Provenance and peer review:

Not commissioned; externally normally peer reviewed. Data sharing statement: Further study data are not to be shared due to patient data confidentiality when the study was undertaken. The quantitative study has unpublished data available from the corresponding author, while appendices A and B are available for data sharing. Further details of the study protocols can be requested from the corresponding author by emailing (moc.liamtoh@ihsuolabla_d).
Malignant pleural effusion is common and can complicate most cancers, including one-third of patients with lung and breast carcinomas1 2 and most (>90%) patients with malignant pleural mesothelioma.3 Malignant pleural effusions cause breathlessness and frequently require hospitalisation for invasive pleural drainage procedures. In Western Australia (population 1.8 million) alone, inpatient care cost

for malignant pleural effusions is estimated to exceed US$12 million per year. Malignant effusions often herald advanced cancers and limited prognosis. The average life expectancy for patients with this condition is 3 (for metastatic carcinomas) to 9 months (for mesothelioma). Minimising days spent in hospital to maximise time spent at home and/or with family is a high priority to patients.4 5 The ideal treatment approach should include effective long-term symptoms relief (especially dyspnoea), minimal hospitalisation and have the least adverse effects.6 Conventional management involves inpatient talc pleurodesis, which requires hospitalisation, often of 4–6 days in reported series.7 8 Talc pleurodesis also has a high failure rate, which necessitates further pleural interventions/drainages and hospital care. A randomised trial of

482 patients with malignant pleural effusions showed that talc pleurodesis, irrespective of whether delivered by thoracoscopic poudrage or talc slurry via tube thoracostomy, successfully controlled fluid recurrence in only ∼75% of patients at 1 month, and 50% by 6 months.9 Our recent study of pleurodesis in patients with mesothelioma also showed that 71% had fluid recurrence, and 32% required further pleural interventions.10 Talc pleurodesis is known also to have significant side effects.11 Pain and fever are common, and transient hypoxaemia in the several days following pleurodesis days has been reported. It is now recognised that pleurodesis with non-graded talc (still the only type of talc preparation available in many countries) can result in acute AV-951 respiratory distress syndrome.12 In the study of Dresler et al,9 5.3% of 419 evaluable patients developed respiratory failure with a mortality rate of 2%. Indwelling pleural catheters (IPCs) allow ambulatory fluid drainage and are free from side effects, the need for hospitalisation and costs of pleurodesis.13 IPC is increasingly employed for the management of malignant effusions.14 15 To date, two randomised studies have compared IPC with talc pleurodesis,7 16 and another with doxycycline pleurodesis.