Patients who have evidence of trapped lung, or who have

significant opacification due to fluid on CXR, may have thoracic suction applied if it is felt appropriate. selleckchem SB203580 Patients should undergo slurry instillation once the primary physician is satisfied that at least 50% of the visible pleura are apposed. If, by 48 h post drain insertion, there is inadequate pleural apposition on CXR, or the primary physician feels that talc slurry instillation would be inappropriate for another reason, then further management decisions lie with the primary physician. Such patients should continue to receive follow-up in the standard manner and should have all treatment decisions clearly documented. A flow chart for patient management in the control

arm is provided (see online supplementary appendix 5). Following slurry instillation, thoracic suction should be applied if available and tolerated. Once documented drainage falls below 250 mL per 24 h (in the presence of a patent drain), the drain should be removed, unless the primary physician feels there is reason for the drain to remain in place for longer. Following drain removal, a further CXR should be performed and an appointment given for the first trial follow-up visit at 1-month postrandomisation. Intervention (talc poudrage) arm All participants who undergo thoracoscopy will have their procedure performed by persons with adequate training and experience. Patients will be given adequate sedation (if required) and local anaesthetic for the procedure. Biopsy samples will be taken as needed. Trial pleural fluid samples (see section below) should also be taken as necessary. At the end of the procedure, 4 g of sterile talc should be sprayed over the pleural surfaces. A 16–24 Fr chest drain should be inserted at the end of the procedure and

connected to an underwater seal. Patients should be attached to thoracic suction, if available and tolerated. The future care decisions of any patient whose procedure is abandoned or curtailed before poudrage is performed (at the discretion of the operator) remain with the primary physician. Such patients will remain under trial follow-up and should have all care decisions and associated delays clearly documented in their notes. A CXR should be performed between 18 and 24 h after drain insertion to assess lung re-expansion. If there is evidence of incomplete re-expansion, then AV-951 drain patency should be checked. The management of patients with incomplete lung expansion is at the discretion of the primary physician, and may include the continued use of thoracic suction. All patients’ drains should remain in place for a minimum of 24 h. When a patient has drained 250 mL or less in the previous 24 h, then the drain should be removed, unless the primary physician feels that it needs to remain in place for longer.