Mineo, T.C., Sellitri, F., Tacconi, F., & Ambrogi, V. (2014). Quality of life and outcomes after nonintubated versus intubated video-thoracoscopic pleurodesis for malignant pleural effusion: Comparison by a case-matched study. Journal of Palliative Medicine, 17, 761–768. 

To evaluate outcomes after video-assisted thoracic surgery pleurodesis among intubated patients and unintubated patients under local anesthesia

Consecutive patients who received unintubated video-assisted pleurodesis were matched with patients who preferred general anesthesia and were intubated for the procedure. Data were obtained from a retrospective review. Cases were matched on age, gender, performance status, history, and type of tumor. Patients with extrathoracic metastases were excluded. Patients received intercostal blocks and sedation with remifentanil. For the intubated group, general anesthesia was induced with propofol, fentanyl, and vecuronium. Talc was used for pleurodesis in both groups. Postoperative management was the same in both groups.

• N = 462–231 (intervention group)  
• MEAN AGE = 64.3 years
• MALES: 55%, FEMALES: 45%
• KEY DISEASE CHARACTERISTICS: Multiple tumor types with secondary pleural malignancy; most common was lung cancer followed by breast cancer

• SITE: Single site  
• SETTING TYPE: Inpatient  
• LOCATION: Italy

• PHASE OF CARE: Active antitumor treatment
• APPLICATIONS: Palliative care 

Retrospective, descriptive study with a matched control comparison

• European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC-QLQ C30)

Anesthesia time (p < 0.0001) and recovery room time (p = 0.0002) were significantly shorter in the unintubated group. Postoperative hospital stays were 1.8 days shorter on average in the unintubated group (p = 0.011), and postoperative morbidity (p = 0.042) and mortality (p = 0.017) were lower in the unintubated group. Pleurodesis was successful in more than 83% of patients in both groups, and costs were lower in the unintubated group. Physical function (p < 0.05) and dyspnea (p < 0.01) were more improved in the short-term among the unintubated patients. There was a higher rate of major subcutaneous emphysema in the unintubated group. There were no differences between the groups in effusion-free time or overall survival.

Video-assisted pleurodesis under local anesthesia without the need for intubation was associated with shorter postoperative hospital stays, fewer short-term postoperative issues, and improved dyspnea compared to similar patients who received traditional pleurodesis under general anesthesia.

• Risk of bias (no blinding)
• Risk of bias (no random assignment)
• Other limitations/explanation: The study included people with good performance statuses, so findings may not be applicable to those with poorer physical conditions overall.

The performance of pleurodesis under local anesthesia with video-assisted thoracic surgery was shown to improve short-term postoperative outcomes compared to procedures done under general anesthesia in this study. There were some differences in postoperative complications between patients who had general anesthesia versus those who did not, so nurses need to be aware of the potential differences in complications according to the type of procedure done and assess patients accordingly. The applicability and safety of this approach in patients with very poor overall performance status is not clear.