Complications of indwelling pleural catheter use and their management

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Abstract

The growing utilisation of indwelling pleural catheters (IPCs) has put forward a new era in the management of recurrent symptomatic pleural effusions. IPC use is safe compared to talc pleurodesis, though complications can occur. Pleural infection affects <5% of patients, and is usually responsive to antibiotic treatment without requiring catheter removal or surgery. Pleural loculations develop over time, limiting drainage in 10% of patients, which can be improved with intrapleural fibrinolytic therapy. Catheter tract metastasis can occur with most tumours but is more common in mesothelioma. The metastases usually respond to analgaesics and/or external radiotherapy. Long-term intermittent drainage of exudative effusions or chylothorax can potentially lead to loss of nutrients, though no data exist on any clinical impact. Fibrin clots within the catheter lumen can result in blockage. Chest pain following IPC insertion is often mild, and adjustments in analgaesics and drainage practice are usually all that are required. As clinical experience with the use of IPC accumulates, the profile and natural course of complications are increasingly described. We aim to summarise the available literature on IPC-related complications and the evidence to support specific strategies.

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Most cited references 46

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Early recognition of malnutrition and cachexia in the cancer patient: a position paper of a European School of Oncology Task Force.

M Aapro, J. Arends, F. Bozzetti … (2014)

Weight loss and cachexia are common, reduce tolerance of cancer treatment and the likelihood of response, and independently predict poor outcome. A group of experts met under the auspices of the European School of Oncology to review the literature and-on the basis of the limited evidence at present-make recommendations for malnutrition and cachexia management and future research. Our focus should move from end-stage wasting to supporting patients' nutritional and functional state throughout the increasingly complex and prolonged course of anti-cancer treatment. When inadequate nutrient intake predominates (malnutrition), this can be managed by conventional nutritional support. In the presence of systemic inflammation/altered metabolism (cachexia), a multi-modal approach including novel therapeutic agents is required. For all patients, oncologists should consider three supportive care issues: ensuring sufficient energy and protein intake, maintaining physical activity to maintain muscle mass and (if present) reducing systemic inflammation. The results of phase II/III trials based on novel drug targets (e.g. cytokines, ghrelin receptor, androgen receptor, myostatin) are expected in the next 2 years. If effective therapies emerge, early detection of malnutrition and cachexia will be increasingly important in the hope that timely intervention can improve both patient-centered and oncology outcomes. © The Author 2014. Published by Oxford University Press on behalf of the European Society for Medical Oncology. All rights reserved. For permissions, please email: journals.permissions@oup.com.

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Phase III intergroup study of talc poudrage vs talc slurry sclerosis for malignant pleural effusion.

G Haasler, Kemp Kernstine, James Herndon … (2005)

To demonstrate the efficacy, safety, and appropriate mode of instillation of talc for sclerosis in treatment of malignant pleural effusions (MPEs). A prospective, randomized trial was designed to compare thoracoscopy with talc insufflation (TTI) to thoracostomy and talc slurry (TS) for patients with documented MPE. The primary end point was 30-day freedom from radiographic MPE recurrence among surviving patients whose lungs initially re-expanded > 90%. Morbidity, mortality, and quality of life were also assessed. Of 501 patients registered, those eligible were randomized to TTI (n = 242) or TS (n = 240). Patient demographics and primary malignancies were similar between study arms. Overall, there was no difference between study arms in the percentage of patients with successful 30-day outcomes (TTI, 78%; TS, 71%). However, the subgroup of patients with primary lung or breast cancer had higher success with TTI than with TS (82% vs 67%). Common morbidity included fever, dyspnea, and pain. Treatment-related mortality occurred in nine TTI patients and seven TS patients. Respiratory complications were more common following TTI than TS (14% vs 6%). Respiratory failure was observed in 4% of TS patients and 8% of TTI patients, accounting for five toxic deaths and six toxic deaths, respectively. Quality-of-life measurement demonstrated less fatigue with TTI than TS. Patient ratings of comfort and safety were also higher for TTI, but there were no differences on perceived value or convenience of the procedures. Both methods of talc delivery are similar in efficacy; TTI may be better for patients with either a lung or breast primary. The etiology and incidence of respiratory complications from talc need further exploration.

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Single-center experience with 250 tunnelled pleural catheter insertions for malignant pleural effusion.

Gaëtane Michaud, Alain Tremblay (2006)

Malignant pleural effusions (MPEs) are a common cause of dyspnea in patients with advanced cancer. Tunnelled pleural catheters (TPCs) can be used in patients with this condition, but the published experience with them is limited. To describe the use of TPCs in the management of MPE in a large group of patients in a clinical setting. Retrospective analysis of 250 sequential TPC insertions in patients with MPEs in a single center. Two hundred fifty TPC procedures for MPE were performed in 223 patients (19 contralateral procedures and 8 repeat ipsilateral procedures) during a 3-year period. Symptom control was complete following 97 procedures (38.8%), was partial in 125 procedures (50%), and was absent in 9 procedures (3.6%); in addition, there were 10 failed TPC insertions (4.0%) and 9 TPC insertions (3.6%) without assessment of symptoms at the 2-week follow-up visit. Spontaneous pleurodesis occurred following 103 of the 240 successful TPC procedures (42.9%) and was more frequent when < or = 20% of the hemithorax contained fluid at the 2-week follow-up visit (57.2% vs 25.3%, respectively; p < 0.001). Catheters stayed in place for a median duration of 56 days. Following successful TPC placement, no further ipsilateral pleural procedures were required in 90.1% of cases. The overall median survival time following TPC insertion was 144 days. Complication rates were low and compared favorably with those seen with other treatment options. TPC placement is an effective method of palliation for MPE that allows outpatient management and low complication rates. The insertion of a TPC should be considered as a first-line treatment option in the management of patients with MPE.

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Author and article information

Journal

Journal ID (nlm-ta): BMJ Open Respir Res

Journal ID (iso-abbrev): BMJ Open Respir Res

Journal ID (hwp): bmjresp

Journal ID (publisher-id): bmjopenrespres

Title: BMJ Open Respiratory Research

Publisher: BMJ Publishing Group (BMA House, Tavistock Square, London, WC1H 9JR )

ISSN (Electronic): 2052-4439

Publication date Collection: 2016

Publication date (Electronic): 5 February 2016

Volume: 3

Issue: 1

Electronic Location Identifier: e000123

Affiliations

[1 ]Division of Respiratory and Critical Care Medicine, Department of Medicine, Queen Mary Hospital, University of Hong Kong , Hong Kong

[2 ]Department of Respiratory Medicine, Sir Charles Gairdner Hospital , Perth, Western Australia, Australia

[3 ]Pleural Medicine Unit, Institute of Respiratory Health , Perth, Western Australia, Australia

[4 ]Centre for Respiratory Health, School of Medicine & Pharmacology, University of Western Australia , Perth, Western Australia, Australia

Author notes

[Correspondence to ] Professor YC Gary Lee; gary.lee@ 123456uwa.edu.au

Article

Publisher ID: bmjresp-2015-000123

DOI: 10.1136/bmjresp-2015-000123

PMC ID: 4746457

PubMed ID: 26870384

SO-VID: d1919e42-5370-480a-a64e-d655308b097d

Copyright © Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/

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This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/

Complications of indwelling pleural catheter use and their management

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Most cited references 46

Early recognition of malnutrition and cachexia in the cancer patient: a position paper of a European School of Oncology Task Force.

Phase III intergroup study of talc poudrage vs talc slurry sclerosis for malignant pleural effusion.

Single-center experience with 250 tunnelled pleural catheter insertions for malignant pleural effusion.

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