Dipper et al., (2020),

Cochrane Database of Systematic Rev, UK [2]

Meta-analysis

(level I)

Databases: CENTRAL, Medline (Ovid), Embase (Ovid).

Inclusions: RCTs of intrapleural interventions for adults with symptomatic MPE.

A: Povidone-iodine via ICC post-VATS (I) versus VATS talc insufflation (TP)

Articles (n = 1)

Participants (n = 42; I = 20, TP = 22)

B: Povidone-iodine via ICC versus talc slurry via ICC (TS)

Articles (n = 2)

Participants (n = 75; I = 36, TS = 39)

A: OR 1.76 [0.26, 11.8], P = 0.56

B: I 15.0% (3/20) vs TP 9.1% (2/22)

A: OR 1.17 [0.32, 4.25], P = 0.81

B: I 16.7% (6/36) vs TS 15.4% (6/39)

This network meta-analysis also examined talc against other available methods of pleurodesis including bleomycin and tetracyclines.

Studies included:

- Mohsen

- Agarwal

- Ibrahim

Conclusions:

Local availability, experience, adverse events and patient preference should be considered when selecting intervention.

A: OR 0.24 [0.02, 2.33], P = 0.22

B: I 5.0% (1/20) vs TP 18.2% (4/22)

A: OR 0.93 [0.28, 3.13], P = 0.91

B: I 16.7% (6/36) vs TS 17.9% (7/39)

Pain

A: Pain requiring NSAIDs or narcotics

B: Any pain

A: OR 0.10 [0.01, 1.99], P = 0.13

B: I 0% (0/20) vs TP 18.2% (4/22)

A: OR 0.5 [0.14,1.83], P = 0.29

B: I 75.0% (27/36) vs TS 82.1% (32/39)

Muthu et al., (2021),

Supportive Care Cancer, Online [3]

Meta-analysis

(level I)

Databases: PubMed, Embase

Inclusions: >10 participants per study receiving povidone-iodine pleurodesis for MPE with efficacy outcomes available.

Exclusions: conference abstracts, editorials, reviews, case reports, <10 patients.

Observational (n = 15)

Comparison of povidone-iodine (I) versus talc (T) (n = 2)

RCT (n = 11)

Comparison of povidone-iodine (I) versus talc (T) (n = 4)

This network meta-analysis also examined povidone-iodine against bleomycin, cyclophosphamide, doxycycline, 5-fluorouracil, tetracycline, vincristine and viscum.

Studies included:

- Mohsen

- Agarwal

- Shouman

- Ibrahim

- Das

Conclusion:

No statistical difference between povidone-iodine and the comparative agents in terms or success or safety.

Agarwal et al., (2011),

Respirology, India [4]

RCT

(level II)

I: Povidone-iodine via ICC (n = 18)

T: Talc slurry via ICC (n = 18)

Inclusions and exclusions as per Dipper et al., meta-analysis

I: 5.5% (1/18)

T: 11.1% (2/18)

Conclusion:

Povidone-iodine and talc are equally efficacious and safe.

I: 100.0%

T: 100.0%

I: 0.0%

T: 0.0%

I: 10.3%

T: 14.7%

I: 0%

T: 0%

Mohsen et al., (2011),

Eur J Cardiothorac Surg, Egypt [5]

RCT

(level II)

Inclusion: MPE due to metastatic breast cancer.

I: Povidone-iodine via ICC post-VATS (n = 20)

T: VATS talc insufflation (n = 22)

Mean follow-up: 22.6 months (range: 8–48)

CR

PR

Failure

I: 85.0% (17/20)

T: 86.4% (19/22)

I: 0.0% (0/20)

T: 4.5% (1/22)

I: 15.0% (3/20)

T: 9.1% (2/22)

P = 0.9

Conclusion:

Povidone-iodine is a good alternative to talc in MPE due to metastatic breast cancer. Povidone-iodine is available, cost effective, safe, can be given through a ICC and can be repeated if necessary

MRC dyspnoea scale I

MRC dyspnoea scale II

I: 75.0% (15/20)

T: 63.6% (14/22)

P = 0.92

I: 25.0% (5/20)

T: 36.4% (8/22)

P = 0.79

I: 0.0% (0/20)

T: 18.2% (4/22)

P = 0.2

I: 5.0% (1/20)

T: 18.2% (4/22)

P = 0.5

I: 4.5 ± 1.1

T: 5.7 ± 2.0

P = 0.02

I: 33.8

T: 27.7

P = 0.2

Shouman et al. (2012),

Egypt J Chest Dis Tuberc, Egypt [6]

RCT

(level II)

Inclusions: MPE

Massive pleural effusion or rapidly accumulation.

Subjective improvement in dyspnoea following thoracocentesis.

Total re-expansion of lung after fluid drainage.

Pleural fluid pH >7.2.

Exclusions:

Atelectasis due to endobronchial obstruction.

Pleural fluid pH <7.2.

Prior intrapleural therapy.

Any hemithorax radiotherapy.

I: Povidone-iodine* (n = 15)

T: Talc slurry 5 g (n = 15)

* 10%, 20 ml diluted with 80 ml normal saline

Via ICC

At 30 days

I: 66.7% (10/15)

T: 80.0% (12/15)

At 60 days

I: 60.0% (9/15)

T: 73.3% (11/15)

This study compared tetracycline, talc slurry, povidone-iodine and bleomycin.

Conclusions:

No agent was significantly better than others. All were better than control group.

I: 13.3% (2/15)

T: 26.7% (4/15)

I: 33.3% (5/15)

T: 26.7% (4/15)

I: 6.7% (1/15)

T: 33.3% (5/15)

Ibrahim et al., (2015),

J Cardiothorac Surg, Egypt [7]

RCT

(level II)

Inclusions:

Clinical and histopathological confirmation of recurrent MPE.

Exclusions:

Povidone-iodine allergy.

Incompletely inflated lung on radiograph.

I: Povidone-iodine (n = 18)

T: Talc pleurodesis (n = 21)

Both through ICC

CR

I: 66.7% (12/18)

T: 71.4% (15/21)

PR

I: 5.6% (1/18)

T: 9.5% (2/21)

Failure

I: 27.8% (5/18)

T: 19.0% (4/21)

P = 0.20

Conclusions:

Povidone-iodine is a good alternative to talc.

It is available, cost effective, safe and repeatable.

None

I: 50.0% (9/18)

T: 33.3 % (7/18)

Mild

I: 50.0% (9/18)

T: 57.1% (12/21)

Moderate/severe

I: 0.0% (0/18)

T: 9.5% (2/21)

P = 0.29

I: 19.2% (4/18)

T: 22.3% (4/21)

P = 0.807

I: 4.7 ± 1.2

T: 4.2 ± 1.0

P = 0.17

Das et al., (2008),

J Indian Med Assoc, India [8]

Observational study

(level III)

Inclusions:

MPE confirmed + dyspnoea.

Life expectancy >4 weeks.

Clinical + radiological evidence of mediastinal shift to the opposite side of pleural effusion.

Relief of dyspnoea with therapeutic thoracentesis.

Exclusions:

Asymptomatic pleural effusion.

Mediastinum central or shifted to the ipsilateral side.

Life expectancy <4 weeks.

Chylothorax.

Pleural effusion secondary to chemosensitive malignancy.

Known hypersensitivity to sclerosing agents.

I: Povidone-iodine (n = 28)

T: Talc slurry (n = 24)

I: 86.0% (n = 24)

T: 79.0% (n = 19)

Conclusion:

Both are equally effective and safe.

Povidone-iodine could be preferred due to availability and low cost.

I: 4.0% (n = 1)

T: 12.0% (n = 3)

I: 11.0% (n = 3)

T: 8.0% (n = 2)

I: 17.0% (n = 5)

T: 16.0% (n = 4)

I: 11.0% (n = 3)

T: 12.0% (n = 3)

Nistor et al., (2014)

FARMACIA, Romania [9]

Observational study

(level III)

Inclusions:

Patients admitted with diagnostic established MPE.

Exclusions:

Known thyroid disease

I: Povidone-iodine 2% (n = 46)

T: Talc powder 5 g (n = 39)

Gender:

M (n = 40)

F (n = 45)

Complete response

I: 76.1% (35/46)

T: 76.9% (30/39)

Partial response

I: 19.6% (9/46)

T: 17.9% (7/39)

Failure

I: 4.3% (2/46)

T: 5.1% (2/46)

Conclusion:

Chemical pleurodesis with povidone-iodine is a safe procedure with high therapeutic efficiency and lower complications than talc powder.

I: 4.3% (n = 2)

T: 64.1–% (n = 25)

I: 26.1% (n = 12)

T: 10.2% (n = 4)

I: 4.3% (n = 2)

T: 5.1% (n = 2)

I: 0.0% (n = 0)

T: 2.6% (n = 1)

I: 0.0% (n = 0)

T: 2.6% (n = 1)