE with known cause or highly suspected?
Recommendation: For these patients, as long as the patient does not have dyspnea and other symptoms, there is no need for chest drainage. There is no evidence of benefit for these patients. Thoracentesis should be considered only if there are other clinical needs, such as collecting specimens for clinical staging or obtaining the expression of molecular markers.
PICO question 3: Should the presence of symptoms of a known cause or highly suspected MPE require massive thoracic drainage and measurement of pleural pressure?
Recommendation: For symptomatic MPE, it is recommended to try a large amount of drainage through the chest (1500ml can be regarded as a large amount), with two purposes: First, to determine whether dyspnea can be relieved after a large amount of drainage; The second is to determine whether there is pulmonary insufficiency. Knowing the presence or absence of atelectasis is of decisive value in selecting subsequent interventions such as pleurodesis.
The measurement of intrathoracic pressure or elasticity with a pleural gauge is the most studied method for determining the presence of pulmonary insufficiency after drainage. If the patient's dyspnea does not resolve after massive drainage, it may be necessary to look for other causes, such as
Pulmonary embolism
, pericardial effusion, etc. At this time, there is no need to consider the operation of the chest itself.
PICO question 4: Should catheter drainage or pleural fixation be used as a first-line thoracic intervention to relieve dyspnea in patients with symptoms of a known cause or highly suspected MPE, without atelectasis, and without treatment for MPE?
Recommendation: Intrathoracic drainage or pleural fixation is recommended as first-line treatment to relieve dyspnea in symptomatic MPE patients as long as the lungs are dilated, as long as there is no prior thoracic intervention (excluding diagnostic thoracic puncture), and as long as the symptoms of acute ventilation are alleviated by massive drainage. This recommendation is an important step forward, as previous guidelines only recommended burying drainage as a treatment option for patients without atelectasis, and some physicians use only burying drainage for MPE with lung dilatation. New evidence published this year in NewEngl J Med reinforces the position of pleurodesis.
PICO Question 5: Should symptomatic MPE patients undergoing talc pleurodesis be sprayed with talc particles via thoracoscopy or injected with talc homogenate?
Recommendation: At this point, spraying talc powder particles or injecting talc powder homogenate has the same effect, and you can choose either one. Previous studies have looked at other hardeners such as bleomycin, tetracycin,
tetracycline
Or bacterial agents, found to be less effective than talcum powder.
It should be pointed out that China has never produced or sold medical talc that can be injected into the chest, only for external use. We have been obtaining talc for internal use, so far without success. It is estimated that the reason for this dilemma is that talc is not a high-tech product, the profit margin of production and distribution is very limited, and no one is willing to operate at a loss. Special caution, do not use external products instead of internal drug conduct pleural fixation, because it is illegal.
PICO Question 6: Should buried drainage or pleural fixation be used in symptomatic MPE patients with pulmonary atenation, pleural fixation failure, or fluid separation?
Recommendation: In this case, buried drainage is recommended and pleural fixation is no longer valuable.
PICO Question 7: Should patients with buried drainage associated infections (cellulitis, puncture hole infection, and chest infection) be treated with medical therapy alone or with catheter removal?
Recommendation: Present
Drainage tube
There is no need to remove the catheter when the infection is associated with it. Antibiotics are usually used to treat the infection. Extubation is only necessary if anti-infective treatment is not responding well.
