Management of Malignant Pleural Effusions

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Known or suspected MPE a With goals of assessing lung expansion and relief of dyspnea. is step may not be necessary if the patient's dyspnea is known to be attributable to the MPE. b Physicians are not great predictors of prognosis. As such, the recommendation of "Predicted very short survival" should be used as a rough guideline and individualized on a case-by-case basis. c Note: there is a low likelihood (2–4%) of indwelling pleural catheter (IPC)–related infection. Escalation of care (intravenous antibiotics, hospital admission, removal of catheter) should be made on a case-by-case basis and is recommended if there are any signs/symptoms of worsening infection. NO YES Figure 1. Management of Patients with Known or Suspected MPE Management Asymptomatic Pleural intervention not needed (unless for diagnostic purposes) Symptomatic Ultrasound-guided therapeutic thoracentesis (i.e., large-volume tap a ) Improvement in dyspnea Investigate for other causes of dyspnea NO YES Predicted very short survival b Lung re-expansion Discussion of relative risks/ benefits of IPC vs. pleurodesis vs. combination approaches NO YES Palliate dyspnea with: repeat thoracentesis if needed, oxygen, morphine Consider placement of IPC (IPC should also be considered in patients with failed pleurodesis or symptomatic loculated effusion) Talc poudrage or talc slurry ± IPC Evidence of IPC- related infection Initiation of oral antibiotics based on local sensitivities. Attempt to keep catheter in place c Lung re-expansion NO YES Consider drainage as guided by symptoms or local protocol Consider daily drainage and/or talc slurry

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