A pleural effusion is an accumulation of fluid in the chest cavity, specifically between the parietal and visceral pleurae. Normally, a person has 10 to 20 cc of fluid between the parietal and visceral pleurae to provide lubrication. An increase in fluid can result from an increase in capillary permeability, an increase in hydrostatic pressure, a decrease in oncotic pressure, or impaired lymphatic drainage. When enough fluid accumulates, a pleural effusion becomes symptomatic, resulting in persistent dyspnea. If medical therapy, such as diuretics, medications for heart failure, or renal dialysis, fails to resolve the effusion, drainage is indicated for symptom relief. An effusion that recurs after drainage is sometimes more difficult to manage. Recurrent pleural effusions may occur in patients with malignancy, fluid overload, inflammation, liver failure, pulmonary embolism, pancreatitis, pleural fibrosis, or mesothelioma. A pleural effusion is considered recurrent when a patient who has undergone a pleural drainage procedure presents with another pleural effusion on the same side. Rather than submitting the patient to repeat thoracentesis procedures, the goal becomes preventing the reaccumulation of fluid. Oftentimes, we cannot reverse the underlying medical condition; but the accumulation of fluid in the chest can be prevented, and thereby the associated respiratory symptoms are eliminated.
An indwelling pleural catheter (IPC) is a flexible catheter that can be used to drain pleural fluid into a glass vacuum bottle. Unlike other chest drains, including chest tubes and pigtail catheters, an IPC is a one-way system that allows air and fluid to escape without entering the chest cavity (see Table 1). When compared with other management options, such as repeat thoracentesis or operative pleurodesis, inser tion of an IPC is associated with lower costs, shorter hospital stays, reduced mortality, and successful relief of symptoms.1-3
CASES
Patient 1 was an 80-year-old female with a history of metastatic ovarian cancer. She was receiving hospice care at the time of presentation. The patient had a recurrent malignant pleural effusion, and she presented to our office after having had her left-sided effusion drained twice as an outpatient procedure. She did not want to undergo major surgery. She also wanted to be discharged as soon as possible.
Patient 2 was a 76-year-old male with a history of metastatic melanoma. He presented to the emergency department with persistent shortness of breath and dyspnea on exertion. Physical examination revealed grossly decreased breath sounds on the right and normal breath sounds on the left. Percussion was dull on the right and tympanic on the left. A chest radiograph revealed a pleural effusion on the right that occupied 75% of his chest cavity (see Figure 1). A pigtail catheter was placed under local anesthetic for immediate therapy. Approximately 600 to 1,000 cc of fluid was drained daily for 4 days into a chest drainage system. Definitive therapy was needed.
Patient 3 was a 36-year-old-female with a history of endstage alcoholic cirrhosis. She was in the hospital being prepared for a liver transplant and progressively developed dyspnea on exertion. Chest radiography revealed an effusion on the right side. The patient admitted to undergoing thoracentesis on the right side a few months ago. The pleural effusion was likely to recur in this patient because of her history of liver disease.
All these patients were candidates for surgical insertion of an IPC. Pleurx pleural catheters (Cardinal Health, Dublin, Ohio) are used at our institution. Insertion is performed under conscious sedation and local anesthetic, rather than general anesthesia; therefore, major preoperative testing is not necessary. The patient is positioned supine with a bump under the affected side or lateral decubitus with the affected side up. Using radiographic images for guidance, thoracentesis is performed at the location of the effusion in the anterior axillary line. The pleural fluid should be examined to make sure it appears to be sterile.
A 2-mm skin incision is made at the site of thoracentesis, and a 14-gauge needle is inserted into the pleural space. A guidewire is fed through the needle, and the needle is removed. A second 2-mm skin incision is made approximately 10 to 12 cm anterior to the initial incision. A tunneling device with the catheter attached is passed subcutaneously, from the newly created skin incision posteriorly until it exits through the original thoracentesis site. The catheter is advanced using the tunneling device until the fabric cuff is subcutaneously buried.
A dilator and pull-away sheath are fed over the guidewire into the pleural space. The catheter is then inserted through the sheath; as the catheter advances into the pleural space, the sheath is peeled away. The posterior wound is closed using subcuticular dissolvable sutures. A dedicated Pleurx pleural catheter dressing, which is included with the insertion kit, is applied to the entry site. The patient is transferred to the postanesthesia-care unit.
A postoperative chest radiograph is taken to confirm placement of the catheter in the thoracic cavity. After IPC insertion, the thoracic cavity is drained as ordered by the thoracic surgery team—usually once daily. Patient education about the IPC begins immediately. The IPC couples to a vacuum bottle to evacuate fluid from the chest. The fluid will not drain out of the chest until the IPC is hooked up to the corresponding adapter of a vacuum bottle or a chest tube drainage system. The IPC should be hooked up for drainage of the pleural cavity once daily to prevent clotting and infection. Consistent drainage promotes self-sclerosis, which is the adhesion of the parietal and visceral pleurae that eliminates the potential space for fluid buildup. This is the ideal outcome following IPC insertion. The catheter remains capped and under a sterile dressing when not in use (see Figure 2). Bottles used to catch drainage from IPC catheters can hold 500 to 1,000 cc of fluid per vacuum bottle. A new sterile dressing must be applied after every drainage; this prevents contamination that can lead to infection of the pleural space. The kit we use for both inpatients and outpatients contains the bottle and all the supplies necessary for a sterile dressing. Arrangements for supply delivery and assistance with the drainage system are made for when patients are discharged home.
A postoperative follow-up visit is scheduled for 2 weeks after discharge. A chest radiograph is obtained to evaluate for recurrent fluid buildup. Although the frequency may decrease with time, drainage should still be attempted on a regular basis. IPCs are typically left in place for 2 to 3 months or until self-sclerosis is achieved. Self-sclerosis is evident by a substantially decreased amount of drainage and the absence of pleural effusion on radiographic imaging of the affected side (see Figure 3). IPC removal is an outpatient procedure performed under conscious sedation.
All our case patients had uncomplicated insertion procedures. Patients 1 and 3 achieved self-sclerosis and had their IPCs removed in an outpatient surgery procedure. Because of the extent of his malignancy, Patient 2 died a few weeks after the IPC insertion.
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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