Clinical question: For pleurodesis, do nonsteroidal anti-inflammatory drugs and smaller chest tubes, as compared with opioids and larger tubes, provide better pain relief while maintaining efficacy of the procedure?
Bottom line: Although nonsteroidal anti-inflammatory drugs (NSAIDs) are not necessarily more effective than opiates for pain relief after pleurodesis, they should be considered a safe and effective analgesic option for these patients. NSAIDs do not lead to higher rates of pleurodesis failure. Using a smaller chest tube, on the other hand, does not provide a clinically significant pain benefit and may ultimately lead to a higher rate of pleurodesis failure. (LOE = 1b)
Reference: Rahman NM, Pepperell J, Rehal S, et al. Effect of opioids vs NSAIDs and larger vs smaller chest tube size on pain control and pleurodesis efficacy among patients with malignant pleural effusion. JAMA 2015;314(24):2614–2653.
Study design: Randomized controlled trial (nonblinded)
Funding source: Government
Setting: Inpatient (any location) with outpatient follow-up
Using concealed allocation, these investigators randomized 320 patients requiring pleurodesis for malignant pleural effusions to receive either NSAIDs or opioids and small or large (12F vs 24F) chest tubes. Patients who underwent thoracoscopy, which necessitates a 24F tube postprocedure, were randomized to receive either NSAIDs or opiates but were not included in the chest tube size analysis. Those who did not undergo thoracoscopy were randomized into both arms of the trial, either NSAIDs or opiates and either 12F or 24F chest tubes.
The NSAID groups received 800 mg ibuprofen 3 times daily as needed; the opiate groups received 10 mg to 20 mg oral morphine up to 4 times daily. The patients were not masked to any of the interventions. All patients also received scheduled 1g acetaminophen 4 times daily and intravenous morphine as needed for breakthrough pain. Pain was measured using a 100-mm visual analog scale. Pleurodesis failure was defined as requiring another pleural intervention within 3 months after randomization. Patients had similar baseline characteristics in all treatment groups, except for more men in the larger chest tube group.
Overall, there was no significant difference detected in mean pain scores while the chest tube was in place in the NSAID group as compared with the opiate group, but the NSAID group required more breakthrough intravenous morphine than the opiate group (38% vs 26%; P = .003). Patients in the smaller chest tube group reported less pain than the larger tube group (mean visual analog scale score = 22 mm vs 27 mm; P = .04). Although this finding was statistically significant, the absolute difference in pain scores was small and not necessarily clinically meaningful. For pleurodesis failure, the NSAID group was noninferior to the opiate group; however, the smaller chest tube group had a higher rate of pleurodesis failure and did not meet noninferiority criteria. Pain scores at 1 or 3 months, adverse events, and mortality did not differ for either of the comparisons.
Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.