Feasibility of ambulatory chest drainage and talc pleurodesis for malignant pleural effusion.

Background: Patients with a malignant pleural effusion (MPE) experience significant morbidity and a significant symptom burden. For some patients the existing options of inpatient chest drain insertion with talc pleurodesis or indwelling pleural catheter (IPC) insertion may not meet their treatment goals. Based on local patient involvement and engagement, we devised a feasibility study to assess whether chest drain insertion and talc pleurodesis was feasible and safe to deliver on an ambulatory basis. Methods: A protocol for ambulatory drain insertion and talc pleurodesis for management of MPE was devised. A detailed schematic of the proforma is included. The primary outcome was safety and feasibility of the protocol. We established recruitment criteria as: clinically or cytologically diagnosed MPE, World Health Organization performance status of two or less (three if due to breathlessness), estimated life expectancy over 30 days and age >18 years. Exclusion criteria were: known non-expansile ipsilateral lung, previous failed ipsilateral pleurodesis, pregnancy or being unable to safely manage in the community as defined by the treating clinician. Our target enrolment was ten cases. Results: Ten eligible patients were recruited. All patients survived to 60 days post protocol completion. Eight patients received the trial protocol on an entirely ambulatory basis, six of whom received talc pleurodesis. There were three hospital admissions affecting two patients during protocol administration. Neither patient was felt to have been admitted as a direct consequence of the trial protocol. There were no other reported complications. Specifically, there were no issues with drain displacement or accidental disconnections during the study period. The intervention pleurodesis failure rate at 60 days for the entire trial cohort was 30%. Three patients required further pleural procedures, all of whom had received talc slurry. Conclusions: Our project demonstrates that our protocol for chest drain insertion and talc pleurodesis can be safely and feasibly delivered on an ambulatory basis to patients with a MPE. More work is required to establish the success of our ambulatory pathway compared to existing standards of care. Additionally, work is required to assess how we improve the appeal of an ambulatory pathway with both our patients and clinicians in order to offer a deliverable treatment that matches the care priorities of our patients.