BACKGROUND: Malignant pleural effusion (MPE) is a common cancer complication. Clinical and economic implications of different recurrent MPE treatment pathways have not been evaluated fully.
OBJECTIVE: What clinical outcomes, complications, health care resource use, and costs are associated with various rapidly recurrent MPE treatment pathways?
METHODS: This retrospective cohort study using Surveillance, Epidemiology and End Results Medicare data (2011-2015) included patients 66 to 90 years of age with rapidly recurrent MPE. Rapid recurrence was defined as receipt of a second pleural procedure within 14 days of the first thoracentesis, including nondefinitive repeated thoracentesis or a definitive treatment option including chest tube, indwelling pleural catheter (IPC), or thoracoscopy.
RESULTS: Among 8,378 patients with MPE, 3,090 patients (36.9%) had rapidly recurrent MPE (mean ± SD age, 75.9 ± 6.6 years; 45.6% male; primary cancer, 62.9% lung and 37.1% other). Second pleural procedures were nondefinitive thoracentesis (62.3%), chest tube (17.1%), IPC (13.2%), or thoracoscopy (7.4%). A third pleural procedure was required more frequently if the second pleural procedure was nondefinitive thoracentesis vs chest tube placement, IPC placement, or thoracoscopy (70.3% vs 44.1% vs 17.9% vs 14.4%, respectively). The mean number of subsequent pleural procedures over the patient\'s lifetime varied significantly among the procedures (1.74, 0.82, 0.31, and 0.22 procedures for patients receiving thoracentesis, chest tube, IPC, and thoracoscopy, respectively; P < .05). Average total costs after the second pleural procedure to death adjusted for age at primary cancer diagnosis, race, year of second pleural procedure, Charlson comorbidity index, cancer stage at primary diagnosis, and time from primary cancer diagnosis to diagnostic thoracentesis were lower with IPC ($37,443; P < .0001) or chest tube placement ($40,627; P = .004) vs thoracentesis ($47,711). Patients receiving thoracoscopy ($45,386; P = .5) incurred similar costs as patients receiving thoracentesis.
CONCLUSIONS: Early definitive treatment was associated with fewer subsequent procedures and lower costs in patients with rapidly recurrent MPE.

Pleural diseases are common and frequently result in disabling symptoms, impaired health-related quality of life and hospitalisation. Both diagnosis and management often require pleural procedures and despite a variety of pain control strategies available for clinicians to employ, many procedures are still complicated by pain and discomfort. This can interfere with procedure success and can limit patient satisfaction. This review examines the evidence for pain control strategies for people undergoing non-surgical pleural procedures. A systematic literature search was undertaken to identify published studies examining different pain control strategies including pharmacological (sedatives, paravertebral blocks, erector spinae blocks, intrapleural anaesthesia, epidural anaesthesia, local anaesthetic, methoxyflurane, non-steroidal anti-inflammatory drugs [NSAIDs], opioids) and non-pharmacological measures (transcutaneous electric nerve stimulation [TENS], cold application and changes to the intervention or technique). Current literature is limited by heterogeneous study design, small participant numbers and use of different endpoints. Strategies that were more effective than placebo or standard care at improving pain included intrapleural local anaesthesia, paravertebral blocks, NSAIDs, small-bore intercostal catheters (ICC), cold application and TENS. Inhaled methoxyflurane, thoracic epidural anaesthesia and erector spinae blocks may also be useful approaches but require further evaluation to determine their roles in routine non-surgical pleural procedures. Future research should utilise reliable and repeatable study designs and reach consensus in endpoints to allow comparability between findings and thus provide the evidence-base to achieve standardisation of pain management approaches.

Pleural disease is common and often requires procedural intervention. Given this prevalence, pleural procedures are performed by a wide range of providers with varying skill level in both medical and surgical specialties. Even though the overall complication rate of pleural procedures is low, the proximity to vital organs and blood vessels can lead to serious complications which if left unrecognized can be life threatening. As a result, it is of the utmost importance for the provider to have a firm grasp of the local anatomy both conceptually when preparing for the procedure and physically, via physical exam and the use of a real time imaging modality such as ultrasound, when performing the procedure. With this in mind, anyone who wishes to safely perform pleural procedures should be able to appropriately anticipate, quickly identify, and efficiently manage any potential complication including not only those seen with many procedures such as pain, bleeding, and infection but also those specific to procedures performed in the thorax such as pneumothorax, re-expansional pulmonary edema, and regional organ injury. In this article, we will review the basic approach to most pleural procedures along with essential local anatomy most often encountered during these procedures. This will lay the foundation for the remainder of the article where we will discuss clinical manifestations and management of various pleural procedure complications.

The decision-making on antiplatelet drug withdrawal or continuation before performing a pleural procedure is based on the balance between the risk of bleeding associated with the antiplatelet therapy and the risk of arterial thrombosis due to its interruption. Knowledge on antiplatelet therapy-associated risk of bleeding after pleural procedures is lacking.
Is the risk of bleeding associated with antiplatelet drugs increased in patients undergoing pleural procedures?
We conducted a French multicenter cohort study in 19 centers. The main outcome was the occurrence of bleeding, defined as hematoma, hemoptysis, or hemothorax, during the 24 h following a pleural procedure. Serious bleeding events were defined as bleeding requiring blood transfusion, respiratory support, endotracheal intubation, embolization, or surgery, or as death.
A total of 1,124 patients was included (men, 66%; median age, 62.6 ± 27.7 years), of whom 182 were receiving antiplatelet therapy and 942 were not. Fifteen patients experienced a bleeding event, including eight serious bleeding events. The 24-h incidence of bleeding was 3.23% (95% CI, 1.08%-5.91%) in the antiplatelet group and 0.96% (95% CI, 0.43%-1.60%) in the control group. The occurrence of bleeding events was significantly associated with antiplatelet therapy in univariate analysis (OR, 3.44; 95% CI, 1.14-9.66; P = .021) and multivariate analysis (OR, 4.13; 95% CI, 1.01-17.03; P = .044) after adjusting for demographic data and the main risk factors for bleeding. Likewise, antiplatelet therapy was significantly associated with serious bleeding in univariate analysis (OR, 8.61; 95% CI, 2.09-42.3; P = .003) and multivariate analysis (OR, 7.27; 95% CI, 1.18-56.1; P = .032) after adjusting for the number of risk factors for bleeding.
Antiplatelet therapy was associated with an increased risk of post-pleural procedure bleeding and serious bleeding. Future guidelines should take into account these results for patient safety.

There is an evolution of pleural procedures that involve broadened clinical indication and expanded scope that include advanced diagnostic, therapeutic, and palliative procedures. Finance and clinical professionals have been challenged to understand the indication and coding complexities that accompany these procedures. This article describes the utility of pleural procedures, the appropriate current procedural terminology coding, and necessary modifiers. Coding pearls that help close the knowledge gap between basic and advanced procedures aim to address coding confusion that is prevalent with pleural procedures and the risk of payment denials, potential underpayment, and documentation audits.

OBJECTIVE: Pleural diseases are common in clinical practice. Doctors in training often encounter these patients and are expected to perform diagnostic and therapeutic pleural procedures with confidence and safely. However, pleural procedures can be associated with significant complications, especially when performed by less experienced. Structured training such as use of training manikin and procedural skills workshop may help trainee doctors to achieve competence. However, high costs involved in acquiring simulation technology or attending a workshop may be a hurdle. We hereby describe a training model using a simple manikin developed in our institution and provide an effective way to document skill acquisition and assessment among trainee medical officers.
METHODS: This was a prospective observational study. The need for training, competence and confidence of trainees in performing pleural procedures was assessed through an online survey. Trainees underwent structured simulation training through a simple manikin developed at our institute. Follow-up survey after the training was then performed to access confidence and competence in performing pleural procedures.
RESULTS: Forty-seven trainees responded to an online survey and 91% of those expressed that they would like further training in pleural procedure skills. 81% and 85% of responders, respectively, indicated preferred method of training is either practising on manikin or performing the procedure under supervision. Follow-up survey showed improvement in the confidence and competence.
CONCLUSIONS: Our pleural procedure training manikin model is a reliable, novel and cost-effective method for acquiring competences in pleural procedures.

BACKGROUND: Pleural procedures are performed to prove the diagnosis of pleural effusion. This study was to assess the incidence and outcome of pleural procedure-related tumour seeding in lung cancer with malignant pleural effusion, and to review the characteristics of the implanted tumours on computed tomography (CT) images.
METHODS: From January 2008 to December 2010, 165 patients with the diagnosis of lung cancer with malignant pleural effusion, who underwent at least one pleural procedure and had follow-up CT, were included. Two radiologists retrospectively reviewed the presence of implanted tumours and their manifestations on CT images. The incidence of tumour seeding, the time to tumour seeding, and hazard ratios for death associated with the procedures and presence of tumour seeding were evaluated. Multivariable logistic regression analysis was used to identify variables that were independently associated with procedure-related tumour seeding.
RESULTS: The incidence of procedure-related tumour seeding was 22.4%. Conventional intercostal drainage (ICD) was the independent predictor of tumour seeding. Patients with a history of ICD rapidly developed implanted tumours (P = 0.0319). The estimated mean time of tumour seeding was 2.9 months. There was an increased risk of death with the presence of tumour seeding (HR: 3.35, 95% CI: 1.87-6.01). The majority of CT features showed ill-defined margins with heterogeneous enhancement.
CONCLUSIONS: Pleural procedure-related tumour seeding in lung cancer with malignant pleural effusion is common. There was a significantly increased risk of death with the presence of tumour seeding. The majority of the CT features in implanted tumours were ill-defined margins with heterogeneous enhancement.

BACKGROUND: When pleural procedures (thoracocentesis, blind pleural biopsies and chest tube insertion) are required in patients taking long-term platelet aggregation inhibitors, the risk of bleeding must be balanced against the risk of arterial thrombosis. Currently, the bleeding risk of pleural procedures is poorly understood.
OBJECTIVE: The objective of the survey was to gather the opinion of respiratory physicians regarding the bleeding risk of pleural procedures in patients taking platelet aggregation inhibitors.
METHODS: We emailed a standardized questionnaire designed by the French National Authority for Health to 2697 French respiratory physicians.
RESULTS: One hundred and eighty-eight of the 2697 questionnaires were returned (response rate: 7 %). The respiratory physicians declared that they performed an average of 8 pleural procedures per month. One hundred and seventy-five responders (95 %) practised pleural procedures in patients receiving platelet aggregation inhibitors; 68 of them (39 %) reported experiencing haemorrhagic complications. The bleeding risk associated with thoracentesis and chest tube insertion was considered minor by 97.8 and 65 % of responders respectively, whereas it was considered major for blind pleural biopsies by 73.4 %. Respiratory physicians were more reticent about performing pleural procedures in patients treated with clopidogrel than in those taking aspirin.
CONCLUSIONS: This study provides an overview of how respiratory physicians perceive the bleeding risk associated with pleural procedures in patients taking platelet aggregation inhibitors.