Drainage Of Malignant Pleural Effusions Research Articles

Minimally invasive approach with small diameter pleural drainage catheter (Easydren®) in malignant pleural effusions

Aim: Treatment of malignant pleural effusions is drainage and chemical pleurodesis. Our aim in this study is to investigate the success and complications of the procedure in patients who underwent drainage with an 8F pleural drainage catheter due to malignant pleural effusion, in the light of the literature.
 Material and Method: The study included 124 patients who underwent 8F pleural drainage catheter (Easydren®) for malignant pleural effusion between August 2020 and October 2022. Clinical, radiological and laboratory findings of all patients were obtained from the automation system and archive files. Age, gender, etiology, number and duration of catheter drainage, complications and hospital stay of the patients were recorded.
 Results: Of the patients, 67 (54.0%) were female and 57 (45.9%) were male. The mean age was 54 (31-87). A total of 136 pleural drainage catheters were applied to 124 patients. Drainage and complete reexpansion of the lung were successful in 125 (91.9%) of 136 procedures. No acute surgical complications were observed during the application of pleural drainage catheters. The mean drainage time was 4.6 days (3 – 11). The hospital stay was 5.7 days (4-12).
 Conclusion: We believe that small diameter pleural drainage catheters are as effective as conventional chest tubes for the drainage of malignant pleural effusion with greater patient comfort. Although it has the disadvantage of rarely occlusion during follow-up, it is less invasive and has fewer complications compared to tube thoracostomy.

Tract seeding in indwelling pleural catheter placement for the drainage of malignant pleural effusions: Incidence and related clinical and imaging factors

BackgroundThe incidence of tract seeding after the placement of indwelling pleural catheter (IPC) for malignant pleural effusion drainage has been variable in the literature. Research questionTo evaluate the incidence of IPC-related cancer tract seeding and find out related demographic, clinical or imaging factors to the tract seeding. Study design and methodsThis retrospective study included 124 consecutive patients seen between January 2011 and December 2021 who underwent IPC placement for malignant pleural effusion drainage. Chest radiographs before IPC placement and serial chest CT studies were obtained. One patient was diagnosed pathologically, and the other patients were diagnosed as tract seeding radiologically. The incidence of and related factors to tract seeding were assessed by reviewing medical records and imaging studies. ResultsThe incidence of IPC tract seeding was 21.7% (27 of 124 malignant effusions). Of 27 patients, 15 had primary lung cancer and remaining 12 had extra-thoracic malignancy. Adenocarcinoma (19 of 27, 70.3%) either from the lung (N = 12) or extra-thoracic malignancy (N = 7) was the most common cell type. Mean time elapsed until tract seeding occurrence after IPC placement was 96 days (ranges; 28–306 days). The survival in seeding group after IPC placement was 185 days (ranges, 32–457 days). On odd ratio analysis, the presence of mediastinal pleural thickening (OR [95% CI]; 9.79 (2.67–35.84), p = 0.001) was significantly related to the occurrence of tract seeding. Neither tumor volume within pleural space (p = 0.168), duration of IPC indwelling (p = 0.142), days of survival after IPC placement (p = 0.26), nor pleural effusion amount (p = 0.481) was related to the tract seeding. InterpretationIPC tract seeding is seen in 27 (21.7%) of 124 malignant pleural effusion patients, particularly with adenocarcinoma cytology. CT features of mediastinal pleural thickening are related to the occurrence of tract seeding.

Non-significant efficacy of icotinib plus pleurodesis in epidermal growth factor receptor positive mutant lung cancer patients after malignant pleural effusion drainage compared to icotinib alone.

BackgroundTo investigate the efficacy and safety of icotinib plus pleurodesis or icotinib alone in epidermal growth factor receptor (EGFR) positive mutant lung cancer patients after malignant pleural effusion (MPE) drainage.MethodsIn this retrospective study from initially reviewed case reports of 230 lung adenocarcinoma patients with MPE who were EGFR mutation positive and treated in our hospital between Jan 2014 and Dec 2016 consecutively, 51 patients who met the inclusion criteria were divided into treated with oral icotinib plus pleurodesis and without pleurodesis after pleural effusion drainage groups. Case records including patient gender, age, smoking status and local treatments, as well as adverse events were collected and retrospectively analyzed. The clinical outcomes which were measured by progression free survival (PFS), objective response rate (ORR) & adverse reactions were analyzed by a Kaplan-Meier curve and a log-rank test after follow-ups.ResultsThe median PFS of patients who received icotinib plus pleurodesis was 8.4 months, while the median PFS of icotinib alone patients was 9.0 months (P=0.996, χ2=7.241). Similarly, the ORR for MPEs, with or without pleurodesis were not significantly difference (64.29% vs. 67.57%, P=0.824, χ2=0.049). Adverse reactions of pleurodesis were mainly fever, chest pain, gastrointestinal reactions and myelosuppression.ConclusionsOur results suggested that pleurodesis after MPE drainage had no difference on outcomes of icotinib therapy patients. However, pleurodesis may increase some adverse reactions, which might be inconvenient for patients in clinical practice.

Drainage of malignant pleural effusion should be performed as much as possible

虽然一部分恶性胸腔积液（MPE）患者起病之初可以无症状，但最终大多数即使在静息状态下也会出现呼吸困难。因MPE预后差，中位生存时间只有3~12个月，治疗的目标旨在以最小的创伤减轻或消除呼吸困难。目前，可供选择的方法主要有两种，一是埋管引流，二是滑石粉固定术，可以选用其中之一或两者合并使用。最新的证据支持采取更加积极的态度尽可能排干MPE，在此基础上可以施行胸膜固定术。.

Invited Commentary

Tunneled pleural catheters were initially introduced as an alternative to pleurodesis for patients with malignant pleural effusions. These catheters offered another treatment option for patients with poor pulmonary reserve who might not tolerate pleurodesis or for patients whose tumor burden might prevent pleural symphysis, resulting in low success rates for pleurodesis. Additionally, the pleural catheters could be placed as an outpatient procedure and thus were shown to have cost advantages compared with surgical sclerosis. The article by Dr Krishnan and colleagues [1Krishnan M. Cheriyath P. Wert Y. Moritz T.A. The untapped potential of tunneled pleural catheters.Ann Thorac Surg. 2015; 100: 2055-2058Google Scholar] discusses the potential benefits of using these tunneled pleural catheters to treat nonmalignant effusions. The study reported on 37 patients with a variety of medical problems, including heart failure, liver disease, and chronic renal failure, who were treated for their chronic effusions. They had excellent results with 31 of the patients (83%), achieving successful pleurodesis in, on average, 56 days. Additionally, hospital admissions decreased for these patients from 60 to 9 days in the first year, and no major adverse events were reported. Chronic recalcitrant nonmalignant effusions represent a therapeutic dilemma for treating physicians. Chemical pleurodesis and pleurectomy have been shown to have marginal success rates for these types of effusions, and repeated thoracentesis is an inefficient and burdensome process for patients and doctors. As with any disease, the causes of nonmedical effusions must be explored to be sure that there is not an effective treatment outside of chronic drainage. This may even include thoracoscopy to rule out trapped lung or inflammatory pleural processes that could be treated with decortication or antiinflammatory medicines, respectively. I have used tunneled pleural catheters in my own practice to treat chronic nonmalignant pleural effusions. In general I have had good results. However, I have had 2 patients experience empyema, requiring catheter removal, and 1 patient had a nonfunctional catheter, requiring replacement. Physicians using this treatment must follow up their patients closely to make sure that adverse events are diagnosed and treated in a timely fashion. In summary, the article by Dr Krishnan and colleague provides excellent data to support the use of tunneled pleural catheters to treat patients with recurrent nonmalignant effusions. This approach offers a much-needed treatment option for patients with a difficult and often frustrating problem. The Untapped Potential of Tunneled Pleural CathetersThe Annals of Thoracic SurgeryVol. 100Issue 6PreviewTunneled pleural catheters (TPCs) are routinely used for outpatient drainage of malignant pleural effusions, although use in recurrent pleural effusions resulting from nonmalignant conditions requires further evaluation. We hypothesized that TPCs could decrease inpatient admission rates for exacerbations of nonmalignant pleural effusions. Full-Text PDF

The Untapped Potential of Tunneled Pleural Catheters

Tunneled pleural catheters (TPCs) are routinely used for outpatient drainage of malignant pleural effusions, although use in recurrent pleural effusions resulting from nonmalignant conditions requires further evaluation. We hypothesized that TPCs could decrease inpatient admission rates for exacerbations of nonmalignant pleural effusions. A retrospective chart review was done of patients with TPCs inserted for recurrent nonmalignant pleural effusions. Patients were set up with home care nursing support and catheter draining two to three times per week and were then followed on an outpatient basis until spontaneous pleurodesis and catheter removal. Data collection included demographics, comorbidities, and hospital admission rates relative to TPC placement as well as removal. Thirty-seven patients with recurrent, nonmalignant pleural effusions were enrolled (17 female and 20 male patients). Patients had comorbid conditions including hypertension (86%), chronic kidney disease (59%), congestive heart failure (67%), liver disease (11%), and malnutrition (22%), and most patients (89%) had multiples of these conditions. Total admissions for pleural effusion exacerbations decreased from 59 to 15 in the 1 year before and after TPC placement and from 42 to 6 in the respective 3-month periods (p < 0.0001). Six of the 37 patients still had TPCs in place; for the remaining 31 patients, admissions decreased from 60 to 9 in the 1-year periods before and after TPC removal and from 33 to 2 in the respective 3-month periods (p < 0.0001); no patients required subsequent pleural interventions. The study results support TPC placement in recurrent nonmalignant pleural effusions refractory to medical management as an effective and plausible management option.

Utility and potential of bedside ultrasound in palliative care.

Bedside ultrasound is an important tool in modern palliative care practice. It can be utilized for rapid diagnostic evaluation or as an image guidance to perform invasive therapeutic procedures. With advent of portable ultrasound machines, it can also be used in community or home care settings, apart from palliative care wards. Major applications of bedside ultrasound include drainage of malignant pleural effusions and ascites, nerve blocks, venous access, evaluation of urinary obstruction, deep vein thrombosis and abscesses. Bedside ultrasound leads to better clinical decision-making as well as more accurate and faster invasive therapeutic procedures. It also enhances patient comfort and reduces cost burden. However, use of bedside ultrasound is still not widespread among palliative care givers, owing to initial cost, lack of basic training in ultrasound and apprehensions about its use. A team approach involving radiologists is important to develop integration of bedside ultrasound in palliative care.

Comparison of modified Borg scale and visual analog scale dyspnea scores in predicting re-intervention after drainage of malignant pleural effusion

Dyspnea is the most common symptom in patients with malignant pleural effusion (MPE). Treatment decisions are primarily based on the perception of dyspnea severity. To study dyspnea perception following therapeutic thoracentesis using the visual analog scale (VAS) dyspnea score and modified Borg scale (MBS). To investigate whether patient reported outcome (PRO) measures can predict pleural re-interventions. Consecutive patients presenting with symptomatic MPE and planned for therapeutic thoracentesis were asked to complete MBS and VAS dyspnea scores (both at rest and during exercise) daily for 14 consecutive days. Physicians, unaware of the results of these PRO measures, decided on the necessity of a re-intervention, according to routine care. PRO measures were analyzed and correlated with performed re-interventions and the volume of removed fluid. Forty-nine out of 64 consecutive patients returned the diaries. Twenty-eight patients (57 %) had a re-intervention within 30 days. Patients who required a re-intervention reported significantly higher MBS than patients who did not. The extent of increase in MBS during exercise was related to the need for re-intervention. Regarding the MBS during exercise, median time to maximal relief was 2 days. Re-intervention was required sooner when larger volumes were drained. Patient reported outcomes are useful tools to assess treatment effect of therapeutic thoracentesis. Median time to maximal relief is 2 days. MBS rather than VAS dyspnea score appears to be more prognostic for repeat pleural drainage within 30 days.

To Drain or Not to Drain: An Evidence-Based Approach to Palliative Procedures for the Management of Malignant Pleural Effusions

Malignant pleural effusions are often symptomatic and diagnosed late in the course of cancer. The optimal management strategy is controversial and includes both invasive and non-invasive strategies. Practitioners have the option of invasive procedures such as intermittent drainage or more permanent catheter drainage to confirm malignancy and to palliate symptoms. Because these effusions are often detected late in the course of disease in patients who may have limited life expectancy, procedural management may be associated with harms that outweigh benefits. We performed a literature review to examine the available evidence for catheter drainage of malignant pleural effusions in advanced cancer and reviewed alternative management strategies for the management of dyspnea. We provide a clinical case within the context of the research evidence for invasive and non-invasive management strategies. Our intent is to help inform decision making of patients and families in collaboration with their health care practitioners and interventionists by weighing the risks and benefits of catheter drainage versus alternative medical management strategies for malignant pleural effusions.

Comparison of effect of central venous catheter and vein detained needle in the drainage of malignant pleural effusion

Objective To compare with the clinical effect central venous catheter and vein detained needle in the drainage of malignant pleural effusion. Methods 142 patients with malignant pleural effusion were randomly divided into control groups and research groups, the patients drained pleural effusion with dwell catheter of central venous catheter were in research groups and vein detained needle draining were in control groups, and therapeutic efficacy and nursing complication were contrasted in two groups. Results In comparison with control groups, time of remaining drainage tube was longer in research group, number of times that patients were stabbed and time of pleural effusion in control group were shorter in research group ( P ＜0. 05). Achievement ratio, incidence rate of pleural response, and infection rate of stab point and pleural cavity was identical in two groups ( P ＞ 0. 05 ), incidence rate of drainage tube blockage and abscission was lower in research group (P ＜0. 05 ). Conclusions Therapeutic efficacy of dwell catheter with central venous catheter was prevalent to those with vein detained needle, and nursing complication was lower and was convenient for clinical nursing. Key words: Pleural effusion; Central venous catheter; Vein detained needle; Nursing; Complication

Large-Volume Drainage of Malignant Pleural Effusions: Risks and Benefits

Large-Volume Drainage of Malignant Pleural Effusions: Risks and Benefits

Malignant Pleural Effusions: Review of Treatment and Our Experience

More than half of patients with malignancy present with a pleural effusion at some time in their course. Recurrent malignant pleural effusions (MPE) impair functions and worsen the quality of life. Once a patient develops MPE, only mechanical drainage relieves pulmonary compression and dyspnea. Optimal treatment is however, still controversial. During January 2001 to January 2006, our group treated 48 patients with outpatient insertion of chronic indwelling pleural catheter (IPC), Pleurx (Pleurx, Surgimedics, Denver Biomaterials, Denver, CO, USA). Primary malignancy of 48 patients included: 27 lung cancers, 11 mesotheliomas, 5 breast cancers, 3 colon cancers, 2 pancreas cancers and 1 ovarian cancer. Eligibility for IPC required prior thoracentesis with histological confirmation of malignancy and chest roentgenogram evidence of effusion. All patients treated were made aware of their prior malignancy and positive cytology for MPE. Major complications, as systemic or pleural infections, were not registered. Permanence mean time of IPC was estimated as 88 days. Median time of draining interval was 7.0 days with maximum amount of effusion drained off being 1000 ml. Pleurodesis occurred in 23 of 48 (47.92%) patients with a mean time of pleurodesis being 43 days. IPC allows ambulatory treatment with a safe and effective drainage of MPE and is an alternative treatment to procedures in use.

Comparison of Percutaneous Management Techniques for Recurrent Malignant Ascites

The Pleurx subcutaneous tunneled catheter is approved for repeated, long-term drainage of malignant pleural effusions; however, there is limited literature describing its use in malignant ascites. The authors compared the safety and efficacy of two percutaneous drainage methods: large volume paracentesis and Pleurx catheter placement over a 41-month period. The Pleurx catheter provided effective palliation with a complication rate similar to that for large volume paracentesis, while preventing the need for frequent trips to the hospital for repeated percutaneous drainage.

Use of Small-Bore vs Large-Bore Chest Tubes for Treatment of Malignant Pleural Effusions

To evaluate the efficacy of small-bore (12 French vanSonnenberg) catheters compared with standard large-bore chest tubes in the drainage and sclerotherapy of malignant pleural effusions. Retrospective review. An academic tertiary care hospital. Adult patients with documented neoplasms and malignant pleural effusions, treated between 1986 and 1995. All patients included in the study underwent drainage of malignant pleural effusions either by large-bore chest tube or by ultrasound-guided small-bore catheter. After drainage, pleurodesis was performed. Outcome as defined by recurrence of effusion was determined by blinded examination of all postpleurodesis chest radiographs. We identified 58 cases of malignant pleural effusion in which small-bore catheters were used and 44 in which large-bore chest tubes were used. The majority of patients had breast (n = 56, 55%) or lung cancer (n = 29, 28%). The median age was 65 years. Fifty-nine patients were actively being treated with chemotherapy at the time of pleurodesis. The following sclerosing agents were used: talc, 27 (26%); tetracycline, 72 (70%); bleomycin, 2 (2%); and interferon, 1 (1%). Actuarial probabilities of recurrence at 6 weeks and 4 months were 45% and 53% for the small tubes vs 45% and 51% for the large tubes. Univariate and multivariate analyses failed to demonstrate that tube size had any influence on the rate of recurrence. We were unable to detect any major differences in outcomes with the use of either size of chest tube. Our study suggests that small-bore catheters may be effective in the treatment of malignant pleural effusions and deserve further evaluation in prospectively designed trials.

Usefulness of pig-tail catheter for palliative drainage of malignant pleural effusions in cancer patients.

We retrospectively collected data from patients enrolled between 1996 and 1997, to evaluate the efficacy of sono-guided pig-tail-catheter drainage in cancer patients with large, symptomatic, amounts of malignant effusion and to evaluate the hemodynamic change after effusion drainage. A total of 477 pig-tail catheter drainage procedures were performed on 342 cancer patients. Sonographic findings, volume drained within 36 h after pig-tail insertion, heart rate and respiratory rate 24 h before and after drainage, and dyspnea sensations were recorded. We found that unilateral right-side effusion was the most frequent presentation. The mean amount of effusion drained within 36 h was 1,747 ml in cancer patients. The decreases in heart rate (from 97/min to 91/min) and in respiratory rate (from 23/min to 21/min) were both statistically significant. There was no significant correlation between the amount of effusion before drainage and the heart rate or respiratory rate. The amount drained within 36 h was correlated significantly with the changes in heart and respiratory rates. Dyspnea sensations decreased or subsided in 91% of the patients within this time period. There were few complications with the pig-tail drainage procedure. Sono-guided pig-tail drainage is a safe and convenient method of effusion drainage in cancer patients. It not only provides temporary relief of symptoms from massive pleural effusions, but can also be used for pleurodesis if needed.

Curved chest tube for drainage of malignant pleural effusion

Thoracentesis with a chest tube insertion and drainage of large pleural effusion is widely performed in patients with malignant lung diseases. One potential problem with a conventional chest tube placement is occasional incomplete evacuation of effusion owing to inappropriate position of the tip where the drainage holes opened. We have developed a curved chest tube and evaluated the position of tip placement just after the placement and before removal on plain chest X-ray in 20 patients with massive pleural effusions due to lung cancer. In 15 of the 20 patients, the tip of the tube was successfully positioned at the paravertebral gutter in posterobasal with higher drainage efficacy compared with other patients whose tube tips happened to be positioned at other sites. There were no significant complications. This study suggested that the curved chest tube would be safe and useful in completing drainage of pleural effusion.

Regional anesthesia for pain associated with terminal pediatric malignancy

The objectives of this study were to identify the characteristics of children who required regional anesthesia for pain associated with terminal malignancy and to identify the safety, tolerability and effectiveness of regional anesthesia as an analgesic modality in terminal pediatric malignancy. A retrospective examination was made of the medical records of children who died of malignancy following treatment at the Dana-Farber Cancer Institute and Children's Hospital, Boston, Massachusetts, and who required either epidural or subarachnoid infusions, or neurolytic blockade for pain management (June, 1936 – April, 1994) during the terminal phase of their illness. Eleven patients were identified, with a duration of epidural or subarachnoid infusions ranging from 3 days to 7 weeks. Indications for this intervention included limiting side effects of opioids, neuropathic pain unresponsive to either rapid escalation of opioids or massive opioid infusions, analgesia for thoracocenteses for the drainage of malignant pleural effusions and instillation of intrapleural chemotherapy. Pain was localized to one area in all patients. Analgesia was judged to be satisfactory in all cases after regional anesthesia was instituted and remained satisfactory in all cases throughout the treatment course. Complications associated with regional anesthesia included dural puncture headache and mild respiratory depression. Five patients were nursed at home with either epidural or subarachnoid infusions.

Thoracoscopy for Empyema and Hemothorax

Video-assisted thoracic surgery (VATS) has assumed greater importance in the management of pleural disease. Since 1990, we have performed VATS procedures to manage a variety of pathologic pleural processes in 306 patients. The 99 patients with complex empyemas or hemothoraces are the focus of this report. Seventy-six patients with complex empyemas (including 26 chronic) were approached with VATS after inadequate chest tube drainage. The causes associated with the thoracic empyemas were parapneumonic collections in 47, after hemothorax in 8, infected sympathetic effusions associated with intra-abdominal sepsis in 6, postresectional in 5, prolonged bronchopleural fistula following spontaneous pneumothorax in 4, chronic drainage of malignant pleural effusions in 4, and chronic drainage of pleural effusion in 2 patients undergoing chemotherapy. Ages ranged from 14 to 78 years. Sixty-three patients (83%) were treated with thoracoscopic drainage +/- decortication alone. Thirteen patients (17%) required subsequent thoracotomy for decortication, including 12 of the 26 (46%) chronic empyemas known to be greater than 3 weeks old. Chest tubes were removed 3.3 +/- 2.9 days postoperatively in 67 patients; 9 patients (12%) were sent home with empyema tubes. Postoperative hospital stay for these patients with empyema averaged 7.4 +/- 7.2 days. There were five deaths, all related to progressive sepsis from associated pneumonia (6.6%). Twenty-three patients underwent thoracoscopic evacuation of hemothoraces that resulted following open heart surgery in 6, thoracic trauma in 7, were iatrogenic in 7, and bleeding into malignant effusions in 3. All were successfully treated by thoracoscopic drainage and pleural debridement alone. Chest tubes were removed 2.8 +/- 0.5 days postoperatively and hospital stay averaged 4.3 +/- 1.9 days. There were no complications; one patient with a hemothrax (after heart transplant) died of unrelated causes. In our experience, VATS has been highly successful in the early management of empyemas and hemothoraces. Conversion to open thoracotomy must always be anticipated, especially when approaching chronic empyemas.

Interventional radiology of the chest: image-guided percutaneous drainage of pleural effusions, lung abscess, and pneumothorax.

Percutaneous catheter drainage of intrathoracic collections has developed as a natural extension of similar interventional radiologic procedures in the abdomen. The advent of CT and sonography, which allow detection and characterization of pleural and parenchymal collections, combined with advances in drainage catheter design and interventional techniques, have made imaging-guided management of intrathoracic collections a safe and effective alternative to traditional surgical therapy. This article begins with a review of the etiology, pathophysiology, diagnosis, and treatment of parapneumonic pleural effusion, which remains the most common indication for image-guided percutaneous drainage. Subsequent sections consider issues related to percutaneous drainage of malignant pleural effusion, lung abscess, and pneumothorax.