Speaker's Highlight

• Don Sin University of British Columbia, St. Paul Hospital (Canada)
  Kenneth R. Chapman Toronto General Hospital Research Institute (Canada)
• Parameswaran Nair McMaster University (Canada)
  Carolyn Calfee UCSF (U.S.A.)
• Gregory P. Downey University of Colorado School of Medicine (U.S.A.)
  David A. Schwartz University of Colorado School of Medicine (U.S.A.)
• Neil Schluger Tuberculosis Control Branch, California Department of Public Health (U.S.A.)
  Nick Kim Critical Care & Sleep Medicine, University of California San Diego (U.S.A.)
• Nicola Hananiah Baylor College of Medicine (U.S.A.)
  Jae-Joon Yim Seoul National University College of Medicine (Republic of Korea)
• Koichiro Asano Tokai University School of Medicine (Japan)
  Diahn-Warng Perng Taipei Veterans General Hospital (Taiwan)
• Konstantinos Kostikas University of Ioannina (Greece)
  Karin Klooster University Medical Center Groningen (Kingdom of the Netherlands)

• Pleurodesis Versus Indwelling Pleural Catheter in Malignant Effusions

  Malignant pleural effusion occurs when cancer causes fluid to collect between the layers surrounding the lung. It is common in advanced lung, breast and ovarian cancers, as well as lymphoma and other tumours. Breathlessness, chest heaviness, cough and reduced exercise tolerance can develop gradually or worsen quickly when the fluid returns after drainage.

  Pleurodesis and an indwelling pleural catheter (IPC) are the main options for controlling recurrent effusions. Pleurodesis aims to seal the pleural space so fluid cannot reaccumulate, while an IPC provides a long-term route for intermittent drainage at home. The preferred approach depends on lung expansion, symptoms, prognosis, treatment goals and available support.

  For people in Australia, decisions may also be shaped by access to respiratory physicians, interventional radiology, community nursing and hospital-based palliative care. A patient living in Sydney or Melbourne may have several specialist options, whereas someone in regional Queensland, Western Australia or the Northern Territory may need to consider travel, local nursing capacity and catheter supply arrangements.

  What Each Treatment Is Designed To Do

  Pleurodesis uses a chemical irritant, commonly sterile talc, to create inflammation between the pleural layers. Once they adhere, there is less space for fluid to collect. The procedure usually begins with drainage through a chest tube, followed by talc administration. It is most successful when the lung fully re-expands after fluid removal.

  An IPC is a soft tunnelled catheter placed through the chest wall into the pleural cavity. A trained patient, relative or community nurse connects a drainage bottle or bag at an agreed interval. Drainage can relieve breathlessness without repeated hospital admissions, and some people eventually develop spontaneous pleurodesis, allowing the catheter to be removed.

  Matching Treatment To Lung Expansion And Health

  A key assessment is whether the lung is expandable. Fluid may remain around a lung that is restricted by tumour, a thickened pleura or previous inflammation. This is often called a non-expandable or trapped lung. Pleurodesis is unlikely to work well in that situation because the pleural surfaces cannot stay in contact.

  An IPC can be suitable for non-expandable lung, rapid fluid recurrence or limited tolerance for inpatient procedures. It may also suit people who value control at home. Pleurodesis can be attractive when a person wants to avoid a long-term catheter, has a reasonable functional status and is likely to benefit from a single definitive intervention.

  Practical Differences In Procedures And Home Care

  The two options involve different burdens. Pleurodesis commonly requires a hospital stay, chest drainage and monitoring for pain, fever and temporary worsening of breathlessness. IPC insertion is usually a shorter procedure, although early discomfort, leakage or blockage can occur.

  Home drainage requires practical teaching and a reliable supply of drainage equipment. The exit site needs regular dressing changes, and the patient should know how to recognise infection or a sudden change in drainage. Important questions to discuss include:

  • Who will perform drainage and change dressings?
  • How often will community nursing be available?
  • Can the patient manage showering, sleep and travel?
  • What is the plan if drainage stops or breathlessness returns?

  Benefits And Trade-Offs Of Pleurodesis

  Successful pleurodesis can provide longer-term freedom from pleural drainage and eliminate the need for a permanent catheter. It may reduce the number of home procedures and simplify daily routines for people who have family, work or caregiving responsibilities. Talc poudrage performed during thoracoscopy may also allow clinicians to inspect the pleura and obtain tissue when the diagnosis remains uncertain.

  The treatment can cause chest pain, fever and inflammation, usually managed with analgesia and monitoring. It may fail, particularly with a non-expandable lung, a very large ongoing air leak or extensive pleural disease. Recovery from a hospital procedure can also be difficult for someone with frailty, severe chronic obstructive pulmonary disease or a short expected survival.

  Benefits And Trade-Offs Of An Indwelling Catheter

  An IPC can relieve symptoms promptly and avoid an extended admission. It gives patients flexibility to drain smaller volumes more frequently, which may be preferable to waiting until severe breathlessness develops. For people receiving systemic cancer treatment, the catheter can often remain in place while chemotherapy or immunotherapy continues.

  Potential problems include infection, cellulitis, catheter blockage, loculated fluid and accidental removal. Some people find the tube uncomfortable or feel self-conscious about it. Drainage supplies and nursing support may create ongoing costs or organisational difficulties, particularly where public hospital services, private insurance and community providers cover different parts of care.

  What The Evidence Means For Patients

  Clinical trials generally show that both strategies improve breathlessness and quality of life when the effusion is drained effectively. IPC treatment often reduces the need for repeat pleural procedures and hospital days. Pleurodesis may offer greater freedom from a catheter when it succeeds, but it has a higher initial procedural and inpatient burden.

  There is no universal winner. The evidence supports shared decision-making rather than choosing solely by cancer type or scan findings. The treating team may use ultrasound, chest X-ray or CT, along with a drainage trial, to determine whether the lung expands and whether fluid is free-flowing or divided into pockets.

  Australian Access, Costs And Safety

  Australian care varies between metropolitan and regional services. Thoracic and pleural teams are concentrated in major centres such as Sydney, Melbourne, Brisbane, Perth and Adelaide, while patients in rural New South Wales or remote Western Australia may need coordinated retrieval, telehealth review or scheduled travel. Medicare may cover hospital-based care, but outpatient nursing, dressings and drainage bottles are not arranged identically in every state or health network.

  Devices supplied in Australia must meet Therapeutic Goods Administration requirements, and consent, privacy and substitute decision-making follow Australian law as applied through state and territory health systems. Before discharge, the team should provide a written plan for after-hours problems, because local emergency departments may not routinely manage an IPC.

  Practical preparation can make home treatment safer:

  • Keep emergency contact details and the drainage schedule accessible.
  • Report fever, spreading redness, pus, severe pain or sudden breathlessness.
  • Confirm who supplies bottles, dressings and replacement equipment.
  • Plan around work, family care, interstate travel and usual showering habits.

  Making A Choice That Reflects The Person

  The decision should reflect the patient’s priorities as much as the imaging. Someone who strongly wishes to remain at home may prefer an IPC, even if pleurodesis is technically possible. Someone who wants to avoid a visible tube and can manage a short admission may prefer pleurodesis. Palliative care involvement can help address breathlessness, pain, anxiety and family concerns alongside the procedure itself.

  The choice can also change over time. An IPC may later be removed after spontaneous pleurodesis, and failed pleurodesis does not remove every future option. Conversely, an IPC may be inappropriate if there is no safe drainage pathway or if infection risk and home support are major concerns.

  The essential point is that both treatments are symptom-control strategies, not cures for the underlying cancer. The best option is the one that safely relieves breathlessness while fitting lung mechanics, expected treatment course, home support and the person’s preferences.

  Richard Russell Nuffield Department of Clinical Medicine, University of Oxford (United Kingdom)
• Mona Bafadhel King’s College London (United Kingdom)
  David Jackson Guy’s and St Thomas’ Hospital, King’s College London (United Kingdom)
• James Chalmers University of Dundee (United Kingdom)
  David Price University of Aberdeen (United Kingdom)