Current guidelines that advocate the avoidance of NSAIDs and use of small chest tubes in patients with malignant pleural effusion undergoing pleurodesis have been challenged by a group of international experts.

Writing in JAMA the research team including Professor Y.C. Gary Lee from Sir Charles Gairdner Hospital in Perth, Western Australia explained that clinicians traditionally avoided NSAIDs because they were thought to reduce the efficacy of the procedure by suppressing acute inflammation caused by pleurodesis agents.

Their 2 x 2 factorial phase III trial involving 320 patients with malignant pleural effusions requiring pleurodesis aimed to assess the effect of analgesia (NSAID vs opiates) and chest tube size on pain and clinical efficacy of the procedure.

Patients undergoing thoracoscopy (n=206) received a 24F chest tube and were randomised to receive NSAIDs or opioids.

Those not undergoing thoracoscopy were randomised into four groups: 24F chest tube plus opioids; 24F tube plus NSAIDs; 12F tube plus opioids; and 12F tube plus NSAIDs.

Patients prescribed NSAIDs reported similar pain levels to those prescribed opioids but the NSAID group required more rescue analgesia.

The type of painkiller used also appeared to have little effect on the success of the procedure, results showed.

Pleurodesis failure at three months in the opioid group was 20% compared to 23% in the NSAID group, a finding that met the criteria for non- inferiority (difference −3%, p=0·004), set at –15% throughout the study.

“The findings reassure people that NSAIDs are okay to use during pleurodesis…it won’t dampen the efficacy,” Professor Lee told the limbic.

However in a finding that challenges current guidelines, the researchers discovered that while the small chest tubes were associated with slightly less pain compared with the larger tubes, they were significantly more likely to result in pleurodesis failure (30% vs 24%).

“There’s no clear cut winner – the bigger drain is more painful but works a little bit better,” Professor Lee said.

“In the end it comes down to individual choice — whether you think a 6% higher success rate warrants the pain or not,” he added.