The Pleural Effusion And Symptom Evaluation (PLEASE) study of breathlessness in patients with a symptomatic pleural effusion

Abstract

IntroductionPathophysiology changes associated with pleural effusion, its drainage and factors governing symptom response are poorly understood. Our objective was to determine: 1) the effect of pleural effusion (and its drainage) on cardiorespiratory, functional and diaphragmatic parameters; and 2) the proportion as well as characteristics of patients with breathlessness relief post-drainage.MethodsProspectively enrolled patients with symptomatic pleural effusions were assessed at both pre-therapeutic drainage and at 24–36 h post-therapeutic drainage.Results145 participants completed pre-drainage and post-drainage tests; 93% had effusions ≥25% of hemithorax. The median volume drained was 1.68 L. Breathlessness scores improved post-drainage (mean visual analogue scale (VAS) score by 28.0±24 mm; dyspnoea-12 (D12) score by 10.5±8.8; resting Borg score before 6-min walk test (6-MWT) by 0.6±1.7; all p<0.0001). The 6-min walk distance (6-MWD) increased by 29.7±73.5 m, p<0.0001. Improvements in vital signs and spirometry were modest (forced expiratory volume in 1 s (FEV1) by 0.22 L, 95% CI 0.18–0.27; forced vital capacity (FVC) by 0.30 L, 95% CI 0.24–0.37). The ipsilateral hemi-diaphragm was flattened/everted in 50% of participants pre-drainage and 48% of participants exhibited paradoxical or no diaphragmatic movement. Post-drainage, hemi-diaphragm shape and movement were normal in 94% and 73% of participants, respectively. Drainage provided meaningful breathlessness relief (VAS score improved ≥14 mm) in 73% of participants irrespective of whether the lung expanded (mean difference 0.14, 95% CI 10.02–0.29; p=0.13). Multivariate analyses found that breathlessness relief was associated with significant breathlessness pre-drainage (odds ratio (OR) 5.83 per standard deviation (sd) decrease), baseline abnormal/paralyzed/paradoxical diaphragm movement (OR 4.37), benign aetiology (OR 3.39), higher pleural pH (OR per sd increase 1.92) and higher serum albumin level (OR per sd increase 1.73).ConclusionsBreathlessness and exercise tolerance improved in most patients with only a small mean improvement in spirometry and no change in oxygenation. Breathlessness improvement was similar in participants with and without trapped lung. Abnormal hemi-diaphragm shape and movement were independently associated with relief of breathlessness post-drainage.

Early pleural effusion control in patients with lung cancer

“…We read with interest the article entitled 'Role of early definitive management for newly diagnosed malignant pleural effusion related to lung cancer' by Chiang et al 1 We have been particularly interested in the management of pleural effusion in patients with lung cancer, [2][3][4] and we would like to raise four issues arising from the article by Chiang et al…”

“…First, in table 1 of Chiang et al's study, 1 the authors showed that 154 patients had targetable oncogenic mutations (142 patients, excluding patients with uncommon epidermal growth factor receptor (EGFR) mutations). How did the authors treat the 12 patients with uncommon EGFR mutations?…”

“…However, figures 1 and 2 in Chiang et al's study 1 indicated that 34 and 11 patients, respectively, had early fluid control measure. In the Results section of Chiang et al's study, 1 11 patients received control treatment in the best supportive care group, with the total being 56 patients. Was one patient lost to follow-up?…”

“…Shinichiro Okauchi, MD, 1 Katsunori Kagohashi, MD, PhD, 1 Toshihiro Shiozawa, MD, PhD, 2 Kunihiko Miyazaki, MD, PhD, 3 and Hiroaki Satoh, MD,…”

“…Notably, the size of effusion may not be a major factor that determine the need of MPE re-intervention or the magnitude of symptom relief after therapeutic MPE drainage. 1 Among the 51 subjects undergoing pleurodesis for early MPE control, 24 of them had effusion in less than half of hemi-thorax upon diagnosis. The decision on pleurodesis instillation depended on the rate of pleural fluid accumulation, need of repeated tapping, availability of effective treatment and patient's preference.…”