[Improve the clinical research and standardize the management of pleural diseases]

Based on the clinical evidence obtained during the past decade, we reviewed herein the evidences in the treatment of 5 types of common pleural diseases. (1) Therapeutic pleural interventions are not recommended for patients with malignant pleural effusion (MPE) who are asymptomatic. In patients with symptomatic MPE, large-volume thoracentesis should be performed in MPE patients to figure out if the patient's symptoms are related to the effusion and/or if the lung is expandable; if so, indwelling pleural catheters and/or talc pleurodesis can be used as first-line definitive intervention. Indwelling pleural catheters, but not pleurodesis should be used in those with symptomatic MPE with nonexpandable lung, failed pleurodesis, or loculated effusion. (2) Randomized controlled trials concerning tuberculous pleurisy management are always scarce. Based on the data from pulmonary tuberculosis trials, it can be accepted that anti-tuberculosis treatment regimen for tuberculous pleurisy with isoniazid, rifampin, and pyrazinamide for two months followed by four months of two drugs, isoniazid and rifampin. (3) A combination of tissue plasminogen activator and deoxyribonuclease can be instilled intrapleurally as the initial treatment, or as a follow-up treatment after surgery for pleural infection. The recommended dosages are as follows: tissue plasminogen activator 10 mg, twice a day, deoxyribonuclease 5 mg, twice a day. (4) The randomized controlled trial has provided evidence that conservative management is an acceptable alternative to interventional management for moderate-to-large primary spontaneous pneumothorax. (5) For patients with malignant pleural mesothelioma, nivolumab plus ipilimumab is capable of significantly improving the overall survival of patients versus platinum plus pemetrexed chemotherapy, supporting the use of this regimen as the first-line treatment for these patients, regardless of histological subtype.