Indwelling Pleural Catheter Research Articles

Topical antibiotics prophylaxis for infections of indwelling pleural/peritoneal catheters (TAP-IPC): A pilot study.

Indwelling pleural catheter (IPC) and indwelling peritoneal catheter (IPeC) have established roles in the management of malignant pleural and peritoneal effusions but catheter-related infections remain a major concern. Topical mupirocin prophylaxis has been shown to reduce peritoneal dialysis catheter infections. This study aimed to assess the (i) compatibility of IPC with mupirocin and (ii) feasibility, tolerability and compliance of topical mupirocin prophylaxis in patients with an IPC or IPeC. (i) Three preparations of mupirocin were applied onto segments of IPC thrice weekly and examined with scanning electron microscope (SEM) at different time intervals. (ii) Consecutive patients fitted with IPC or IPeC were given topical mupirocin prophylaxis to apply to the catheter exit-site following every drainage/dressing change (at least twice weekly) and followed up for 6 months. (i) No detectable structural catheter damage was found with mupirocin applied for up to 6 months. (ii) Fifty indwelling catheters were inserted in 48 patients for malignant pleural (n = 41) and peritoneal (n = 9) effusions. Median follow-up was 121 [median, IQR 19-181] days. All patients tolerated mupirocin well; one patient reported short-term local tenderness. Compliance was excellent with 95.8% of the 989 scheduled doses delivered. Six patients developed catheter-related pleural (n = 3), concurrent peritoneal/local (n = 1) and skin/tract (n = 2) infections from Streptococcus mitis (with Bacillus species or anaerobes), Staphylococcus aureus, Klebsiella pneumoniae and Pseudomonas aeruginosa. This first study of long-term prevention of IPC- or IPeC-related infections found topical mupirocin prophylaxis feasible and well tolerated. Its efficacy warrants future randomized studies.

Effect of geographical distance on repeat pleural procedures in patients managed by indwelling pleural catheters: A retrospective cohort study

INTRODUCTION Malignant pleural effusions are typically initially managed with thoracentesis or chest tubes prior to indwelling pleural catheter insertion. We sought to examine whether geographical distance from a specialized pleural effusion clinic affected the number of pleural procedures prior to the insertion of a definitive indwelling pleural catheter. METHODS This retrospective single-center cohort study included adult patients from Alberta with malignant pleural effusions who underwent indwelling catheter insertion at an outpatient pleural effusion clinic in Edmonton from November 1, 2012, to December 31, 2018. We collected data on demographic and indwelling pleural catheter characteristics. We computed a multivariable logistic analysis adjusting for age, sex, and malignancy type. RESULTS A total of 515 indwelling pleural catheters were inserted during the study period. Patients living in communities over 300 km away from the clinic were more likely to have undergone 3 or more pleural procedures prior to their indwelling pleural catheter insertion compared with patients living within 50 km of the clinic (OR 2.67; 95%CI 1.23 to 5.81; p = 0.0130). This association was also significant if their travel time was over 90 min when compared to 45 min or less (OR 1.98; 95%CI 1.10 to 3.56; p = 0.0232). CONCLUSION Patients residing in distant communities were more likely to have had multiple pleural procedures prior to the insertion of their indwelling pleural catheter for their malignant pleural effusion. This study highlights the impact of distance and limited access on how Canadians with refractory pleural effusions are treated.

Disparities in Access and Use of PleurX Catheters for Treatment of Malignant Pleural Effusion: A Literature and Experience Based Review

It is not uncommon for patients with metastatic cancer to experience recurrent buildup of fluid in their pleural space. These malignant pleural effusions (MPE) are often experienced in late-stage illness with limited (<1 year) life expectancy and often present with shortness of breath, chest pain and discomfort, contributing to the morbidity of the patient’s illness. Tunneled indwelling pleural catheters (IPCs), including the PleurX by Beckton Dickinson (Franklin Lakes, NJ), are devices that are inserted on an outpatient basis that allow rapid and self-administered relief of symptomatic dyspnea, thereby offering an important palliative care option to patients with MPE. Current literature suggests these IPCs have enhanced efficacy compared with existing treatment options for MPE such as recurrent thoracentesis. However, the maintenance of these IPCs, including dressing changes and monitoring of fluid levels to avoid overuse or contamination, ideally requires the assistance from a family member or a home health aide. In this paper, we postulate whether the cost and maintenance demand of IPCs make them inaccessible to underserved communities, thereby contributing to the existing health disparities in health outcome by socioeconomic class. While there exists, no current literature looking at this issue specifically, existing literature does support a significantly lower utilization of health home aids in black, hispanic, and low-income populations. Our own experience at a level 1 trauma center in Newark, NJ, serving an at risk, underserved community, further suggests that the required visiting nurse and bottle replacement time and resource costs are prohibitive for this population. Given our experience and the limited literature, we believe additional research is warranted to establish plausibility of IPC use in lower socioeconomic strata.

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.

The Psychosocial Impact of Indwelling Pleural Catheters: A Scoping Review.

We aimed to identify research on the psychosocial impact of Indwelling Pleural Catheters (IPC); report on the extent, range, and nature of studies; and summarize the findings. A secondary aim was to capture reports on patient support needs and/or self-management of IPC. A systematic literature search was undertaken, with evidence synthesis planned if sufficient literature was identified. We searched ten databases available through the United Kingdom National Health Service Knowledge and Library Hub: the British Nursing Index (BNI), Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane, Excerpta Medica Database (Embase), Exerpta Medica Care (Emcare), E-thesis Online Service (EThOS), Medical Literature Analysis and Retrieval System Online (Medline), National Grey Literature Collection, Psychological Information Database (PsycInfo), and PubMed. We included studies reporting on the psychosocial impact of indwelling pleural catheters or their effect on quality of life (QoL). The latter was limited to those studies using qualitative research methods from which we could identify psychosocial impacts. The evaluation of psychosocial factors was not the primary objective of any identified study, and we found no studies in which quality of life was assessed using qualitative methods. Two studies met the inclusion criteriabut only tangentially. While indwelling pleural catheters may improve the quality of life in patients with pulmonary effusion when assessed quantitatively, there is a dearth of research examining their psychosocial impact.

Management of malignant pleural effusion in Italian clinical practice: a nationwide survey

BackgroundPleural disease (PD), particularly malignant pleural effusion (MPE), is a common cause of hospital admission and its prevalence is rising worldwide. Recent advances in diagnostic and therapeutic options, such as Indwelling Pleural Catheters (IPCs), have simplified PD treatment, allowing an effective outpatients management. Therefore, dedicated pleural services can improve PD care, guaranteeing specialized management and optimizing time and cost. We aimed to provide an overview on MPE management in Italy, mainly focused on distribution and characteristics of pleural services and IPCs use.MethodsA nationwide survey, endorsed by the Italian Thoracic Society, was distributed by email to members of selected subgroups in 2021.ResultsNinety (23%) members replied, most of whom being pulmonologists (91%). MPE resulted the most common cause of pleural effusion and was managed with heterogenous approaches, including talc pleurodesis via slurry (43%), talc poudrage (31%), repeated thoracentesis (22%) and IPCs insertion (2%). The setting of IPC insertion was inpatient care in 48% of cases, with a predominance of draining frequency every other day. IPC management mainly relied on caregivers (42%). The presence of a pleural service was reported by 37% of respondents.ConclusionsThe present study provides an extensive overview of MPE management in Italy, showing a highly heterogeneous approach, a scarce prevalence of out-patient pleural services, and a still limited adoption of IPCs, mainly due to lack of dedicated community care systems. This survey emphasizes the need of promoting a higher spreading of pleural services and an innovative healthcare delivery with more favourable cost-benefit ratio.

Outcomes for Malignant Pleural Effusions Because of Melanoma Treated With Indwelling Pleural Catheters.

Indwelling pleural catheters (IPCs) reduce dyspnea and improve quality of life in patients with malignant pleural effusions (MPEs). Data on outcomes of MPEs secondary to metastatic melanoma managed with IPCs are scarce. We aimed to evaluate outcomes of patients receiving IPCs for MPEs secondary to melanoma compared with other malignancies. We identified patients from our prospectively collected database of all patients who had an IPC insertion for MPEs at our tertiary care center for melanoma between May 2006 and November 2018 and for nonmelanoma between May 2006 and June 2013. Chart reviews were conducted to obtain patient demographics, catheter complications, time of IPC removal or death, x-ray imaging, and pleural fluid characteristics. We identified 27 MPEs because of melanoma and 1114 because of nonmelanoma malignancies treated with IPC. The most frequent complication was pleural fluid loculation requiring fibrinolytics which was significantly higher in the melanoma (14.8%) compared with the nonmelanoma group (3.8%; P=0.02). Cumulative incidence functions for catheter removal (P=0.8) or death with catheter in situ (P=0.3) were not significant between melanoma and nonmelanoma groups in competing risk analysis. Baseline radiographic pleural effusion scores were similar, but became significantly higher (increased pleural opacity) in the melanoma group at time points following IPC insertion (P<0.05). MPEs because of melanoma had a higher rate of loculations requiring fibrinolytics and less radiographic improvement after IPC insertion suggesting this patient subgroup has a more complicated pleural space which may be less responsive to drainage.

Combination Tissue Plasminogen Activator and DNase for Loculated Malignant Pleural Effusions: A Single-center Retrospective Review.

Indwelling pleural catheters (IPCs) are frequently used for the management of malignant pleural effusions (MPEs), but drainage can be impaired by pleural loculations. We aimed to evaluate the safety and effectiveness of intrapleural tissue plasminogen activator (tPA) versus combination tPA-deoxyribonuclease (DNase) in the treatment of loculated MPE. We performed a retrospective review of patients with confirmed or presumed MPEs requiring IPC insertion. We compared the efficacy of intrapleural tPA, tPA-DNase, and procedural intervention on pleural fluid drainage. Secondary endpoints included the need for future pleural procedures (eg, thoracentesis, IPC reinsertion, chest tube insertion, or surgical intervention), IPC removal due to spontaneous pleurodesis, and IPC-related complications. Among 437 patients with MPEs, loculations developed in 81 (19%) patients. Twenty-four (30%) received intrapleural tPA, 46 (57%) received intrapleural tPA-DNase, 4 (5%) underwent a procedural intervention, and 7 (9%) received ongoing medical management. tPA improved pleural drainage in 83% of patients, and tPA-DNase improved pleural drainage in 80% of patients. tPA alone may be associated with increased rates of spontaneous pleurodesis compared with tPA-DNase. There was no difference in complications when comparing tPA, combination tPA-DNase, procedural intervention, and no therapy. Both intrapleural tPA and combination tPA-DNase appear to be safe and effective in improving pleural fluid drainage in selected patients with loculated MPE, although further studies are needed.

Validación de la ecografía torácica en la valoración de la retirada del catéter pleural tunelizado ambulatorio en pacientes con un derrame pleural maligno

IntroductionThere are no defined criteria for deciding to remove a non-functioning indwelling pleural catheter (IPC) when lung re-expansion on chest X-ray is incomplete. Chest computed tomography (chest CT) is usually used. The objective of this work is to validate the usefulness of chest ultrasound performed by a pulmonologist and by a radiologist compared to chest CT. Patients and methodsProspective, descriptive, multidisciplinary and multicenter study including patients with malignant pleural effusion and non-functioning IPC without lung reexpansion. Decisions made on the basis of chest ultrasound performed by a pulmonologist, and performed by a radiologist, were compared with chest CT as the gold standard. Results18 patients were analyzed, all of them underwent ultrasound by a pulmonologist and chest CT and in 11 of them also ultrasound by a radiologist. The ultrasound performed by the pulmonologist presents a sensitivity of 60%, specificity of 100%, PPV 100% and NPV 66% in the decision of the correct removal of the IPC. The concordance of both ultrasounds (pulmonologist and radiologist) was 100%, with a kappa index of 1. The 4 discordant cases were those in which the IPC was not located on the ultrasound. ConclusionsThoracic ultrasound performed by an expert pulmonologist is a valid and simple tool to determine spontaneous pleurodesis and remove a non-functioning IPC, which would make it possible to avoid chest CT in those cases in which lung reexpansion is observed with ultrasonography.

Efficacy and Safety of Indwelling Catheter for Malignant Pleural Effusions Related to Timing of Cancer Therapy: A Systematic Review

IntroductionTo compare the efficacy and safety of indwelling pleural catheters (IPC) in relation with the timing of systemic cancer therapy (SCT) (i.e., before, during, or after SCT) in patients with malignant pleural effusion (MPE). MethodsSystematic review of randomized controlled trials (RCT), quasi-controlled trials, prospective and retrospective cohorts, and case series of over 20 patients, in which the timing of IPC insertion in relation to that of SCT was provided. Medline (via PubMed), Embase, and Cochrane Library were systematically searched from inception to January 2023. The risk of bias was assessed using the Cochrane Risk of Bias (ROB) tool for RCTs and the ROB in non-randomized studies of interventions (ROBINS-I) for non-randomized designs. ResultsTen studies (n=2907 patients; 3066 IPCs) were included. Using SCT while the IPC was in situ decreased overall mortality, increased survival time, and improved quality-adjusted survival. Timing of SCT had no effect on the risk of IPC-related infections (2.85% overall), even in immunocompromised patients with moderate or severe neutropenia (relative risk 0.98 [95%CI: 0.93–1.03] for patients treated with the combination of IPC and SCT). The inconsistency of the results or the lack of analysis of all outcome measures in relation to the SCT/IPC timing precluded drawing solid conclusions about time to IPC removal or need of re-interventions. ConclusionsBased on observational evidence, the efficacy and safety of IPC for MPE does not seem to vary depending on the IPC insertion timing (before, during, or after SCT). The data most likely support early IPC insertion.

Pleural procedures: an audit of practice and complications in a regional Australian teaching hospital.

Pleural procedures are essential for the investigation and management of pleural disease and can be associated with significant morbidity and mortality. There is a lack of pleural procedure complication data in the Australian and New Zealand region. To review pleural procedure practices at Wollongong Hospital with an emphasis on the assessmentof complications, use of thoracic ultrasound (TUS), pathology results and comparison of findings with international data. Retrospective analysis of medical records was performed on pleural procedures identified through respiratory specialist trainee logbooks at Wollongong Hospital from January 2018 to December 2021. Comparison of complication rates was made to the British Thoracic Society 2011 a national pleural audit. One hundred and twenty-one pleural procedures were identified. There were 71 chest drains, 49 thoracocentesis and one indwelling pleural catheter (IPC) insertion. Ninety-seven per cent of procedures were performed for pleural effusions and 3% for pneumothorax. This audit demonstrated a complication rate (excluding pain) of 16.9% for chest drains and 4.1% for thoracocentesis. This gave an overall complication event rate of 10.8% (excluding pain) for pleural procedures. There was no major bleeding, organ puncture, pleural space infection or death. Bedside TUS was used in 99% of procedures. Complication rates for pleural procedures performed by respiratory specialist trainees at Wollongong Hospital are comparable with international outcomes. This audit provides data for comparison on pleural procedure complication rates in Australia. Future studies are required to determine complication rates with IPCs.

Expert Review on Contemporary Management of Common Benign Pleural Effusions.

Heart failure (HF) and cirrhosis are frequently associated with pleural effusions (PEs). Despite their apparently benign nature, both HF-related effusions and hepatic hydrothorax (HH) have poor prognosis because they represent an advanced stage of the disease. Optimization of medical therapy in these two entities involve not only the use of diuretics, but also other pharmacological therapies. For instance, all HF patients with reduced or mildly reduced left ventricular ejection fraction can benefit from angiotensin receptor-neprilysin inhibitors, beta blockers, mineralocorticoid receptor antagonists, and sodium-glucose cotransporter 2 inhibitors. Conversely, it is better for HH patients to avoid nonselective beta blockers. Refractory cardiac- and cirrhosis-related PEs are commonly managed by iterative therapeutic thoracentesis. When repeated aspirations are needed, thereby diminishing quality of life, the insertion of an indwelling pleural catheter (IPC) may be warranted. However, in selected HH patients who are diuretic-resistant or diuretic-intractable, placement of transjugular intrahepatic portosystemic shunts should be considered as a bridge to liver transplantation, whereas in transplant candidates the role of IPC is debatable. Another benign condition, pleural tuberculosis (TB) is a serious health problem in developing countries. Diagnostic certainty is still a concern due to the paucibacillary nature of the infection, although the use of more sensitive nucleic acid amplification tests is becoming more widespread. Its treatment is the same as that of pulmonary TB, but the potential drug interactions between antiretroviral and anti-TB drugs in HIV-coinfected patients as well as the current recommended guidelines for the different types of anti-TB drugs resistance should be followed.

Patient perspectives on the use of indwelling pleural catheters in malignant pleural effusions

BackgroundIndwelling pleural catheters are an effective treatment option for patients with malignant pleural effusions. Despite their popularity, there remains a paucity of data on the patient experience and key patient-centred...

Indwelling pleural catheters for persistent pleural effusions secondary to post lung resection for malignancies.

Malignant and nonmalignant pleural effusions (NMPEs) such as those due to hepatic hydrothorax have been successfully treated with an indwelling pleural catheter (IPC) with a low complication rate. There is no literature on the utility or safety of this treatment modality for NMPE post lung resection. We aimed to assess the utility of IPC for recurrent symptomatic NMPE secondary to post lung resection in lung cancer patients over a period of 4 years. Patients who underwent lobectomy or segmentectomy as part of the treatment plan for lung cancer between January 2019 and June 2022 were identified, these patients were screened for post-surgical pleural effusion. A total of 422 underwent lung resection, of which 12 had recurrent symptomatic pleural effusions requiring IPC placement and were selected for final analysis. The primary end points were improved symptomatology and successful pleurodesis. Mean time to IPC placement was 78.4 days post-surgery. The mean length of IPC catheter was 77.7 days standard deviation (SD) 23.8. All 12 patients achieved spontaneous pleurodesis (SP), there was no second pleural intervention or re-accumulation of fluid on follow up imaging in any of the subjects after IPC removal. Two patients (16.7%) had skin infection related to catheter placement that was managed with oral antibiotics, there were no cases of pleural infections that required catheter removal. IPC is a safe and effective alternative in managing recurrent NMPE post lung cancer surgery with high rate of pleurodesis and acceptable complication rates.

The randomised thoracoscopic talc poudrage+indwelling pleural catheters versus thoracoscopic talc poudrage only in malignant pleural effusion trial (TACTIC): study protocol for a randomised controlled trial

IntroductionMalignant pleural effusion (MPE) is common, with 50 000 new cases per year in the UK. MPE causes disabling breathlessness and indicates advanced disease with a poor prognosis. Treatment approaches...

Assessing Factors That May Impact Physician-based Decisions for Placing Indwelling Pleural Catheters.

Malignant pleural effusion is a common finding in patients with advanced cancer and is a frequent cause of dyspnea. Current guidelines indicate thoracentesis for symptomatic patients, while indwelling pleural catheters (IPC) are recommended for patients who develop pleural fluid re-accumulation. IPC maintenance, however, requires a significant level of financial and social support. This study aims to analyze potential influencing factors that may play a role in the decision for placing IPCs in patients with recurrent malignant pleural effusions. This study retrospectively collected baseline sociodemographic and laboratory data in patients who underwent thoracentesis for malignant pleural effusion from August 2016 to October 2021, and selected patients who presented with re-accumulation of pleural fluid within 30 days or had a pulmonary physician's note documenting that IPC is a potential management option. Of these selected patients (IPC candidates), we stratified patients who underwent IPC placement and those who did not, and performed statistical analysis between these 2 groups. One hundred seventy-six patients who underwent thoracentesis were regarded as IPC candidates. Almost all baseline sociodemographic characteristics, including ethnicity ( P =0.637), sex ( P =0.655), and marital status ( P =0.773) were similar between the 2 groups, but significantly higher ECOG scores ( P =0.049) were noted in the IPC group. No statistically significant differences were noted in age, body mass index, platelet, PTT, international normalized ratio, creatinine, white blood cell, red blood cells, fluid protein, or fluid lactate dehydrogenase. Fluid albumin ( P =0.057) and serum neutrophil:lymphocyte ratio ( P =0.003) were significantly higher in patients without IPC placement. This study did not recognize any baseline sociodemographic factors that may contribute to the decision to place IPCs.

Impact of a Dedicated Pleural Clinic on Indwelling Pleural Catheter Related Outcomes: A Retrospective Single Center Experience.

Recurrent pleural effusions are a major cause of morbidity and frequently lead to hospitalization. Indwelling pleural catheters (IPCs) are tunneled catheters that allow ambulatory intermittent drainage of pleural fluid without repeated thoracentesis. Despite the efficacy and safety of IPCs, data supporting postplacement follow-up is limited and variable. Our study aims to characterize the impact of a dedicated pleural clinic (PC) on patient outcomes as they relate to IPCs. Patients who underwent IPC placement between 2015 and 2021 were included in this retrospective study. Differences in outcomes were analyzed between patients with an IPC placed and managed by Interventional Pulmonology (IP) through the PC and those placed by non-IP services (non-PC providers) before and after the PC implementation. In total, 371 patients received IPCs. Since the implementation of the PC, there was an increase in ambulatory IPC placement (31/133 pre-PC vs. 96/238 post-PC; P=0.001). There were fewer admissions before IPC placement (18/103 vs. 43/133; P=0.01), and fewer thoracenteses per patient (2.7±2.5 in PC cohort vs. 4±5.1 in non-PC cohort; P<0.01). The frequency of pleurodesis was higher in the PC cohort (40/103 vs. 41/268; P<0.001). A Fine and Gray competing risks model indicated higher likelihood of pleurodesis in the PC cohort (adjusted subhazard ratio 3.8, 95% CI: 2.5-5.87). Our experience suggests that the implementation of a dedicated PC can lead to improved patient outcomes including fewer procedures and admissions before IPC placement, and increased rates of pleurodesis with IPC removal.

Day Case Local Anaesthetic Thoracoscopy: Experience from 2 District General Hospitals in the United Kingdom

Local anaesthetic thoracoscopy (LAT) can be a vital procedure for diagnosis of unexplained pleural effusions. Traditionally, poudrage for pleurodesis and insertion of a large bore drain necessitated admission. There has been a shift towards performing LAT as a day case procedure with indwelling pleural catheter (IPC) insertion. This was advocated during the COVID pandemic by the British Thoracic Society (BTS). To determine the feasibility of such pathways, continuous evaluations are required. All day case LAT procedures with IPC insertion, performed in theatre, were identified at two large district general hospitals (Northumbria HealthCare in the North East of England and Victoria Hospital, NHS Fife, in Scotland). Rapid pleurodesis with talc was not performed due to local staffing problems. All patients had their LAT in theatre under conscious sedation with a rigid scope. Demographics, clinical, radiological and histopathological characteristics and outcomes were collected. 79 patients underwent day case LAT. The lung did not deflate, meaning biopsies were not enabled, in four of the patients. The mean age was 72 years (standard deviation 13). Fifty-five patients were male and twenty-four were female. The main diagnoses were lung cancers, mesotheliomas and fibrinous pleuritis with an overall diagnostic sensitivity of 93%. Other diagnoses were breast, tonsillar, unknown primary cancers and lymphomas. Seventy-three IPCs were simultaneously placed and, due to normal macroscopic appearances in two patients, two large bore drains were placed and removed within one hour of LAT termination. Sixty-six (88%) patients were discharged on the same day. Seven patients required admission: one for treatment of surgical emphysema, four because they lived alone, one for pain control and one for control of a cardiac arrythmia. Within 30 days, there were five IPC site infections with two resultant empyemas (9%), with no associated mortality. Two patients developed pneumonia requiring admission and one patient required admission for pain management. The median number of days for which the IPCs remained in situ was 78.5 days (IQR 95). The median length of stay (LoS) was 0 days (IQR 0). No patients required further interventions for pleural fluid management. Day case LAT with IPC insertion is feasible with this current set up, with a median stay of 0 days, and should be widely adopted. The health economics of preventing admission are considerable, as our previous analysis showed a median length of stay of 3.96 days, although we are not comparing matched cohorts.

The Impact of Anticoagulation on Indwelling Pleural Catheter Removal due to Pleurodesis in Patients with Malignant Pleural Effusion

Background: A well-recognized therapy to improve the symptoms of patients with malignant pleural effusion (MPE), indwelling pleural catheters (IPCs) can also achieve spontaneous pleurodesis. Chemical pleurodesis is associated with a significant pro-coagulation and fibrinolytic environment. Hence, anticoagulation could theoretically interfere with this process. Objective: The aim of this study was to evaluate if anticoagulation can interfere with successful spontaneous pleurodesis in patients treated with IPC. Methods: This was a cohort study of all patients with MPE treated with IPC. The primary objective was to determine if anticoagulant use after IPC placement decreased the rate of spontaneous pleurodesis. The secondary objective was to identify other factors associated with spontaneous pleurodesis. We used a Fine-Gray subdistribution hazard model and a direct acyclic graph to identify variables associated with time to spontaneous pleurodesis. Results: Of the included 410 patients, 210 patients (51.2%) achieved pleurodesis and had their IPC removed. We found no association between anticoagulation and likelihood of pleurodesis. Multivariate analyses revealed that prior chemotherapy, ECOG score of 2–4 were associated with unsuccessful pleurodesis, while chemotherapy or radiotherapy after IPC placement remained associated with increased likelihood of spontaneous pleurodesis. Conclusions: We failed to demonstrate an association between anticoagulation and pleurodesis. We found that better performance status and chemotherapy or radiotherapy after IPC placement can increase the rate of pleurodesis and catheter removal.

Indwelling pleural catheters for benign pleural effusions: a concise review.

Benign pleural effusions (BPEs) are more common than malignant effusions and their treatment involves treating the underlying disease process. However, in cases refractory to medical management, pleural interventions might be necessary. Use of indwelling pleural catheters (IPCs) has been gaining popularity for patients with refractory effusion. In this review, we will focus on reviewing the data assessing safety and efficacy of IPC in patients with BPE related to congestive heart failure (CHF), hepatic hydrothorax, end-stage renal disease (ESRD) and chylothorax. Several small studies including the most recent randomized control trial have looked into the efficacy and safety of IPC in BPE. Majority of data come from patients having CHF and hepatic hydrothorax as the underlying cause of the effusion. Limited data are available in patients with ESRD and chylothorax. Time to pleurodesis varies but is relatively higher in this patient population. Caution must be addressed in patients with immunocompromised status given a high risk of infection. IPCs are increasingly being used in patients with BPE refractory to medical management. They can be used both for palliation and to achieve pleurodesis in some cases. Further data in the form of randomized control trials are still needed to evaluate the efficacy and safety of its use in this patient population.