Pleural disease

What the evidence shows

Pleural infection needs both drugs, not either. Intrapleural alteplase with DNase improved drainage and cut surgical referral from 16% to 4%; the factorial design showed that alteplase alone and DNase alone were each no better than placebo (MIST2).

Malignant effusion is a palliative problem, and the trials that matter chose endpoints to match. An indwelling pleural catheter kept patients out of hospital more than talc pleurodesis (AMPLE). Within pleurodesis, talc poudrage at thoracoscopy was no better than talc slurry down a drain (TAPPS) — so there is no reason to take a patient to theatre for pleurodesis alone. During large-volume drainage, manometry did not reduce chest discomfort and is not needed routinely (Pleural manometry).

Primary spontaneous pneumothorax is increasingly left alone. 85% of conservatively managed patients needed no intervention at all, with fewer serious adverse events and less recurrence — though the authors were careful to report that their non-inferiority result did not survive a pessimistic imputation of missing data (PSP). For those who do need drainage, an ambulatory device sent most patients home the same day at the cost of more adverse events (RAMPP).