PM-POCUS in Palliative OPDs: Bridging Home-Based Assessment and Hospital Expertise for Malignant Pleural Effusion Management in Advanced Cancer

INTRODUCTION

Malignant pleural effusion (MPE) is a common and uncomfortable sequela of malignant disease, represented by the presence of cancer-associated fluid within the pleural space. It is a major contributor to morbidity due to restriction of lung expansion and breathlessness. More than 1 million people worldwide are affected by MPE, with an incidence of 660/million.^[1]

Lung and breast cancers are responsible for 50–65% of MPE cases, while lymphomas account for approximately 10%, and ovarian or gastric cancers account for around 5%. MPE occurs nearly universally in mesothelioma and is found in more than 90% of patients.^[2,3] Dyspnoea is the most frequent and distressing symptom, frequently necessitating an emergent medical response.^[1] Thoracentesis is commonly used to treat symptoms, but may become intolerable and necessitate multiple hospital visits or admissions for patients being cared for at home.

Point-of-care ultrasound (POCUS), a bedside, transportable imaging modality, comes with enormous benefits. It provides real-time visualisation of pleural effusions and facilitates the safe guidance of thoracentesis or appropriate clinical decision-making without having to transport patients to hospital-based imaging facilities.

Palliative medicine POCUS (PM-POCUS) is defined as the utilisation of POCUS by palliative care professionals to evaluate and treat complicated symptoms in seriously ill patients. POCUS in palliative medicine is an emerging practice, with varied uses spanning from bedside diagnostic assessment to procedural guidance, including paracentesis, thoracocentesis and chronic pain management. Its application is increasingly noted to improve symptom management, decrease time to treatment and alleviate patient discomfort. Its inclusion in regular palliative care practice is most warranted in resource-poor settings where access to radiology services is delayed or not available. It minimises the demand for inappropriate referrals and admissions while enabling palliative care teams to make rapid, evidence-based decisions at the bedside.

We report a case that demonstrates the manner in which a home-hospital workflow coordinated through PM-POCUS facilitated timely and efficient symptom control in a patient with MPE. This case highlights the critical contribution of PM-POCUS to palliative care in the home environment and to resource optimisation.

CASE REPORT

A 44-year-old female, triple-negative breast cancer (diagnosed 2021), type 1 diabetes status post-neoadjuvant chemotherapy followed by right simple mastectomy with axillary clearance and adjuvant chemotherapy and local radiotherapy, was a registered case with the palliative medicine department and registered under home palliative care. In 2023, there was a chest wall recurrence which required a repeat surgery (mastectomy scar wide excision + pectoralis major excision + latissimus dorsi flap) and locoregional radiation therapy, then was later continued on palliative chemotherapy. She was subsequently transitioned to best supportive care in June 2024 [Figure 1]. During her home visit by our palliative care team on 18^th December (2024), she was found to have severe breathlessness (Modified medical research council grade 4) requiring oxygen support (SpO₂ 90% at 2 L/min), significantly impacting her daily activities such as bathing, dressing and sleeping, all of which required assistance.

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Figure 1:

Timeline of clinical events. PM-POCUS: Palliative Medicine Point-of-Care Ultrasound, OPD: Outpatient department.

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On examination, pulse rate was 140 beats/min, respiratory rate 26/min and blood pressure 112/62 mm Hg.

She also had an extensive wound over the right anterior chest wall (approximately 10×12 cm) extending laterally, covered with slough, necrotic tissue and seropurulent discharge, along with multiple right posterior chest wall swellings (largest 5×4 cm) [Figure 2a and b]. A portable chest X-ray revealed right-sided homogeneous opacification [Figure 3]. The patient was urgently referred to the palliative medicine outpatient department (OPD) for PM-POCUS evaluation. The patient visited the OPD the next day. A dedicated palliative medicine physician performed the ultrasound, confirming a large right-sided pleural effusion. The use of PM-POCUS allowed precise identification of the fluid pocket while avoiding chest wall lesions, ensuring procedural safety. Following written informed consent, due to the large malignant wound, PM-POCUS was utilised to chart the pleural effusion and determine a safe entry point along the posterior mid-scapular line. The optimal puncture site was located in the 5^th intercostal space along the midpoint of spine and right scapular line [Figure 4]. An 18G needle was inserted under aseptic precautions, and pleural tapping was successfully performed. A total of 1520 mL of straw-coloured fluid was aspirated, providing symptomatic relief.

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Figure 2:

(a and b) Extensive wound over the right chest wall.

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Figure 3:

Chest X-ray suggestive of the right-sided pleural effusion.

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Figure 4:

Puncture site along the midpoint of spine and right scapular line.

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Post-procedure, the patient reported significant subjective improvement in breathlessness with an ESAS-R score of 3/10 post-procedure. There were no adverse events following the procedure. On frequent phone follow-ups with the patient, no exacerbation of breathlessness was reported; she returned to her routine activities and was able to spend quality time with her family. However, relatives reported that the patient had a peaceful death after 5 days of procedure [Figure 1].

DISCUSSION

POCUS is an effective palliative care bedside tool, through which timely diagnosis, symptom management and procedural guidance like thoracentesis are facilitated to make fluid aspiration safer. POCUS is easy to use, rapid and can be repeatedly carried out at the bedside of patients.^[4]

The most critical diagnostic uses of POCUS in palliative medicine [Table 1] are bedside ultrasound for differential diagnosis of abdominal pain, breathlessness, musculoskeletal pain, deep vein thrombosis and venous thromboembolism.^[5,6]

POCUS decreases inpatient visits, reduces the reliance on other imaging investigations and provides real-time assessment to improve patient-focused care. Economical and cost-effective, POCUS increases the comfort of patients, the quality of life and clinical decision-making for patients with palliative care. POCUS is more useful for the diagnosis of pleural effusion compared to Chest X-ray. Systematic review and meta-analysis of POCUS versus radiography have demonstrated that POCUS is more sensitive and specific in the diagnosis of pleural effusion compared to CXR (94.54 % vs. 67.68% and 97.88 % vs. 85.30%, respectively).^[4]

In this case, the patient’s pleural effusion was identified and assessed through a combination of home-based care and POCUS. The integration of POCUS in the outpatient setting facilitated timely and accurate diagnosis, demonstrating its utility in resource-constrained or non-hospital environments. Koegelenberg et al.^[1] noted that thoracentesis relieves dyspnoea in 85% of MPE cases, consistent with this outcome. This case highlights three innovations:

1. Home-hospital coordination: Home teams reported emergencies, and OPD-based PM-POCUS facilitated same-day intervention-crucial for patients with a week’s prognosis

2. Procedural safety: PM-POCUS reduced the danger of chest wall injuries, consistent with findings reporting 94.5% sensitivity for effusion compared to 67.7% with X-ray.

3. Continuity of care: Seamless transition from home assessment to OPD intervention, avoiding emergency hospitalisations.

Pleural effusion is one of the most frequent complications in patients with advanced malignancy, especially metastatic breast cancer. It usually causes serious morbidity in the form of severe dyspnoea, decreased functional status and compromised quality of life. It also means that the disease is currently far advanced, and life expectancy is usually brief, with a median survival of 3–12 months based on the stage of the disease and the primary malignancy.^[7]

The home care team’s prompt response and multidisciplinary approach highlight the importance of proactive communication and coordination in palliative care. Despite the challenges posed by extensive chest wall lesions and an infected malignant wound, pleural tapping was successfully performed, resulting in significant symptomatic improvement.

This case also highlights the potential for home care teams to take palliative care beyond the walls of a hospital, increase accessibility and treat urgent symptoms in the moment. This can avoid unnecessary hospitalisations, increase patient comfort and reduce caregiver distress.

CONCLUSION

PM-POCUS in palliative OPDs fills invaluable gaps for homebound patients, providing swift diagnosis and safe interventions. There should be a high emphasis on PMPOCUS training programs to increase the availability of bedside care. It is crucial to develop formal PM-POCUS training modules specific to palliative care physicians to build competency and confidence in employing it. Scalability in low-resource environments has to be studied in future research.