DISCUSSION
The treatment options for recurrent pleural effusions include pleurodesis, insertion of a pleuroperitoneal shunt, repeat thoracentesis, and insertion of an IPC. Pleurodesis is the process of causing an inflammatory reaction in the pleural and visceral pleurae; the apposition of the two pleurae thereby eliminates potential space for fluid to accumulate. This can be achieved mechanically, as a minimally invasive procedure in the operating room or through a pleural drain, or medically. The most commonly used agents are bleomycin (Blenoxane, generics), talc (Sclerosol), and doxycycline. Success rates of chemical pleurodesis through a chest drain are not as high as success rates of pleurodesis performed in the operating room. Some patients may not be surgical candidates because of comorbidities that place them at too high a risk for general anesthesia. A major disadvantage to using a pleuroperitoneal shunt is that this is a manual pump. The patient pushes the pump throughout the day; however, one push removes only about 1 to 2 cc of pleural fluid.1
If an empyema is suspected, an IPC catheter is not indicated; empyema treatment requires insertion of conventional chest tubes. These drains allow for constant drainage. Additionally, the holes in the tube are a much larger bore. Signs and symptoms of an empyema include fever, leukocytosis, and purulent pleural fluid at the time of drainage.
IPC insertion provides an alternative to invasive surgery with a prolonged hospital stay. Cost for an IPC procedure is lower compared with the cost of inpatient pleurodesis via a surgical procedure or a chest drain.1-4 A recent prospective randomized trial showed that the median hospital stay for an IPC insertion was 6 days shorter than for chemical pleurodesis. Both treatments provided similar efficacy and relief of dyspnea.1 Patients who have a limited life expectancy may not desire an operation or hospital stay. An open procedure has the potential to reduce a patient's quality of life if complications are encountered. In patients with advanced malignancy, palliative therapy may be the only indicated treatment for a pleural effusion. A review of the use of IPCs in 250 patients at a single institution demonstrated that after insertion, repeat ipsilateral drainage procedures were required in only 9.9% of cases.3
An IPC may also be the preferred treatment for patients with trapped lung. This condition occurs when a thick peel has formed around the visceral pleura that inhibits full lung expansion following thoracentesis (see Figure 4). These patients will not benefit from sclerosing therapy because the lack of apposition of the pleural surfaces allows fluid to reaccumulate. Pulmonary decortication, a major, invasive surgical procedure, consists of peeling the fibrous layer from the chest wall and the lung. An IPC is an alternative for a patient who is unable or unwilling to undergo such intervention.5
Patients who are being considered for IPC placement must be able to learn how to operate and dress the drain correctly or have a caregiver who can do so. With careful patient selection, outpatient insertion of an IPC and management of a recurrent effusion can be safe and effective.2 Self-sclerosis rates with a chronic IPC are approximately 70% and may be higher in patients with gynecologic cancers.6 A recent preliminary report on a small study of 17 patients was unable to show that adding doxycycline improves pleurodesis rates in patients with a an IPC.7
CONCLUSION
The case patients with recurrent pleural effusions discussed in this article were candidates for an IPC. An IPC is a preferred option for the treatment of recurrent pleural effusions. PAs should be aware of this option for patients who present with a pleural effusion. Pleural catheters can be used to treat benign recurrent effusions or trapped lung in patients who are not candidates for surgical intervention and patients with recurrent effusions secondary to malignancy. IPCs provide an alternative to surgical intervention. They have good patient satisfaction, eliminate prolonged hospital stays, and are cost effective. JAAPA
Julie Schrader practices at the Heart, Lung, and Esophageal Surgery Institute, in the Division of Thoracic Surgery, University of Pittsburgh Medical Center (UPMC), Pittsburgh, Pennsylvania. Peter Ferson is professor of surgery at UPMC and serves as Chief of Thoracic Surgery at the Pittsburgh VA Hospital. They have indicated no relationships to disclose relating to the content of this article.
Steve Wilson, PA-C, department editor
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