S118 Interventions for the management of malignant pleural effusions: a network meta-analysis

Introduction and Objectives Wider availability of interventions such as indwelling pleural catheters (IPCs) has increased the range of treatment approaches for patients with malignant pleural effusion (MPE). We have updated the 2016 Cochrane review to define the optimal management strategy for MPE in terms of pleurodesis success. Secondary outcomes were adverse events, breathlessness, quality of life, cost, mortality, survival, duration of inpatient stay and patient acceptability. Methods Databases (including CENTRAL, MEDLINE and Embase) were searched to June 2019 for randomised controlled trials of intrapleural interventions for adults with symptomatic MPE. We performed network meta-analysis (NMA) of primary outcome data and secondary outcomes with sufficient data, and pairwise meta-analysis of direct comparisons. Sensitivity analyses explored causes of heterogeneity. We assessed the certainty of evidence using GRADE. Results Our primary NMA on pleurodesis failure included 55 studies of 21 interventions. The pleurodesis failure rate of talc poudrage (TP) compared to talc slurry (TS) was similar (OR 0.50, 95% Cr-I 0.21, 1.02), with direct meta-analysis demonstrating comparable breathlessness control (100 mm visual analogue dyspnoea scale mean difference 4.00 mm, 95% CI -6.26, 14.26). IPCs were less likely to effect a pleurodesis than TS (OR pleurodesis failure 7.60, 95% Cr-I 2.96, 20.47). Daily IPC drainage or instillation of talc via IPC may enhance pleurodesis rates. In direct meta-analysis, participants with an IPC required fewer repeat invasive pleural procedures than those receiving TS pleurodesis (OR 0.25, 95% CI 0.13, 0.48) with comparable breathlessness control (mean difference -6.12 mm, 95% CI -16.32, 4.08). Networks evaluating fever, pain and mortality found uncertain evidence of minimal differences between interventions. Heterogeneity was reduced in sensitivity analysis of studies at low of risk of bias. We summarised our data using summary of findings tables (see table 1). Conclusions This is the largest systematic review of the evidence for interventions for MPE in the literature. Our updated NMA, demonstrating that TS, TP and IPCs offer comparable breathlessness control, highlights the importance of informed patient choice. IPCs confer a lower risk of requiring a repeat invasive pleural procedure. Future research to determine the healthcare utilisation associated with IPC use, including potential burden of community drainages would be beneficial.