Agent For Pleurodesis Research Articles

Can Sericin Prove Useful as a Pleurodesis Agent or Tissue Glue?

Background Sericin is a natural, gum-like, macromolecule protein, synthesized from silkworms for the formation of cocoon shells. The aim of the present study is to describe the effects of sericin when used for pleurodesis and/or as tissue glue. Methods Adult, male, 12-week-old Wistar albino rats, weighing 257 to 395 g were used in the present study (n = 12). The animals were randomly divided into two equal groups as the sericin and the control group. After intramuscular administration of the anesthetic agent, the rats were intubated and mechanically ventilated. A left thoracotomy was performed and 30 mg sericin powder was instilled into the thoraxes of the sericin group. The remaining rats were allocated to a sham thoracotomy group. The animals were housed in individual cages, fed ad-libitum, and sacrificed 8 days after. After sacrifice, the left hemithoraxes were removed en bloc and underwent histopathologic examination. Results Masson trichrome staining was applied on the visceral pleura sections of all the animals. Each animal specimen (n = 6, 100%) in the control group showed minimal collagen deposition, while only one rat (16.67%) in the sericin group had minimal collagen deposition. However, in the sericin group, five animals (83.33%) showed dense collagen deposition, fibroblastic activity, and fibrosis. According to the test method, independent t-test, developing fibroblastic activity and fibrosis are statistically significant between the two groups (p < 0.01). There were no foreign-body reactions and no evidence of biological glue on the specimens in the sericin group. The rats in the sericin group had lower inflammatory reactions compared with those in the control group. Emphysema was observed in two rats (33.33%) in the sericin group and in four rats (66.67%) in the control group. Therefore, sericin was found to be associated with an increase in fibroblastic activity and fibrosis in visceral pleura without exerting any adverse effect on the lung parenchyma. Conclusion Sericin is a new and researchable protein for chest diseases and thoracic surgery. To develop an effect of dense collagen deposition, fibroblastic activity, and fibrosis in the visceral pleura, without significant adverse effects, is remarkable. Therefore, sericin may be useful as a pleurodesis agent or natural biological glue in the future. Sericin treatment can add value to the disciplines of pulmonology and thoracic surgery.

Outcome of pleurodesis using different agents in management of malignant pleural effusion

IntroductionMalignant pleural effusion is a serious problem for both patients and physicians. Pleurodesis is considered the good solution for this dilemma. Chemical pleurodesis was used to prevent fluid reaccumulation and decrease patient suffering. This study was designed to compare and evaluate the efficacy and safety of three different sclerosing agents for preventing recurrent malignant pleural effusion. Materials and methodsForty five patients with recurrent malignant pleural effusion were enrolled in three groups; 15 patients in each one, and were subjected to pleurodesis using three chemical agents.Vincristine (2mg), viscum (100mg) and povidone–iodine (20ml). All patients were subjected to the thoracotomy tube for drainage of pleural fluid, then sclerosing agents were instilled intrapleurally via the tube. ResultsVincristine, viscum and povidone–iodine resulted in complete pleurodesis in 53.3%, 73.3% and 73.3% respectively. Failed pleurodesis was higher in the vincristine group 26.7% but in viscum and iodine groups were 13.3% and 20% respectively.Pain was the most common complication 48.89% and reported in a higher ratio in the vincristine group 66.67%, while in viscum and iodine groups it was 53.33% and 26.67% respectively.There was no statistically significant difference between the three groups regarding pleural fluid chemistry and duration of ICT. ConclusionAccording this study, povidone iodine is considered the ideal sclerosing agent for pleurodesis in comparison to vincristine and viscum because of its high efficacy, availability, cheapness and least side effects.

The Efficacy and Safety of Sterile Graded Talc in Pleurodesis for Malignant Pleural Effusion: Phase II Study

Objective: Introduction of NPC-05 (sterile graded talc) into Japanese clinical practice is expected to lead to persistent prevention of re-accumulation of MPE and alleviation of concomitant symptoms in patients, including dyspnea and chest pain. We conduct an investigator-initiated trial in Japan to clarify the efficacy and safety of NPC-05 for use as a pleurodesis agent. Methods: This study is a multicenter uncontrolled open-label phase II study. An uncontrolled open-label joint clinical study is conducted in 6 institutes, involving 30 patients with MPE. Conclusion: Sterile graded talc has been described as the most useful pleurodesis drug for treating malignant pleural effusion in many guidelines and meta-analyses; thus, it is used as a standard pleurodesis agent in Western countries. However, its efficacy and safety have not been examined in Japan. This study assessed the efficacy and safety of NC-05, sterile graded talc, in 30 Japanese patients with malignant pleural effusion.

Efficacy of tranexamic acid as pleurodesis agent in malignant pleural effusion

DesignA prospective case series. AimOn a search for an effective, safe, cheap, and available sclerosing agent, the present study aimed to evaluate the effectiveness and the safety of tranexamic acid as a chemical agent for pleurodesis in malignant pleural effusion (MPE). MethodsTube thoracostomy was done for drainage of pleural fluid. Once the tube in the pleural space drains 150ml per day or less with fully expanded lung, infusion of pleurodesis solution containing 2000mg of tranexamic acid [four ampoules of tranexamic acid each is 5ml (100mg/ml), mixed with 50ml of normal saline] was done through the intercostal tube. The tube was then clamped immediately and left in the pleural cavity for 2h. Follow up chest radiographs were done every 24h till removal of the tube which was done when daily drainage is 100ml or less. Chest X ray (CXR) was done after three months to judge success (no fluid re-accumulation). The results were statistically analyzed and tabulated. ResultsSixteen patients with MPE were included in this study, 9 (56%) males and 7 (44%) females with age ranging from 45 to 70 with mean age±SD=57.5±8.3years. The follow up after 3months showed a complete response rate (no fluid re-accumulation on CXR) of 75% (12⧹16), a partial response rate (asymptomatic fluid re-accumulation on CXR) of 12.5% (2⧹16) and a no response rate (symptomatic fluid re-accumulation on CXR that required pleural drainage) of 12.5% (2⧹16). ConclusionTranexamic acid was found to be an effective, safe, cheap, and available sclerosing agent for pleurodesis in recurrent malignant pleural effusion.

Acute pneumonitis consequent on pleurodesis with Viscum album extract: severe chest images but benign clinical course

&#x0D; &#x0D; &#x0D; &#x0D; Chemical pleurodesis is widely recommended in the treatment of pulmonary air leak of different etiologies as well as malignant pleural effusions and chylothorax. Conventional chemical pleurodesis using erythromycin, tetracycline, hydrophilic fumed silica, autologous blood and talc slurry has been standardized, and its complications, including high fever, intractable chest pain, and acute lung injury, seem to be frequent. Viscum album extract is a new chemical agent for pleurodesis, and only a few studies have reported outcomes of such chemical pleurodesis in the treatment of malignant pleural effusion. Moreover, the complications resulting from pleurodesis using Viscum album extract are very rare, and acute pneumonitis has not been reported. in this paper we report the first case of acute pneumonitis after pleurodesis using Viscum album extract in a 58-year-old man who had prolonged air leaks after a left upper lingularsegmentectomy for metastatic lung cancer. We performed repeated pleurodesis four times with 2 to 4 days intervals. While the patient had no symptoms of pneumonia, such as cough, sputum, chilling, and fatigue, a follow-up chest X-ray revealed increasing peribronchial consolidations and infiltrations in the left upper lobe. A chest tomography showed extensive parenchymal consolidations and ground-glass appearances in the left lungs, representing pneumonia with acute lung injury. The acute pneumonitis was spontaneously resolved with supportive care, and the patient was discharged ten days after the development of pneumonitis. We think that pleurodesis with Viscum album extract is effective, but repeated pleurodesis should be avoided for possible onset of acute pneumonitis.&#x0D; &#x0D; &#x0D; &#x0D;

Recommendations of Diagnosis and Treatment of Pleural Effusion. Update

Although during the last few years there have been several important changes in the diagnostic or therapeutic methods, pleural effusion is still one of the diseases that the respiratory specialist have to evaluate frequently. The aim of this paper is to update the knowledge about pleural effusions, rather than to review the causes of pleural diseases exhaustively. These recommendations have a longer extension for the subjects with a direct clinical usefulness, but a slight update of other pleural diseases has been also included. Among the main scientific advantages are included the thoracic ultrasonography, the intrapleural fibrinolytics, the pleurodesis agents, or the new pleural drainages techniques.

Normativa sobre el diagnóstico y tratamiento del derrame pleural. Actualización

Although during the last few years there have been several important changes in the diagnostic or therapeutic methods, pleural effusion is still one of the diseases that the respiratory specialist have to evaluate frequently. The aim of this paper is to update the knowledge about pleural effusions, rather than to review the causes of pleural diseases exhaustively. These recommendations have a longer extension for the subjects with a direct clinical usefulness, but a slight update of other pleural diseases has been also included. Among the main scientific advantages are included the thoracic ultrasonography, the intrapleural fibrinolytics, the pleurodesis agents, or the new pleural drainages techniques.

Viscum Album Versus Bleomycin for Pleurodesis among Patients with Malignant Pleural Effusion

OBJECTIVE: To compare between mistletoe(Viscum album) and bleomycin as chemical agents for pleurodesis in malignant pleural effusions. METHODS: In this study 50 patients with pathologically confirmed, symptomatic, malignant pleural effusion irrespective of the primary tumor were studied at Suez Canal University hospital in the period of 3 years from January 2009 to December 2012. Patients were divided into 2 groups; 25 patients each: group A(pleurodesis with Mistletoe using 100mg – 5 ampoules-repeated two or three times, injected every other day) and group B(pleurodesis with Bleomycin1 iu/kg average-4 ampoules-or maximally 60 units). follow-up included postero-anterior and lateral chest radiography done after one week, month and 3 months. RESULTS: Most of the patients among both groups show complete remission defined as no effusion detected within four weeks of pleurodesis (72% and 56% among bleomycin and Viscum groups respectively). Significant difference was found between both groups. Recurrences were more frequent among group A (20% versus 8% in group B), P < 0.05. Hospital stay was shorter in the bleomycin group of patients, with a mean of (6.2) day. CONCLUSION: Both bleomycin and Viscum album are effective and safe agents for chemical pleurodesis, however bleomycin has some advantages over Viscum album due to its lower incidence of failure, and being more economic and for the shorter hospital stay.

Acute pneumonitis consequent on pleurodesis with Viscum album extract: severe chest images but benign clinical course.

Chemical pleurodesis is widely recommended in the treatment of pulmonary air leak of different etiologies as well as malignant pleural effusions and chylothorax. Conventional chemical pleurodesis using erythromycin, tetracycline, hydrophilic fumed silica, autologous blood and talc slurry has been standardized, and its complications, including high fever, intractable chest pain, and acute lung injury, seem to be frequent. Viscum album extract is a new chemical agent for pleurodesis, and only a few studies have reported outcomes of such chemical pleurodesis in the treatment of malignant pleural effusion. Moreover, the complications resulting from pleurodesis using Viscum album extract are very rare, and acute pneumonitis has not been reported. in this paper we report the first case of acute pneumonitis after pleurodesis using Viscum album extract in a 58-year-old man who had prolonged air leaks after a left upper lingularsegmentectomy for metastatic lung cancer. We performed repeated pleurodesis four times with 2 to 4 days intervals. While the patient had no symptoms of pneumonia, such as cough, sputum, chilling, and fatigue, a follow-up chest X-ray revealed increasing peribronchial consolidations and infiltrations in the left upper lobe. A chest tomography showed extensive parenchymal consolidations and ground-glass appearances in the left lungs, representing pneumonia with acute lung injury. The acute pneumonitis was spontaneously resolved with supportive care, and the patient was discharged ten days after the development of pneumonitis. We think that pleurodesis with Viscum album extract is effective, but repeated pleurodesis should be avoided for possible onset of acute pneumonitis.

A new look at an old agent for pleurodesis

Background and objectiveMalignant pleural effusion (MPE) is a common problem in patients with malignancies. Chemical pleurodesis is the most commonly used palliative option. Parenteral tetracycline (TET) and doxycycline (DOX) are cost-effective and safe in producing pleurodesis but mostly unavailable currently. We investigated whether oral doxycycline could produce an efficient and safe pleurodesis as does parenteral doxycycline, which is currently unavailable in many countries. MethodsA prospective study of 24 pleurodesis procedures in 22 patients with malignant pleural effusions were conducted over a 3-year period. All pleurodesis was performed with oral forms of doxycycline as the sclerosing agent, where about 1000mg of doxycycline was taken and prepared from the oral preparation (vibramycin 100mg/capsule) and mixed in 50ml. Physiological saline was then administered via tube thoracostomy. We assessed the success or failure of pleurodesis in addition to the frequency of complications and survival. Post-pleurodesis postero-anterior (PA) radiographs were obtained after tube removal and 30days following the procedure. ResultsTwenty-two patients were included (6 women, 16 men), the mean age was (62.5years). Origins of MPE were: lung and pleura 8 (36.4%), breast 2 (9.1%), ovarian 2 (9.1%), digestive 3 (13.6%), lymphoma 3 (13.6%) and unknown 4 (18.2%). No immediate perioperative complications were noted. Chest tube duration averaged 4.2±2.6days. Immediate postoperative events included chest pain in 10 patients (45.5%), fever in 2 (9.1%) patients, pain and fever in 5 patients (22.7%). Sixteen patients (72.7%) had successful pleurodesis and 6 patients (27.3%) had failed pleurodesis at 1month. ConclusionsPleurodesis with oral forms of doxycycline dissolved in sterile saline solution have a high success rate with a low incidence of complications and could be a good option as palliative therapy in patients with symptomatic malignant pleural effusions.

Comparative evaluation of VATS assisted combined mechanical and chemical pleurodesis with chemical pleurodesis—is it worthwhile?

Introduction Malignant Pleural Effusion (MPE) is a common terminal clinical problem in patients with advance cancer. Treatment options for MPE include observation, thoracocentesis, or pleurodesis. In the current study, we compared the effectiveness and safety of combined mechanical and chemical pleurodesis by Video Assisted Thoracoscopic Surgery (VATS) with chemical pleurodesis via intercostals tube alone, using talc as pleurodesis agent in both.

New agents for pleurodesis

At times when patients have a malignant pleural effusion or a pneumothorax, one wishes to eliminate the pleural space by pleurodesis. This article describes results from attempting pleurodesis with silver nitrate, iodopovidone (betadine), transforming growth factor beta (TGFβ), OK432, and lipoteichoic acid-T. The two most promising agents seem to be silver nitrate and iodopovidone. Both agents induce pleurodesis that is at least comparable with that produced by talc, and neither induced the acute respiratory distress syndrome that sometimes occurs after intrapleural administration of talc.

Pleurodesis with povidone-iodine, as an effective procedure in management of patients with malignant pleural effusion.

Overtime, malignant pleural effusion (MPE) arises in advanced-stages of malignancies and frequently heralds a poor prognosis. If the underlying malignancy is chemo sensitive, systemic chemotherapy may control pleural effusion. A common method for the management of the patients with refractory MPE is pleurodesis through the introduction of sclerosing agents such as talc, bleomycin administered/instilled into the pleural cavity. However, the present prospective study aimed to investigate the efficacy and safety of pleurodesis with povidone-iodine (Betadine) in patients with MPE admitted in Sari General Hospital during 2008-2011. Thirty-six patients who underwent pleurodesis by instilling povidone-iodine through a thoracostomy tube, as a bedside procedure were enrolled in the study. For evaluating the effect of povidone-iodine on thyroid gland, the authors measured the thyroid function tests before and after the pleurodesis at 1 week. The response to this procedure was complete in 26 patients (72.2%) and partial in 7 patients (19.4%). Treatment failure was displayed in 3 patients (8.3%). The overall success rate was 91.6%. In post-procedure, the most common complaints of the patients were pain (35.9%) followed by dyspnea, burning and fever. Povidone-iodine does not affect on thyroid function tests. Povidone-iodine is an effective, inexpensive, safe and feasible agent for chemical pleurodesis in management of MPE.

Medical thoracoscopy

Medical thoracoscopy is an important technique for assessment of undiagnosed exudative pleural effusion. It is also important in the management of pleural disease, benign or malignant. Standard equipment available from several manufacturers enables the procedure to be performed through a single port of entry, frequently under conscious sedation. With good patient selection, thoracoscopy is a highly successful and safe procedure. Adequate training is mandatory and a period of mentoring is highly recommended. In this paper we discuss the use of thoracoscopy for some benign and malignant conditions and reveal that controversy remains over issues including the optimum mode and agent for pleurodesis. In addition, opinions differ on the precise role of thoracoscopy for pleural infection. In this paper we discuss key background information necessary for the safe provision of thoracoscopy. We then undertake a review of recent literature addressing important aspects of this procedure.

Pleurodesis by erythromycin, tetracycline, Aerosil™ 200, and erythromycin plus Aerosil™ 200 in a rat model: a preliminary study

BackgroundNone of the current pleurodesing agents fulfil all the criteria for best pleural sclerosant. Therefore, the search for the ideal agent for chemical pleurodesis still continues. The aim of the present study was to compare the effectiveness of erythromycin, tetracycline, Aerosil™ 200 (hydrophilic fumed amorphous silica), and erythromycin plus Aerosil™ 200 in producing pleurodesis in rats. In the present study, talc was not used as a pleurodesing agent due to an unavailability of its sterile and pure form in Iran.MethodsOverall, 75 adult male Spraque-Dawley rats were randomized to 5 treatment groups. Each group received an intrapleural injection via 5 Fr Silastic tubes of one of the following sterile agents: 35mg/kg erythromycin in 2 ml of saline, 35mg/kg tetracycline in 2 ml of saline, 35mg/kg Aerosil™ 200 in 2ml of saline, erythromycin (35mg/kg in 2 ml of saline) plus Aerosil™ 200 (35mg/kg in 2 ml of saline), or 2 ml of saline as a control. The animals were euthanized and necropsied 30 days after injection. The pleurae were assessed for macroscopic and microscopic evidence of surrounding inflammation and fibrosis.ResultsThe median macroscopic score in the Aerosil™ 200 group was significantly higher than that in the erythromycin group (P < 0.005). The median microscopic score in the erythromycin group was significantly lower than that in the Aerosil™ 200 and erythromycin plus Aerosil™ 200 groups (P < 0.005). Furthermore, maximum and minimum pleural fibrosis was observed in the erythromycin plus Aerosil™ 200 and erythromycin groups, respectively (P < 0.05).ConclusionThis study suggests that Aerosil™ 200 with or without erythromycin may be more potent pleurodesis agent than erythromycin and tetracycline.

Pleurodesis using different agents in malignant pleural effusion

ObjectiveMalignant pleural effusions (MPE) are characterized by rapid reaccumulation, after tapping, and many symptoms related. Pleurodesis, for the management of MPE, is intended to achieve symphysis between parietal and visceral pleura, and to prevent relapse of pleural effusion. Many chemical agents are tried to induce abrasion and damage of the pleural mesothelial layer to achieve this symphysis. AimThe aim of this study is to compare the results of medical pleurodesis, using 4 different chemical agents in these cases, to reach an efficient one with minimal complications. MethodsBetween July 2010 and July 2012, 40 patients with MPE, divided into 4 groups, underwent medical pleurodesis using 4 chemical agents in comparison: bleomycin, doxycycline, povidone iodine and 5-fluorouracil. ResultsImmediately and for 3months after the procedure, the results of pleurodesis were assessed and the final reported success rates were 70% for bleomycin, 80% for doxycycline and 80% for povidone iodine, while 5 fluorouracil had the lowest success rate (50%) (P-value<0.05). ConclusionBleomycin, doxycycline and povidone iodine are nearly equally effective and safe pleurodetic agents when used in the optimal dose, while 5-fluorouracil had a much higher failure rate. Although povidone iodine and doxycycline are as effective and safe as bleomycin, they are cheaper alternatives and more available chemical agents for pleurodesis in cases with MPE.

Chemical pleurodesis for malignant pleural effusion

Background and ObjectivesMalignant pleural effusion is a common complication of primary and metastatic pleural malignancies. It is usually managed by drainage and pleurodesis, but there is no consensus as to the best method of pleurodesis, this study was designed to compare the effectiveness, side effects, and cost of different chemical pleurodesis agents used in patients with malignant pleural effusion. MethodsSeventy-five patients with malignant pleural effusion were assigned into five groups each of 15 patients, Talc slurry 5gm, Tetracycline500mg, Bleomycin1IU/kg, Iodopovidone (2%) and patients underwent tube drainage only. Tube thoracotomy was performed in all patients and agents were administered through the chest tubes. ResultsTetracycline, talc slurry, iodopovidone andbleomycin, resulted inan insignificantly different success rates of 80%, 80%, 66.6%.73.3%, at 30days and, 66.6%, 73.3%, 60%, 66.6%, at 60days respectively while tube alone was much lower, 40% and 26.7% respectively. Chest tubes were removed after an average of 7.2±1.4days for tetracycline, 7±0.8days for talc slurry, 7.6±0.9days for iodopovidone and 6.4±1.5 days for bleomycin which did not differ significantly. Chest pain was more common in the tetracycline group, dyspnea was more common in the talc group, and fever was more common in the iodopovidone group. ConclusionSince tetracycline, talc slurry, iodopovidone, andbleomycin achieved comparable success rates in this study, we suggest that the drug availability and cost are important factors in choosing a sclerosing agent in developing countries.

Application of Subcutaneous Talc after Axillary Dissection in a Porcine Model Safely Reduces Drain Duration and Prevents Seromas

Talc, the most common pleurodesis agent, has recently been shown to prevent seromas and decrease drain duration when placed subcutaneously after large subcutaneous dissection accompanying open ventral hernia repair. We hypothesized that talc would decrease drain duration and prevent seromas after axillary dissection without local or systemic side effects. Six pigs underwent full, bilateral axillary dissection (n 12 dissections). Three animals each had aerosolized small particle (SP) talc and large particle (LP) talc sprayed unilaterally (TALC) before closure, with the contralateral axillary dissection serving as the control (NOTALC). Functional status, wound complications, and drain duration were recorded. Local neurovascular structures and systemic organs were harvested at 28 days, processed with hematoxylin and eosin, and examined under normal and polarized light microscopy by blinded physicians. All pigs were back to baseline functional status by 72 hours. Two seromas (33%) were noted in the NOTALC dissections vs 0 in the TALC group (0%). Drain duration was significantly decreased in TALC vs NOTALC dissections (8.3 ± 2.7 vs 12.0 ± 3.2 days, p = 0.03), as was total drain volume (222.5 ± 127.1 mL vs 334.2 ± 137.9 mL, p = 0.02). Gross and histologic evaluation revealed neurovascular structures to be intact. Minimal splenic deposition of talc within macrophages without evidence of injury was identified in all specimens, with fewer deposits in the large particle talc group. Serum laboratory examination at time of harvest revealed all animals to have normal values. Direct application of talc throughout the wound after axillary dissection in pigs decreased drain duration and drain volume and prevented seroma formation. Gross, histologic, and serum laboratory evaluation demonstrated no talc-related local or systemic complications. Aerosolized talc is an effective and safe pretreatment to prevent seromas and hasten drain removal after axillary dissection.

A randomized controlled trial of the efficacy of cosmetic talc compared with iodopovidone for chemical pleurodesis

Talc is an effective and widely used agent for chemical pleurodesis. However, limited availability and high cost hamper the routine use of talc in resource poor countries. In this study, we compared the efficacy and safety of iodopovidone with that of cosmetic talc, for chemical pleurodesis. Patients with recurrent pleural effusions and/or spontaneous pneumothorax were prospectively randomized to undergo pleurodesis with cosmetic talc (5g) or iodopovidone (20mL of a 10% solution) by tube thoracostomy. The cosmetic talc was pretested for impurities (asbestos-free) and particle size (20-60µm), using energy dispersive analysis by X-ray and scanning electron microscopy. The success rate (complete or partial), time to pleurodesis and safety of these two agents was compared. Pleurodesis was performed in 73 patients (39 with iodopovidone, 34 with cosmetic talc; 56 men, 17 women; mean age 51.7 years; 38 pleural effusions, 35 pneumothoraces). A complete response was obtained in all patients with pneumothorax in both the iodopovidone and talc groups. Among patients with pleural effusions, a complete response was observed in 16/19 and 15/19 patients in the iodopovidone and talc groups, respectively. A partial response was observed in two additional patients from each group. The time to pleurodesis was similar in the two groups. Minor side-effects (fever, chest pain) were observed with similar frequencies in the two groups. None of the patients experienced hypotension or ARDS. Iodopovidone and cosmetic talc are equally efficacious and safe agents for chemical pleurodesis.

Pleural controversy: Pleurodesis versus indwelling pleural catheters for malignant effusions

Malignant pleural effusions (MPE) are a common complication of advanced malignancy. The treatment of MPE should be focused on palliation of associated symptoms. The traditional approach to MPE has been to attempt pleurodesis by introducing a sclerosant into the pleural space. A more recent development in the treatment of MPE has been the use of indwelling pleural catheters (IPC) for ongoing drainage of the pleural space. Controversy exists as to which approach is superior. Pleurodesis approaches will have the advantage of a time-limited course of treatment and high pleurodesis rate at the cost of a more invasive procedure requiring a general anaesthetic or conscious sedation (for thoracoscopic approaches) and an inpatient hospital stay. Use of IPC will allow the patient to be treated on an outpatient basis with a minimally invasive procedure, at the cost of long-term need for catheter drainage and care. Symptom control appears similar between techniques. Complication rates between the two approaches cannot be easily compared, but studies suggest more frequent severe complications such as respiratory failure, arrhythmias and even mortality following pleurodesis, with infection rates similar between the two approaches. IPC will likely see increasing utilization in the future but patient preference and local resources and expertise will continue to play a significant part in treatment decisions. Randomized trials directly comparing the two approaches are needed and some are underway. Novel combination approaches utilizing both IPC and pleurodesis agents have the potential to further improve the care of these patients.