Tunneled Pleural Catheters for Palliation of Malignant Pleural Effusions

Several treatment options have been proposed for malignant pleural effusion (MPE), usually focusing on achieving pleurodesis given that systemic treatments are only an option in chemosensitive tumors such as lymphoma and small cell lung cancers.1 Pleurodesis may be performed through thoracoscopy and pleural abrasion or pleurectomy, but chemical pleurodesis, through thoracoscopy or chest tube, remains the treatment of choice for the palliation of MPE in most centers. A vast array of sclerosing agents have been proposed, as have a variety of techniques for intrapleural administration. Multiple studies have been published comparing various methods with respect to efficacy, cost, recurrence rates, and toxicities.8 There have been recent concerns regarding the association between the intrapleural instillation of talc and the development of acute respiratory distress syndrome that may be dose-related or alternatively as a result of the size of the talc particle.7 As well, thoracoscopy is not universally accessible, may be contraindicated in many patients with MPE with poor performance levels or multiple comorbidities, would not be useful in the setting of trapped lung, and has recently been shown to achieve similar outcomes than talc slurry administered through a chest tube.2 As a result of concerns with respect to the safety and efficacy of sclerosing agents and lack of availability of medical thoracoscopy, the use of tunneled pleural catheters (TPCs) (Pleurx; Denver Biomedical, Denver, CO)3-6 was introduced in our center several years ago and has become a first-line treatment option for the palliation of MPE with over 300 catheters placed since October 2001. This article details our approach to use of this new technique. TUNNELED PLEURAL CATHETER SYSTEM The system essentially consists of a catheter, which allows intermittent home drainage of pleural fluid into plastic vacuum bottles. The catheter itself is a 15.5 French silicone tube with a 24-inch long fenestrated distal end and a valve for drainage purposes on the proximal end. The valve can be accessed with the supplied adapter or, if unavailable, a 14- or 16-gauge intravenous catheter with the needle removed. The midportion of the tube has a polyester cuff that holds the tunneled portion just beneath the skin and acts as a barrier to infection. The drainage kit is comprised of a dressing tray as well as disposable, 600-mL plastic vacuum bottles connected to a drainage line and valve adapter. PATIENT SELECTION A major advantage of TPC as an option for treatment of MPE is the liberal patient selection. Performance status and operative risk have little impact on patient selection. Given that this patient population is at risk for multiple conditions leading to dyspnea (ie, lymphangitic carcinomatosis, anemia, radiation fibrosis, pulmonary embolus, pericardial disease, chronic obstructive pulmonary disease, and so on), demonstration of at least partial symptomatic improvement after therapeutic thoracentesis is needed before TPC insertion. This provides other relevant information, including whether the lung is able to reexpand or if it is trapped, and also whether and how rapidly fluid reaccumulates. If the lung is partially trapped, few therapeutic options exists other than TPC. Conversely, there is no need for a TPC if the fluid does not reaccumulate after a large-volume thoracentesis or if symptoms are not improved by the procedure. Patients with very a short life expectancy in the range of days to a few weeks or those who are quite debilitated may be better served with other treatment options such as intermittent thoracentesis or nontunneled small-bore chest drain. In these patients, the cost of intermittent drainage supplies and protection from pleural infection from a tunneled catheter may confer any significant benefit. On the other hand, a TPC attached to a leg bag for continuous drainage is an inexpensive and well-tolerated method to achieve pleural drainage during the end stage of life. Contraindications to placement include coagulopathy, extensive malignant skin involvement (eg, inflammatory breast cancer) or infection over the site of insertion, and multiloculated/septated pleural disease. SPECIALIZED CLINIC MODEL We established a specialized clinic in a regional cancer center to evaluate and treat patients with cancer with pleural effusions. Patients are evaluated by a multidisciplinary team comprised of a pulmonary physician with interest in malignant pleural disease and expertise in the insertion and management of the TPC, a clinic nurse coordinator, and a palliative care nurse specialist. The evaluation includes a complete history and physical examination to identify contraindications to the procedure and other contributors to the patient's respiratory symptoms. Chest radiographs are performed on all patients, and bedside chest ultrasonography is available, as needed, although not required in the majority of cases. Patients felt to be good candidates for TPC undergo placement in the clinic on the day of consultation without sedation. After the TPC insertion, the patient is sent for a chest radiograph and, once verified by the attending physician, is discharged home, remaining in the clinic for approximately 1 hour postinsertion. The team is completed by trained palliative home care nurses who assist all patients with TPC care and drainage. Many of our patients do self-drain and the system is set up for this practice. CATHETER PLACEMENT Site of Insertion and Patient Position The optimal position depends on the location of the effusion, operator preference, and anatomic barriers. For reasons of technical ease and patient comfort, a site devoid of excessive soft tissue or breast tissue that is disease-free is selected whenever possible. One should avoid tunneling through an area with evidence of subcutaneous tumor or radiation changes. Using percussion and auscultation, an appropriate entry site is identified. Bedside ultrasound can be used to confirm appropriate location but is not required in the majority of cases. The confirmation by ultrasound ensures that the site is indeed intrathoracic and can identify pleural loculations, metastases, and adhesions, which could make insertion more difficult. Most commonly, the patient is positioned in the semirecumbent position with the arm placed comfortably above the head or laterally in a partially adducted position. Alternatively, the patient may be in the seated position, leaning forward against a table, similar to the position used for thoracentesis. The positioning is dependent on the intended catheter insertion site, which is based on patient preference and clinical factors. Tunneled Pleural Catheter Placement The skin is cleansed with povidone-iodine with a large margin around the insertion site to allow for tunneling of the catheter. The catheter is usually tunneled anteroinferiorly approximately 5 to 10 cm. A sterile field is then delineated with placement of sterile drapes. The operator is masked, gowned, and gloved in usual sterile fashion. The skin and subcutaneous tissues down through to the parietal pleura are infiltrated with approximately 10 mL of 1% lidocaine (Fig. 1A). Unlike with thoracentesis, the local anesthetic and subsequently the catheter are placed closer to the middle of the intercostals space to avoid kinking of the soft silicone TPC over the rib.FIGURE 1: A-H, Insertion of a tunneled pleural catheter. See text for details. Photographs courtesy of Dave Lowery. A color version of this figure can be accessed using the Article Plus feature on the Journal's Web site: www.bronchology.com.A complete list of the necessary materials can be found in Table 1. A 7-cm long 18-gauge needle is used to enter the pleural space and a guidewire is passed through the needle and into the pleural space (Fig. 1B). Caution must be taken to ensure no excess air is allowed to enter the pleural space. Once the guidewire is well within the pleural space, the needle is removed, leaving the guidewire in the pleural space. The tunnel is then anesthetized with approximately 10 mL of 1% lidocaine along the preselected and cleansed path. The tunnel, and therefore local anesthesia, is to be directly below the skin surface through the subcutaneous tissues. A 1-cm incision is made at the site of entry of the guide wire using a no. 11 scalpel. A second, smaller incision (about the width of the base of the scalpel) is made approximately 5 to 10 cm from the wire. The incisions should be less than 1 cm in length and just large enough to allow the 15.5-Fr catheter and cuff to pass and fit snugly (Fig. 1C).TABLE 1: Required Supplies in Addition to Tunneled Pleural Catheters Insertion KitA hard plastic tunneler is advanced through the anesthetized subcutaneous tunnel between the 2 incisions exiting at the site of the guidewire (Fig. 1D). The fenestrated end of the catheter is then attached to the plastic tunneler and pulled through the tunnel until the polyester cuff is positioned just beyond the distal incision and no longer visible. The tunneler is then removed from the end of the catheter. A peelaway introducer system (16 Fr) is advanced over the guidewire and gently into the pleural space dilating the soft tissues (Fig. 1E). The introducer does not need to be advanced into the pleural space by its full length, but only enough to allow introduction of the catheter. Once the dilator is in the pleural space, the guidewire and the internal rigid portion of the introducer system are withdrawn from the peelaway softer portion and removed. The catheter is then advanced through the peelaway portion and into the pleural space. A curved mosquito forceps can be useful to advance the catheter in some cases (Fig. 1F). Once the catheter is in place, the peelaway portion of the dilator is split and gently pulled apart and out of the pleural space while an index finger maintains the catheter in place. The drainage line is connected to the one-way valve at the end of the TPC, and pleural drainage is initiated into a wall suction apparatus or vacuum bottle. Pleural fluid is removed as tolerated until a maximum volume of 2 L is achieved or the patient develops symptoms such as cough, pain, or dyspnea. The drainage system is then disconnected and a plastic valve cap provided is clicked onto the valve. Two simple sutures are placed at the wire entry site to close the incision and another at the tunnel entry site, leaving 2 long ends wrapped around the catheter to secure it in place (Fig. 1G). Finally, a foam drain sponge is placed over both incisions with the catheter through the central opening and curled over the sponge, which is then covered by 2 to 4 layers of gauze and by a self-adhesive, water-resistant dressing (Fig. 1H). A chest radiograph is performed after catheter insertion to ensure adequate placement and lack of complications. Once the radiograph is reviewed by the physician, the patient is discharged home. Tunneled Pleural Catheter Removal Catheter removal (see subsequently) is also done in the clinic. The skin surrounding the exit site is cleansed and approximately 5 mL of 1% lidocaine is infiltrated around the tissue cuff with a 25-gauge needle. The catheter is then withdrawn by applying a steady and firm traction on the catheter with a circular motion. Occasionally, a small mosquito forceps is required to free the cuff from the subcutaneous tissues. Steri-Strips and a dry dressing are applied to the exit site. Occasionally, a significant amount of pleural fluid drains from the site after removal of the TPC, likely from loculated fluid pockets near the insertion site. We have managed this by applying an ileostomy system over the incision to contain the fluid, which can usually be removed within 48 hours once drainage stops. FOLLOW UP Patients are visited on a 3-times-per-week basis by a palliative home care nurse trained in the care of TPCs. The catheter is accessed in a sterile fashion with a drainage apparatus attached to a suction bottle (maximum volume 600 mL per bottle). Drainage is considered complete once 2 bottles have been filled or the patient becomes symptomatic. On rare occasions when patients are producing large volumes of fluid on a daily basis, the frequency of drainage is increased to daily or a urinary catheter leg bag connected to the catheter to decrease costs and need for frequent drainage procedures. These urinary bags also have a unidirectional valve of prevent backflow of air into the pleural space. The rate of spontaneous pleurodesis is higher in a patient whose lungs fully reexpand after catheter insertion, suggesting the importance of maintaining pleural apposition and minimizing residual fluid in the pleural space. A routine follow-up visit is scheduled for all patients 2 weeks after insertion. At this time, an x-ray is performed and symptoms, concerns, and complications are addressed. Sutures are removed if not done by the home care team and the wound inspected. Patients are then seen on an as-needed basis if problems or new symptoms arise or if catheter removal is indicated. Our criterion for catheter removal is drainage of less than 50 mL on 3 consecutive attempts with absence of increasing symptoms or effusion on x-ray. Rates of spontaneous pleurodesis in published series have varied from 21% to 58%.3-6 If a pleurodesis has indeed taken place, the catheter is removed and the patient discharged from the clinic. COMPLICATIONS In general, the procedure is quite safe and free of complications in most of patients. Empyema can occur in 1% to 5% of patients, usually late in the course of treatment.5,6 We have treated this complication with intravenous antibiotics and continuous pleural drainage through the TPC with good success. We have used additional small-bore chest drains or thrombolytics for loculated infections on occasion. The TPC is removed once the infection has resolved, because the pleural space usually achieves symphysis secondary to the infection. Recurrence of the MPE after TPC removal is rare. Cellulitis has been reported in 7%5 but has been lower in our experience (1.4%). This is usually an early event and responds to oral antibiotics without need for catheter removal. Significant bleeding necessitating catheter removal is rare, although fluid drained is often bloody. The hematocrit of the fluid can be measured but is rarely found to be elevated and should not be considered the sole cause for anemia in most patients. Patients often notice fibrin deposits partially occluding the tube. These deposits will often clear spontaneously during drainage and rarely occlude the TPC itself; however, it may block the drainage line. In rare cases, the tube may need to be flushed with sterile saline and then aspirated to dislodge the fibrin. Unfortunately, there exist patients who have failed attempts at catheter insertion, developed loculated fluid or recurrence. If symptomatic loculation occur while the TPC is still in place, administration of thrombolytics may facilitate drainage. On occasion, we have also inserted new catheters into large loculations guided by ultrasound. Finally, there are some technical issues related to the insertion that deserve mention. First, the introducer has recently been changed and is now stiffer, therefore eliminating the problem of kinking and breakage on insertion of the catheter into the pleural space. Air is also commonly introduced into the pleural space when the introducer is inserted into the pleural space, although this is of no clinical significance because it is aspirated during drainage either immediately after insertion or alternatively over the next few drainages. Finally, extrapleural extension of the tumor through the insertion site can be seen. This occurs in less than 3% of cases and is rarely clinically significant but may respond to local radiation treatment if symptomatic. CONCLUSION Insertion of TPC can be done on an outpatient basis with local anesthesia with low complication rates. The technique is easy to learn by physicians already familiar with thoracentesis and standard chest tube placement. More important than technical skills, the successful use of TPC for MPE will involve the support and expertise of a multidisciplinary team committed to the care of these patients.

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