pleurx catheter results in fewer pleural procedure than talc pleurodesis
- related: pleural effusion
- tags: #literature #pulmonary
In trials comparing the insertion of an indwelling pleural catheter (IPC) to chemical pleurodesis for the management of symptomatic malignant pleural effusions (MPEs), those randomized to the IPC had a shorter hospital length of stay and fewer repeat pleural procedures.
The management of MPEs requires a thoughtful approach. The goals are usually palliative, the population is often frail, and the procedures performed are not without complications. Management decisions are based on the likelihood of improving symptoms and minimizing support needs without causing harm.
Management starts with an assessment of the impact of the MPE on the patient's well-being. Neither drainage of the fluid nor definitive management of the effusion has been shown to improve outcomes in those who are without related symptoms. If diagnosis or staging information is needed, a thoracentesis should be performed, but thoracentesis, chemical pleurodesis, or IPC insertion are not otherwise required. When symptoms are present, a large-volume, ultrasound-guided thoracentesis should be performed. Ultrasound guidance has been shown to minimize the rate of pneumothorax and decrease the frequency of having a dry tap (ie, no fluid returned). The thoracentesis can help to determine whether symptoms improve (if not, other causes of the symptoms should be sought) and whether the lung re-expands.
If the lung re-expands, options for definitive management include chemical pleurodesis or insertion of an IPC. Despite the improved outcomes with IPC insertion described above, survival has not been shown to be different, and cellulitis is more common with IPC use. Local availability of these treatment options and patient preference may influence the choice of definitive management option. If an IPC is inserted, talc administered through the IPC has been shown to increase the rate of pleurodesis and the ability to remove the catheter. Doxycycline and betadine have been used if talc is not available. Daily drainage has been shown to increase the rate of pleurodesis compared with drainage every other day.
If the lung does not re-expand (occurs approximately 30% of the time) and survival is predicted to be very short, repeat thoracentesis and palliation of dyspnea should be considered. Otherwise, IPC insertion is favored because chemical pleurodesis is very unlikely to be successful. If the lung does not ultimately re-expand with the IPC in place, drainage can be guided by symptoms. If the lung does re-expand, talc use and daily drainage can be considered.
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Catheter-related infections do occur. Local IPC-related infections (eg, cellulitis) occur in approximately 7% of those with an IPC, while IPC-related pleural space infections occur approximately 4% of the time. IPCs can remain in place during the initial treatment of an IPC-related infection. Initial treatment with antibiotics alone for local infection, or antibiotics and more aggressive drainage of the pleural space for pleural space infections, should be escalated if the patient is not responding to therapy.1