Rational and Helpless Choices: Seven Issues of 2018 ATS/STS/STR Management Guideline for the Malignant Pleural Effusion

"Management of malignant pleural effusions (MPE)", an official clinical practice guideline approved by the American Thoracic Society, the Society of Thoracic Surgeons, and the Society of Thoracic Radiology, was published in the American Journal of Respiratory and Critical Care Medicine on October 1st, 2018. Using the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) approach and the PICO (Population, Intervention, Comparator, and Outcomes) format, a multidisciplinary panel raised and answered seven questions on the clinical management of MPE. The relevant evidences were summarized and recommendations were developed for clinical practice. Based on the available evidence, the panel made the following recommendations:(1)ultrasound imaging should be used to guide pleural interventions in patients with known or suspected MPE; (2)therapeutic pleural interventions should not be performed in asymptomatic patients with known or suspected MPE; (3)either an indwelling pleural catheter (IPC) or chemical pleurodesis can be used in symptomatic patients with MPE and suspected expandable lung; (4)large-volume thoracentesis can be conducted to assess symptomatic response and lung expansion; (5)the use of either talc poudrage or talc slurry can be considered in patients with symptomatic MPE and expandable lung; (6)IPC should be used instead of pleurodesis in patients with nonexpandable lung or failed pleurodesis; and (7)antibiotics should be used in IPC-associated infections and there is no need to removed the catheter.