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• The experiences of patients living with malignant pleural effusions
  Rachel Jones, Henry Steer, Nancy Preston and Paul Perkins
  Published on: 2 February 2021

• Published on: 2 February 2021

  The experiences of patients living with malignant pleural effusions

  • Rachel Jones, Medical Registrar Gloucestershire Hospitals NHS Foundation Trust
  • Other Contributors:
    • Henry Steer, Consultant Respiratory Physician
    • Nancy Preston, Professor
    • Paul Perkins, Consultant in Palliative Medicine

  To the editor
  We commend Twose et al for their qualitative study conducted with sixteen patients who had therapeutic thoracocentesis for malignant pleural effusions (MPE)1. Respiratory symptoms improved while constitutional symptoms did not; and even though symptomatic benefit was only for a matter of days, patients thought that it was worth any discomfort.
  We conducted a similar study with patients with MPE who were identified by the pleural team at a large district general hospital. Patients were interviewed four weeks after a talc pleurodesis or placement of an in-dwelling pleural catheter (IPC). An IPC is a plastic tube which can be placed during a day case procedure and allows intermittent fluid drainage in the community.
  A semi-structured electronically recorded interview was conducted by a researcher following a topic guide and, once transcribed, the transcripts were reviewed using thematic analysis by the researchers.

  Some of our results echo those of Twose et al. We had a male and mesothelioma preponderance with our participants – 8 of 10 were male and 6 had mesothelioma. Thoracocentesis was the initial pleural instrumentation for all (some therapeutic, some diagnostic) but subsequently 9 of 10 had an IPC and 6 of 10 had attempted talc pleurodesis (some had both). Pre-procedure symptoms were respiratory and constitutional, and for some thoracocentesis was uncomfortable. Where our study differs is the additional data with regard to patient...

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  To the editor
  We commend Twose et al for their qualitative study conducted with sixteen patients who had therapeutic thoracocentesis for malignant pleural effusions (MPE)1. Respiratory symptoms improved while constitutional symptoms did not; and even though symptomatic benefit was only for a matter of days, patients thought that it was worth any discomfort.
  We conducted a similar study with patients with MPE who were identified by the pleural team at a large district general hospital. Patients were interviewed four weeks after a talc pleurodesis or placement of an in-dwelling pleural catheter (IPC). An IPC is a plastic tube which can be placed during a day case procedure and allows intermittent fluid drainage in the community.
  A semi-structured electronically recorded interview was conducted by a researcher following a topic guide and, once transcribed, the transcripts were reviewed using thematic analysis by the researchers.

  Some of our results echo those of Twose et al. We had a male and mesothelioma preponderance with our participants – 8 of 10 were male and 6 had mesothelioma. Thoracocentesis was the initial pleural instrumentation for all (some therapeutic, some diagnostic) but subsequently 9 of 10 had an IPC and 6 of 10 had attempted talc pleurodesis (some had both). Pre-procedure symptoms were respiratory and constitutional, and for some thoracocentesis was uncomfortable. Where our study differs is the additional data with regard to patients undergoing IPC and pleurodesis.

  In general IPC placement was well tolerated and patients liked that having an IPC meant that there was no need to return to hospital for further thoracocentesis. Care at home, with the support of District Nurses was greatly appreciated, but there were occasional frustrations. For some, placement of an IPC led to a gradual reduction of fluid drainage and pleurodesis leading to tube removal. . For some, subsequent tube removal did not change quality of life, for others it felt liberating.
  For those undergoing chest drain and pleurodesis, there was some dissatisfaction that this necessitated a hospital stay and the chest drain bottle was inconvenient, but improvements in quality of life were worth the effort. We asked patients to reflect on the journey they had taken and whether they would have chosen the same pleural interventions again (multiple therapeutic thoracocenteses versus pleurodesis or IPC). Patients fell into two categories: those who thought that the decision should be made by the medical team and those who were keen for a particular option such as IPC or intermittent drainage.

  Conclusions
  While our findings with regards to removal of pleural fluid are similar to Twose et al’s, our data give some interesting insights into the experiences of patients who have undergone IPC or pleurodesis. Both procedures have burdens and benefits and it is important that patients are guided by clinicians so that they can make informed choices with regards to treatments.

  Table 1: Perceptions of patients after IPC placement or talc pleurodesis

  Perception of patient Exemplar quote(s)
  IPC

  Placement was generally well tolerated “I just felt pushing.” (Patient 1)
  “It wasn’t very pleasant, but it was pain-free, it was just a lot of, sort of, faffing position-wise, and pushing, and shoving, and prodding…” (Patient 7)

  No need to return to hospital “I wouldn’t want to stay in hospital unless I really had to.” (Patient 1)

  Community support “…there was a hiccup the first weekend, the district nurses didn’t turn up.” (Patient 6)

  IPC leading to pleurodesis Initially, it was every couple of days, but now, for the last few weeks, or even four weeks, it’s been weekly” (Patient 5)

  Talc Pleurodesis

  Inconvenience Interviewer: “And for the sake of coming into hospital and spending days in hospital was that transformation sort of worth it?”
  Respondent: “Oh very definitely, yeah, yeah.” (Patient 4)“I don’t recall any particular pain from it, it was just the fact you wanted to go to the loo you’ve got to somehow drag this bucket around with you.” (Patient 4)

  Decision making

  Medical team lead on decision making “Medical people, they should know which you need most.” (Patient 2)

  Patient taking lead on decision making “…you may have to have regular visits all the time, and that means, you know, constant interference. I mean, it’s not the most pleasant experience, and there’s a degree of pain in it…You need something a bit more permanent…” (Patient 5)

  REFERENCES
  1 Twose C, Ferris R, Wilson A, et al. Therapeutic thoracentesis symptoms and activity: a qualitative study. BMJ Supportive & Palliative Care 2021 doi:10.1136/ bmjspcare-2020-002584

  ACKNOWLEDGEMENTS
  We are grateful to the patients who participated in this study.

  CONTRIBUTORS
  PP conceived the study. RJ, HS and NP made substantial contribution to its design. RJ collected the data. All authors contributed to the analysis and interpretation of the data and critically revised drafts of the paper. They also read and approved the final version of the manuscript. PP is the guarantor.

  FUNDING
  Funding for this study was received from the Gloucestershire Hospitals Chest Fund and the Gloucestershire Hospitals NHS Foundation Trust Research and Innovation Forum Fund.

  COMPETING INTERESTS
  All authors have completed the Unified Competing Interests form at http://www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author). There are no competing interests.

  APPROVALS/ETHICS
  The study was approved by Gloucestershire Research Support Service, the Sue Ryder Research Governance Group, the National Research Ethics Service Committee West Midlands (REC Reference 16/WM/0222).

  PROVENANCE AND PEER REVIEW
  Not commissioned; externally peer reviewed.

  DATA SHARING STATEMENT
  Unpublished data are held by Sue Ryder Leckhampton Court Hospice.

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  Conflict of Interest:
  None declared.

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