A practical approach to the diagnosis and management of malignant pleural effusions in resource-constrained settings

Abstract

No pleural intervention in a patient with confirmed malignant pleural effusion (MPE) prolongs life, but even the recommended interventions for diagnosis and palliation can be costly and therefore unavailable in large parts of the world. However, there is good evidence to guide clinicians working in low- and middle-income countries on the most cost-effective and clinically effective strategies for the diagnosis and management of MPE. Transthoracic ultrasound-guided closed pleural biopsy is a safe method of pleural biopsy with a diagnostic yield approaching that of thoracoscopy. With the use of pleural fluid cytology and ultrasound-guided biopsy, ≥90% of cases can be diagnosed. Cases with an associated mass lesion are best suited to an ultrasound-guided fine needle aspiration with/without core needle biopsy. Those with diffuse pleural thickening and/or nodularity should have an Abrams needle (<1 cm thickening) or core needle (≥1 cm thickening) biopsy of the area of interest. Those with insignificant pleural thickening should have an ultrasound-guided Abrams needle biopsy close to the diaphragm. The goals of management are to alleviate dyspnoea, prevent re-accumulation of the pleural effusion and minimise re-admissions to hospital. As the most cost-effective strategy, we suggest early use of indwelling pleural catheters with daily drainage for 14 days, followed by talc pleurodesis if the lung expands. The insertion of an intercostal drain with talc slurry is an alternative strategy which is noninferior to thoracoscopy with talc poudrage.Educational aimsTo provide clinicians practising in resource-constrained settings with a practical evidence-based approach to the diagnosis and management of malignant pleural effusions.To explain how to perform an ultrasound-guided closed pleural biopsy.To explain the cost-effective use of indwelling pleural catheters.

Comparative Evaluation of Chest Ultrasonography and Computed Tomography as Predictors of Malignant Pleural Effusion: A Prospective Study

“…However, this invasive procedure poses risks, such as pneumothorax, bleeding, and patient discomfort. Moreover, the diagnostic yield of thoracentesis can be limited, with false-negative rates ranging from 20% to 40% due to factors like paucicellular effusions or suboptimal sampling techniques [4][5][6]. In recent years, noninvasive imaging modalities such as ultrasonography (US) and computed tomography (CT) have become increasingly important in evaluating pleural effusions and diagnosing MPE.…”

Diagnosing and managing pleural disease

“…Dealing with pleural disease is made substantially more straightforward by easy access to tools like thoracic ultrasound, but much of the Breathe readership will be all too aware that a huge proportion of the global burden of pleural disease has to be dealt with in resource-limited environments. S haw et al [ 3 ] outline practical approaches to the diagnosis and management of malignant pleural effusions in resource-constrained settings, while M c N ally et al [ 4 ] examine the unique clinical challenges posed by pleural tuberculosis.…”