Pigtail drainage in the treatment of tuberculous pleural effusion: a randomized study

Abstract

Thorax 2003;58:149–52. Lai Y-F, Chao Y-H, Wang Y-H, Lin A-S. Comments: The authors performed a randomized, controlled trial to study whether placement of a pigtail catheter is beneficial in the management of patients with tubercular pleural effusion. All patients had closed-needle pleural biopsy and diagnostic thoracentesis. The biopsies showed caseating granuloma with or without acid-fast bacilli in every patient. Chest roentgenograms were performed on a monthly basis. A visual analog score (VAS) was used to grade dyspnea, cough, night sweats, appetite, and sense of well-being, and so on. The outcome measures in this study were duration of fever and dyspnea after starting treatment, improvement in VAS, forced vital capacity, and residual pleural thickening (RPT) 6 months after treatment. Initially, 65 patients were enrolled into the study, but 5 patients were excluded from final analysis because they were either noncompliant with the medications or were lost to follow up. Of the remaining 61 patients, 30 received pigtail catheter and antitubercular treatment, and 31 patients received only antitubercular treatment. The authors do not provide information on how long the pigtail catheter was kept in the pleural space. The baseline characteristics were similar in both groups. The only difference in outcome was a more rapid resolution of dyspnea in those who had received the pigtail catheter and antitubercular treatment (median duration, 4 days) compared with antitubercular treatment only (median duration, 8 days; P <0.001). Both groups showed similar improvement in VAS score after initiating the treatment. The forced vital capacity (FVC) was similar in both groups (85.5% of predicted in the drainage group and 88% in the nondrainage group) after the completion of therapy. The incidence of RPT was also similar at 6 months (53% in the drainage group and 51% in the nondrainage group). The authors concluded that the addition of a pigtail catheter to effective antitubercular treatment is not warranted and does not reduce the incidence of RPT. Residual pleural thickening develops in 40% to 50% of patients after treatment of tubercular pleural effusion (Chest 1991;100:1264–7, Chest 1997;112:1293–7). The role of pleural drainage to reduce the chances of residual pleural thickening has been a controversial subject. This well-conducted study by Lai and coworkers shows that there are no benefits from pleural drainage in patients with tubercular pleural effusion. Although nearly one half of all patients developed some degree of RPT in this study, its functional consequences were minimal. The majority of patients did not develop a significant restrictive pulmonary defect. Based on this study, it can be concluded that drainage of the pleural cavity on a routine basis is not helpful in patients with tubercular pleural effusion.