Malignant pleural effusion in the presence of trapped lung. Five-year experience of PleurX tunnelled catheters

Abstract

Malignant pleural effusions in the presence of trapped lung remain notoriously difficult to treat. Various methods exist ranging from minimally invasive procedures including repeated needle thoracocentesis to the need for a formal surgical procedure such as placement of a pleuroperitoneal shunt and even thoracotomy and decortication. Controversy exists as to what is the optimum treatment for this condition. Any planned treatment should balance the therapeutic benefit provided against convalesce for a disease with a limited life expectancy. Patients should not spend a significant proportion of their remaining life span recovering from palliative procedures. In a series of patients with malignant pleural effusion the medial survival time was 20 weeks, with 30 days and 1 year mortality rates of 12.8% and 83.6%, respectively. We describe our five-year experience with the use of indwelling PleurX catheters in patients with malignant pleural effusions in the presence of confirmed trapped lung on radiological or VATS investigation. Patient health related quality of life was investigated by telephone questionnaire. The parameters analysed were symptomatic relief, mobility and ease of management following insertion. One hundred and sixteen patients underwent PleurX catheter insertion by a single operator, 48 questionnaires were completed. Of the 48 cases analysed, improvement in all three quality of life indices was recorded following catheter insertion. Ease of mobility was recorded as moderately satisfied and very satisfied in 50% and 15% of patients, respectively. Symptomatic improvement was found to have been increased with 42% and 6% of patients responding to moderately satisfied and very satisfied, respectively. Ease of management was recorded as 'slightly satisfied' and moderately satisfied in 50% and 33% of patients, respectively, demonstrating a high satisfaction index in patients with chronic progressively debilitating malignancies. Complications were either transient or readily correctable. Pain was the predominant complication occurring in 35% of patients lasting <3 days. No patient required catheter removal for resolution of discomfort. Our findings support the use of PleurX catheters for palliative patients with malignant pleural effusions in the presence of trapped lung. The catheters are not only easy to insert and discrete but they can be managed effectively by patients and community nurse practitioners and prevent repeated admissions to hospital in palliative patients with compromised life expectancy.

Advanced medical interventions in pleural disease

“…The presence of NEL and the lack of pleural apposition it causes significantly increase the chances of pleurodesis failure should this be attempted [11], meaning the early use of IPCs tends to be preferred in this setting [12]. It should be noted, however, that such recommendations are based upon relatively limited evidence and by no means guarantee symptomatic benefit for patients (figure 1) [14].…”

“…Patients and carers are empowered, therefore, to manage their recurrent collections at home and, in many cases, can avoid or significantly reduce hospital admissions [51][52][53]. Initially recommended for the management of those patients who had failed pleurodesis [12,54] or those in whom trapped lung was the primary pathology [14,55,56], recent years have seen a shift in many centres towards an alternative paradigm, one in which IPCs are viewed as a valid first-line alternative to chemical sclerosant therapy [57,58]. This idea was cemented by the publication of the TIME2 study, a multicentre RCT comparing standard chest drain and talc pleurodesis to IPC for the management of MPE.…”

Management of malignant pleural effusions in patients with trapped lung with indwelling pleural catheter: how to do it

“…The family members or friends and others personnel performed the chronic management of the IPC. Community nurses involved in each patient's care underwent a vigorous training programme with thoracic nurse (6). When the patient was not in a facility or the home nursing not arranged, initial education included videos, reading materials, and observation of drainage by members of the health care team was performed (7).…”

Indwelling Pleural Catheters

“…This method dispenses with the notion that achieving pleurodesis is the priority, but instead looks to simply manage fluid as it builds up. IPCs are the ideal way to achieve this as they can be sited easily and quickly, and can be drained as often as is required to alleviate symptoms, allowing for consistent improvement in the breathlessness which will afflict the vast majority of patients with a malignant effusion [41], with improvements seen even in those with trapped lung [49]. In fact it is the improvement in dyspnoea, which occurs in over 90% of patients with IPCs placed for MPE [25], which led to the idea of offering IPCs as a first-line alternative to inpatient pleurodesis [50].…”