• Najib M Rahman, Justin Pepperell, Sunita Rehal, Tarek Saba, Augustine Tang, Nabeel Ali, Alex West, Gihan Hettiarachchi, Dipak Mukherjee, Johnson Samuel, Andrew Bentley, Lee Dowson, Jonathan Miles, C Frank Ryan, Ken Y Yoneda, Anoop Chauhan, John P Corcoran, Ioannis Psallidas, John M Wrightson, Rob Hallifax, Helen E Davies, LeeY C GaryYCSchool of Medicine and Centre for Asthma, Allergy, and Respiratory Research, University of Western Australia, Crawley, Australia., Melissa Dobson, Emma L Hedley, Douglas Seaton, Nicky Russell, Margaret Chapman, Bethan M McFadyen, Rachel A Shaw, Robert J O Davies, Nick A Maskell, Andrew J Nunn, and Robert F Miller.
• Oxford Respiratory Trials Unit and Oxford Pleural Diseases Unit, Churchill Hospital, Oxford, England2National Institute for Health Research Oxford Biomedical Research Centre, University of Oxford, Oxford, England.
• JAMA. 2015 Dec 22; 314 (24): 2641-53.

ImportanceFor treatment of malignant pleural effusion, nonsteroidal anti-inflammatory drugs (NSAIDs) are avoided because they may reduce pleurodesis efficacy. Smaller chest tubes may be less painful than larger tubes, but efficacy in pleurodesis has not been proven.ObjectiveTo assess the effect of chest tube size and analgesia (NSAIDs vs opiates) on pain and clinical efficacy related to pleurodesis in patients with malignant pleural effusion.Design, Setting, And ParticipantsA 2×2 factorial phase 3 randomized clinical trial among 320 patients requiring pleurodesis in 16 UK hospitals from 2007 to 2013.InterventionsPatients undergoing thoracoscopy (n = 206; clinical decision if biopsy was required) received a 24F chest tube and were randomized to receive opiates (n = 103) vs NSAIDs (n = 103), and those not undergoing thoracoscopy (n = 114) were randomized to 1 of 4 groups (24F chest tube and opioids [n = 28]; 24F chest tube and NSAIDs [n = 29]; 12F chest tube and opioids [n = 29]; or 12F chest tube and NSAIDs [n = 28]).Main Outcomes And MeasuresPain while chest tube was in place (0- to 100-mm visual analog scale [VAS] 4 times/d; superiority comparison) and pleurodesis efficacy at 3 months (failure defined as need for further pleural intervention; noninferiority comparison; margin, 15%).ResultsPain scores in the opiate group (n = 150) vs the NSAID group (n = 144) were not significantly different (mean VAS score, 23.8 mm vs 22.1 mm; adjusted difference, -1.5 mm; 95% CI, -5.0 to 2.0 mm; P = .40), but the NSAID group required more rescue analgesia (26.3% vs 38.1%; rate ratio, 2.1; 95% CI, 1.3-3.4; P = .003). Pleurodesis failure occurred in 30 patients (20%) in the opiate group and 33 (23%) in the NSAID group, meeting criteria for noninferiority (difference, -3%; 1-sided 95% CI, -10% to ∞; P = .004 for noninferiority). Pain scores were lower among patients in the 12F chest tube group (n = 54) vs the 24F group (n = 56) (mean VAS score, 22.0 mm vs 26.8 mm; adjusted difference, -6.0 mm; 95% CI, -11.7 to -0.2 mm; P = .04) and 12F chest tubes vs 24F chest tubes were associated with higher pleurodesis failure (30% vs 24%), failing to meet noninferiority criteria (difference, -6%; 1-sided 95% CI, -20% to ∞; P = .14 for noninferiority). Complications during chest tube insertion occurred more commonly with 12F tubes (14% vs 24%; odds ratio, 1.91; P = .20).Conclusions And RelevanceUse of NSAIDs vs opiates resulted in no significant difference in pain scores but was associated with more rescue medication. NSAID use resulted in noninferior rates of pleurodesis efficacy at 3 months. Placement of 12F chest tubes vs 24F chest tubes was associated with a statistically significant but clinically modest reduction in pain but failed to meet noninferiority criteria for pleurodesis efficacy.Trial Registrationisrctn.org Identifier: ISRCTN33288337.

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