Randomized Trial of Pleural Fluid Drainage Frequency in Patients with Malignant Pleural Effusions. The ASAP Trial.

RATIONALE: Patients with malignant pleural effusions have significant dyspnea and shortened life expectancy. Indwelling pleural catheters allow patients to drain pleural fluid at home and can lead to autopleurodesis. The optimal drainage frequency to achieve autopleurodesis and freedom from catheter has not been determined. OBJECTIVES: To determine whether an aggressive daily drainage strategy is superior to the current standard every other day drainage of pleural fluid in achieving autopleurodesis. METHODS: Patients were randomized to either an aggressive drainage (daily drainage; n = 73) or standard drainage (every other day drainage; n = 76) of pleural fluid via a tunneled pleural catheter. MEASUREMENTS AND MAIN RESULTS: The primary outcome was the incidence of autopleurodesis following the placement of the indwelling pleural catheters. The rate of autopleurodesis, defined as complete or partial response based on symptomatic and radiographic changes, was greater in the aggressive drainage arm than the standard drainage arm (47% vs. 24%, respectively; P = 0.003). Median time to autopleurodesis was shorter in the aggressive arm (54 d; 95% confidence interval, 34-83) as compared with the standard arm (90 d; 95% confidence interval, 70 to nonestimable). Rate of adverse events, quality of life, and patient satisfaction were not significantly different between the two arms. CONCLUSIONS: Among patients with malignant pleural effusion, daily drainage of pleural fluid via an indwelling pleural catheter led to a higher rate of autopleurodesis and faster time to liberty from catheter. Clinical trial registered with www.clinicaltrials.gov (NCT 00978939).

Short-term Placement of Multiple Self-expandable Metallic Stents for the Treatment of Bilateral Bronchial Dehiscences Complicating Lung Transplantation.

Bronchial dehiscence after lung transplantation is a rare complication yet has high morbidity and mortality. The majority of the patients are not surgical candidates. We present the case of a 59-year-old man with bilateral lung transplantation for interstitial pulmonary fibrosis who was readmitted with symptoms of acute rejection and severe hypoxemic respiratory failure on day 14. Bronchoscopy showed bilateral bronchial anastomotic dehiscences. A computerized tomography scan showed evidence of significant peribronchial air collection in the pleural space and the mediastinum. Owing to a high predictive operative mortality, endobronchial management was planned, and 3 uncovered self-expanding metallic stents (Ultraflex, Boston Scientific Corp) were placed (in the left main stem bronchus, the anterior segment of the right upper lobe, and the right intermediate bronchus). At 5 weeks bronchoscopy showed complete healing of the dehiscences with granulation. The stents were then removed by rigid bronchoscopy. Three weeks after the stent removal a bronchoscopic examination showed a normal tracheobronchial tree except for a slightly narrowed right anastomosis. We conclude that short-term placement of uncovered self-expanding metallic stents provides a safe and minimally invasive option in the management of bilateral dehiscences.