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Thoracic oncology and chest procedures network: Pleural disease section

Management of recurrent transudative pleural effusions (REDUCE trial)

Nonmalignant pleural effusions contribute significantly to health care costs and mortality (Mummadi SR et al. CHEST. 2021 Oct;160[4]:1534-51; Walker SP et al. CHEST. 2017 May;151[5]:1099-105). Management of transudative effusions has traditionally been to treat the underlying etiology. However, despite maximal medical therapies, these recurrent effusions may add to patients’ symptom burden and often create a challenge for the clinician. In 2017, the FDA approved the use of indwelling pleural catheters (IPC) in patients with recurrent transudative effusions, but data are limited.

In a recent prospective multicenter randomized control trial, Walker and colleagues (Eur Respir J. 2022 Feb;59:2101362) aimed to compare IPCs to repeated therapeutic thoracentesis (TT) in the management of transudative effusions. Pleural fluid etiologies included heart (68%), liver (24%), and renal failure (8%). The primary outcome was mean dyspnea score (daily visual analog scales) over 12 weeks, and there was no significant difference noted (39.7 vs. 45.0, mean difference –2.9 mm, 95% confidence interval [CI] –16.1 to 10.3; P = .67). Secondary outcomes demonstrated increased overall drainage in the IPC vs. TT group (17,412 mL vs. 2,901 mL, difference 13,892 mL, 95% CI, 7,669-20,116 mL; P < .001) and fewer invasive procedures required in the IPC group. Adverse events were noted in 59% of the IPC group compared with 37% managed with TT (OR, 3.13, 95% CI, 1.07-9.13, P = .04).

The REDUCE trial offers valuable data, but failure to meet primary outcome, study size, and adverse events highlight limitations to a definitive change in practice. Further study with specific-disease processes (ie, cardiac) may be helpful in the future. As in malignant pleural effusions, the selection of definitive pleural intervention should be tailored for each patient.

Maria Azhar, MD

Network Member-at-Large

Saadia A. Faiz, MD FCCP

Section Steering Committee Chair