The patient is oxygen dependent because of pleurodesis for one month. She is suffering from breathlessness after talc pleurodesis. She has metastatic breast cancer with a distant spread to the lung and liver. There is residual pleural effusion along with bilateral lower lobe consolidation. She has pleurodesis-related inflammation, interstitial pneumonia as well as interstitial lung disease due to pleural disease showing ground glass opacification. She has talc related leg injury. The patient is currently on a tablet Methylprednisolone 16 mg every day. Along with this, she is taking tablet Mucinac 600 mg daily thrice a day. Blood reports, current X-rays, and CT scans are attached for your reference. His CT chest is suggestive of patchy areas of consolidation along with bilateral pleural effusion. Doctors are not sure about the reason for breathlessness. I need your valuable opinion to treat this breathlessness.
I have read all the reports (attachment removed to protect the patient's identity) including your CT (computed tomography) scan. It is very sad to be in such a situation with multiple problems. Metastatic breast cancer with underlying lung comorbidities is the cause of her breathlessness. Overall the distress is a result of all lung problems happening at the same time. First thing, having malignant pleural effusion compresses both the lungs and compromises oxygen dissociation in blood. Pleurodesis (procedure to adhere the pleura - outer layer of lungs) is performed again because of fibrosis around the lungs which again limits oxygenation. At the same time, she has lung consolidation, interstitial disease, and residual effusion. In such a complicated situation, oxygenation is affected very much. So supplemental oxygen has to be continued to keep oxygen saturation above 95 %. If only oxygen is not enough to maintain saturation, she may require long-term noninvasive ventilation. So, we are dealing with too many lung problems at the moment. As and when the parameters improve, her distress will be reduced to some extent. Management of such cases should ideally be in ICU (intensive care unit) with monitoring. Steroids are the mainstay of treatment for pleural inflammation, interstitial problem, and ALI (acute limb ischemia). She is already receiving the tablet Medrol (Methylprednisolone) 16 mg thrice daily. Appropriate antibiotics according to sensitivity tests should be used to treat lung consolidation. It takes time for healing pleural inflammation, especially after talc pleurodesis and underlying lung disease. Recurrent effusions are making the situation worse for which guided aspirations are required to evacuate the pleural space for faster healing. Treatment of the underlying breast cancer simultaneously is very important as effusions will be recurring because of uncontrolled malignancy. Good nutritional and protein supplements are a must. Proper nursing, care, and prevention of bed sores should be looked for. In total, in my experience, her respiratory distress is multifactorial as we discussed above and she will need time to improve with all supports. At present, she is on the best treatment for a lung problem. But, you should remember that any cancer especially metastatic is a progressive disease and we can only treat the symptoms but not the disease permanently. I hope she will respond to this maximum treatment and come out of this complex disease.
Thank you for your reply.
Earlier she took Piptaz 4 mg IV two times daily for 14 days. Currently, she is having a tablet of Medrol 16 mg once daily and not taking any antibiotics. Now, I am thinking to give her the tablet Pirfenex 200 mg tds along with tablet Medrol 16 mg. Will this help her? Does she need any antibiotics? Please suggest.
At this moment, I will not recommend the tablet Pirfenex (Pirfenidone) as I do not think this case is idiopathic pulmonary fibrosis unless she has some collagen vascular disorder. Tablet Pirfenex is not recommended for any fibrosis. But, the final decision should be taken by the treating physician with appropriate evidence like HRCT (high-resolution computed tomography) thorax or lung biopsy in favor of IPF (idiopathic pulmonary fibrosis). So, I do not think tablet Pirfenex will help her at the moment. Tablet Medrol can be continued in tapering doses. Also, regarding antibiotics, if there is no fever or any laboratory evidence of infection or sepsis, they should not be used for the long term. So, what she needs now is steroids in tapering doses and oxygen support. The outcome depends totally on her response to the current appropriate treatment.
I hope I have addressed your concerns. Feel free to reach out if you have any further questions.
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