What is the key question?

• Is talc poudrage, administered during thoracoscopy with local anaesthesia, more effective at inducing pleurodesis than talc slurry delivered via chest tube?

What is the bottom line?

• Randomised trial of 330 participants with confirmed diagnosis of MPE able to tolerate thoracoscopy. The trial excluded those who needed diagnostic thoracoscopy or had non-expandable lung.
• Groups were randomised to thoracoscopy under moderate sedation or intercostal catheter insertion with local anaesthetic. Each group received 4gm of talc (166 in the talc thoracoscopy/ poudrage group and 164 in the ICC/ talc slurry group).
• Groups were then monitored for 90 days post procedure. Primary outcome was pleurodesis failure, defined as subsequent removal of more than 100mL of fluid, later ICC insertion for management of fluid reaccumulation, insertion of an IPC or thoracoscopy.
• Secondary outcomes were pleurodesis failure at 30 and 180 days, percentage of pleural opacification on chest Xray after ICC removal and at 30,90 and 180 days post randomisation, all-cause mortality up to 180 days, time to pleurodesis failure, health related QOL at 30,90 and 180 days post randomisation.
• 320 patients were included in the analysis. At 90 days, failure rate for pleurodesis was 36/161 (22%) in the thoracoscopy/ poudrage group and 38/159 in the ICC/ talc slurry group (adjusted OR 0.91); P=0.74. No statistically significant difference between groups was noted in secondary outcomes,

Why read on?

• This trial shows no difference between interventions for drainage of MPE when comparing thoracoscopy and poudrage with ICC insertion and talc slurry. The trial may not detect small differences between groups due to a small sample size.