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This is right therapy, right conversation, right system, a four-part podcast series focused on practical, patient-centered approaches to recurrent pleural effusion care. In this first episode, moderator Doctor Argento is joined by Doctor Gillespie for a practical discussion on choosing a definitive strategy for patients with recurrent pleural effusion. Together they explore how clinicians can move beyond repeated short-term drainage and instead match therapy to the patient's symptoms, lung expandability, clinical trajectory, care goals, and support at home. From pleurodesis to indwelling pleural catheters and combination approaches, this conversation highlights the key decision points that can help teams select the right therapy for the right patient at the right time. Welcome to a podcast series named Right Therapy, Right Conversation, Right System. This is going to be a four-episode series um where we discuss all aspects of management of recurrent pleural effusions. Welcome to episode one. I am being joined today by Doctor Colin Gillespie from the Cleveland Clinic. My name is Doctor Christine Argento. I'm from Johns Hopkins. We're both interventional pulmonologists, and we're gonna talk today about choosing a definitive strategy for recurrent pleural effusion matching therapy to the patient. Welcome, Doctor Gillespie, and thanks so much for joining me today. Thank you very much, Christine. It's always a pleasure to have the opportunity to, to speak with you. So tell me, so you're an interventional pulmonologist at Cleveland Clinic. How often do you see pleural disease and patients who have pleural effusions? Um, we have a, a robust clinical practice focused around pleural effusions. Um, and I think this is something that is, uh, an idea that's taking off around our, the pulmonary world, um, recognizing that The role of a pulmonologist in the management of people with pleural effusions is far beyond just performing thoracentesis. So when you have recurrent malignant effusions, Or just recurrent pleural effusions in general, how do you decide what is the best approach to take? Do you, do you repeat a thoracentesis multiple times and then come up with an answer? Is it a multidisciplinary decision? Is it something that you discuss mainly with the patient? And are there specific things that you talk about or that you think about to individualize your approach with each of your patients? So at our institution, we have uh a plural service where any patient with an infusion can be sent. Um, in focusing on the population of the patients with an underlying malignancy and recurrent diffusion, you know, our primary goals really are far beyond just seeing them with an infusion as a single entity. The goal really is to focus on how do we take this patient. Perform the fewest number of procedures and allow them to get the greatest benefit in terms of avoiding dyspnea and other complications related to that effusion. In doing those things, they generally are the best version of themselves as far as getting treated for the underlying problem, which is the primary issue. So then how do you counsel someone between doing sort of a one and done type of attempt such as a pleurodesis versus like a home pathway where they're gonna have continual management of a device like an indwelling pleural catheter? So this is something that um I think um really falls into the The umbrella of not just a multidisciplinary, but, you know, a shared decision making process. I mean, we take a lot of um energy and effort to make sure that patients understand what their options are and that they actually have options. Many times people will come having had multiple taps previously without any understanding of what their potential options are. Um, and so we really want to make sure that people um understand that there are often Different approaches that can be taken and we try very hard to tailor those to what's best for the patient and what matches their um primary treatment guidelines, um, uh, or their, their treatment plans, um, uh, so that we get the best possible outcomes. So can you give me an example of what kind of things a patient tells you that makes you lean towards a tachypleurodesis? Well, so when someone comes in, you know, a lot of it depends on what's the underlying cancer, what's their underlying performance status. So is this somebody who is an inpatient that's coming to you? Um, is this somebody who's an outpatient who's walking into your office after having been seen by the oncologist and complaining of shortness of breath? The people that we're talking about, um, performing a pleurodesis on, the first sort of major threshold they have to clear is we have to know and understand that their lung fully re-expands to fill their chest. So patients who have an underlying entrapped lung are generally not patients who are going to be candidates for a CAC or any other kind of pleurodesis, and those patients will get shunted directly to a tunnel pleural catheter to manage their symptoms. For patients that have, um, uh, a fully expandable lung and an adequate performance status, you know, we often will talk to them about what their, um, uh, interests are, um, in terms of time in the hospital, uh, the theoretic invasiveness of the procedure, um, what their social situation is like, you know, people who have You know, supportive families and supportive environments, you know, tunnel catheters are a fantastic approach to manage their symptom burden. Um, for somebody who is, um, uh, doesn't have that, that depth of, of, of support at home, those people often will, will, will lean hard towards, uh, uh, a pleurodesis to manage their symptoms. Um, and then some of it's, you know, if a, a patient has a robust performance status and is very active, um, you know, they might opt. To, to go one direction or another. And to be honest, I've been surprised that, you know, I have patients that I would never suggest, um, that I would think would want a pleurodesis that, um, say they, they don't want to spend one minute in the hospital longer than, than they absolutely have to. And if they could get an outpatient procedure done, that's their preference. So, you know, there's a lot of time spent, um, sort of sounding out these different approaches for patients. And you mentioned something kind of important, this idea of a non-expendable or entrapped lung. Um, how do you decide if somebody has one of those? So there's, um, uh, a number of different things that you can, can see, find, and experience, um, you know, you know, some, some clues potentially are when you're draining patients, people who often have a lot of, of discomfort with, um, uh, the drainage of the simple thoracentesis, um, you know, you have the potential option of measuring intrapleural pressures, um, and people with very negative pressures or people that you would suspect. And I think that, you know, the world is sort of swings and pendulums, and I think that the idea of post thoracentesis chest X-rays, people have sort of fallen away from because they think like, oh, there's data that says you don't need it, but you don't need it for finding complications. But that post-procedure X-ray is invaluable in understanding. Does that lung expand? Do you document what percentage of that lung is non-expandable? Um, is this somebody who you think is a, is a candidate, um, to have other options? So the chest X-ray is a big part of what we do. Yeah. And do you, does your lung have to fully expand, like 100% in order to get blurred yeast, or is it sometimes possible if you have a little bit of trapped or entrapped lung? That's going into the, the weeds a little bit, but, but yes, um, you don't necessarily have to have 100% pleural acquisition. Um, and the data on this question isn't great, but, you know, the number that I think about is, is 80%. As long as I've got an 80% expansion of the chest, I'll consider it. But some of that depends on where is the entrapment, um, you know, How frequently is this patient re-accumulating, you know, the volume of accumulation of fluid to me has a has a role in deciding whether a pleurodesis is a good choice. You know, there's lots of literature about pleurodesis that's been around for a long, long time, but there's so much subtlety to this that, you know, it takes a lot of time and experience to sort of start to put together what's your approach. And so people who are having, you know, Taps once a week or, you know, large, large volume, 1 L 1.5 L, um, uh, at a, at a good clip. The, the high output pleural effusions in my personal experience are patients that tend to have higher failure rates from top pleurodesis. Um, and, um, and so, you know, I make sure that when we're talking to patients about options that I give them some sort of assessment of what do I think their, their outcome of the outcome that they're looking for to be achieved. Yeah, I think that's so important. And then, you know, so then what would guide you, I think you've covered some of this already, but towards the patients that maybe wouldn't be a great pleurodesis candidate but would do really great with an, an indwelling pleural catheter or an IPC. Um, so again, someone who's got a good home environment, um, uh, you know, somebody who's got a supportive, stable structure, um, those are people that are, are, you know, first and foremost, have the, the opportunity, um, to do well with the catheter. Um, uh, and then, you know, making sure that, um, Uh, that, you know, they understand that the, the duration of this catheter is something that they have to be comfortable with because, you know, when you, you give someone a tunnel catheter, they have to understand that. I can't look them in the eye and tell them that you're going to have this catheter for X period of time. So, you know, we can talk about some of the trials that have been done about the frequency of achieving an auto pleurodesis, um, uh, versus the, the indefinite need for a tunnel catheter. Um, uh, you know, we have to talk about the frequency that they're going to be draining this catheter and what the implications of that frequency are on potentially achieving an auto pleurodesis. Um, uh, but I think that, you know, The most valuable sort of messaging that I give the patients is that, you know, this is really a choice that they can make. In what's best for them, because the outcome of having a tunnel catheter versus a pleurodesis in terms of management of their symptoms is the same. One doesn't perform better than the other, um, and that your personal choice is, is really, uh, a huge variable to be considered. Well, that's a great segue also. So, um, so speaking about drainage of an indwelling pleural catheter, how often do you counsel your patients to drain them? So for patients, um, That have fully expandable lungs, um, you know, I tend to, to fall into the side of an aggressive drainage strategy, at least initially. Um, you know, um, while the data is not perfect, um, you know, we do think that aggressive daily drainage upfront is associated with a shorter duration of, um, uh, um, catheter need. Um, and so, you know, we will often have people drain aggressively, um, make sure that they understand the importance of recording those outputs. Because when they come back to see us in the office, um, Looking at that tells us a lot about sort of their potential trajectory. People that have a slowly diminishing, um, output or people that, you know, I might continue on an aggressive drainage strategy. People who have, um, persistent high output, I, you know, sometimes we'll, you know, say that it's OK at this point, maybe we just go to every other day, and some of it depends on, then the most importantly is how do they feel, you know, the goal of this catheter is to give that patient control over their symptoms. And if patients obviously feel better with daily drain, that's the way to go. And if they can get away with every other day drainage, um, uh, that's also an acceptable route. I feel like you're just anticipating all my questions. I was gonna ask if the goal is always autopleurodesis or if sometimes the goal is just to make them feel well enough to go about their daily life, and if so, does that change your drainage strategy? So, um, you know, people who haven't, you know, either, um, demonstrated a, a decreasing, um, uh, output from their tunnel catheter, um, I will frequently, um, you know, advise them to go to a, an alternating day, uh, approach, or, you know, patients will often develop their own sense of, you know, How much value do they get from that drainage? Um, uh, sometimes it's financial, um, but, you know, there are many different pathways to, to obtain, um, drainage materials. So, you know, there's lots of nuance there. Um, uh, the place where I think an important designation is for people with a trapped lung. Those are patients that, um, uh, I will counsel to drain frequently on a, a, a less frequent basis. Uh, I generally never go less than once a week, um, but, you know, uh, the frequency of draining somebody with an entrapped lung, um, uh, you know, we can do on a, on a symptom-based approach. Um, the other thing that I tell everyone, regardless of whether the lung expands or they have an entrapped lung, I, you know, we spend a lot of time making sure people understand that we want them to drain slowly, um, because the slower you drain, generally, the more fluid you get and the more comfortable it is for the patient. Um, rapid drainage is often more associated with discomfort for people, and so we wanna go, go slow, um, uh, and, and get, get the fluid off. Is there a scenario where you can actually combine both of these approaches, where you can do pleurodesis as well as having indwelling catheter and Maybe make things better or shorten the process. Um, so in our practice, we have, uh, an active thoracoscopy program and we have a great relationship with our thoracic surgical colleagues. Um, and so for patients who You know, either we don't have a diagnosis yet or there's a need for more tissue and they have a known malignant pleural effusion. Those are people that we will do a procedure called thoracoscopy on. And if we're doing thoracoscopy and our index of suspicion is high for a malignant process, we will talk to people beforehand. About the possibility of doing, uh, a combined, uh, diagnostic and therapeutic procedure where we give them the option of having their biopsies done. And if they, and usually we know in advance that this lung expands. Um, and if their lung expands fully, we will tell them they have the option of having talc, um, uh, sprayed into the chest, um, and then, um, We'll finish that procedure by placing a tunnel catheter. Um, now, what's different about having a tunnel catheter placed in that, um, scenario in our practice is You know, we do drain quite aggressively to start. Um, uh, sometimes that means that I keep people in the hospital overnight for one night. Um, and I drain them continuously, um, uh, through that tunnel catheter, um, while they're, uh, in-house overnight and then they'll be capped and we, um, you know, I, I, I will drain twice a day for a few days and then go to once a day drain it until they come back to see me. Um, and we usually see people within 2 weeks of that procedure. There is some sense that, you know, when you do this approach, you do have a shorter duration of need for that tunnel catheter, and that's something that many people find to be a very valuable option. OK. So for those, so then this would be sort of a smaller group of patients that would be able to tolerate a surgical procedure, um, and that are looking to sort of get the best of both worlds. That's how you select these folks? For sure. Um, and you know what, we generally have, you know, I generally am very comfortable in, I don't offer this to somebody who I don't think can handle the procedure. And um the nice part about medical thoracoscopy is that we generally will do this in the absence of general anesthesia and so that physiologic sort of um uh uh challenge for patients is certainly less and you know I have had um uh a long, long history of doing this with really great outcomes. So, you know, I feel like we can do this with uh minimal um perturbations to the patient's underlying. Um, uh, condition, um, we can get, uh, people through the procedure very successfully and get them out with the best possible outcome. So the combined approach is something that is definitely worth doing. But, um, it's also important to recognize that if you choose a tunneled catheter and you're in that unfortunate population that isn't pleurodesing, um, you still have the potential to have a pleurodesis performed with that tunneled catheter. You stole my thunder. That was my next question, but I love it. Um, so that's perfect. So if you didn't, let's say, go through this, uh, thoracoscopy where you potentially have biopsies, you drain the, the fluid, and then undergo either a pleurodesis or an, uh, an IPC placement at that time. Um, if you just undergo an IPC placement, then you can down the road, attempt a pleurodesis with talc through that catheter. Absolutely. Um, so there was a, a, a paper, um, uh, in, in the New England Journal, and, and interventional pulmonary papers published in the England Journal aren't very common, so they generally get a lot of attention. So that was the first time that an ambulatory pleurodesis was sort of demonstrated as a potential option, and they did find that utilizing the tunnel catheter as a conduit for a tau pleurodesis. Um, uh, was successful in increasing the ability to achieve that pleurodesis. I think that's amazing. So Doctor Gillespie, I think we're getting to the end of our time here. Is there any, are there any good great papers or resources um that you would recommend uh our listeners to go to if they have further questions or want to dive a little bit deeper? Um, so in 2023, the British, the British Thoracic Society published, um, a series of guidelines on the management of pleural disease, um, and malignant pleural effusion management is part of that document. I think it's a, it's a great resource, um, and it gives you links to lots of uh seminal papers to help you formulate a practice that works within your infrastructure, um, uh, and your patient population. Thank you so much for joining and please join us for episode 2, The Right Conversation, Shared Decision Making Across Oncology and plural teams with Doctor Nisha Mohindra, a medical oncologist. That will be our next episode. Thank you for listening to this episode of Right Therapy, Right Conversation, Right System. We hope this discussion with Doctor Argento and Doctor Gillespie helped clarify how to think through therapy selection for patients with recurrent pleural effusion and how to match the treatment strategy to the patient's clinical picture and goals of care. Be sure to tune in to the next episode where Doctor Argento will be joined by Doctor Mohindra to explore the right conversation. Shared decision making across oncology and plural teams. Thanks for being part of the BD Advanced Community. This podcast is intended for educational purposes only. Follow and subscribe so you never miss an episode. For more clinical education, visit advanced EDU.bd.com. We look forward to continuing the conversation in our next episode. BD and the BD logo are trademarks of Becton Dickinson and Company or its affiliates. Copyright 2026 BD all rights reserved.
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