Intrapleural Catheter Research Articles

Intra-pleural and intra-peritoneal tocilizumab therapy for managing malignant pleural effusions and ascites: The Regional Immuno-Oncology Trial (RIOT)−2 study protocol

BackgroundMalignant pleural effusions (MPE) and malignant ascites (MA) are serious complications of advanced cancer, marked by debilitating symptoms and limited treatment options. Based on a wealth of previous literature implicating the cytokine IL-6 as a central mediator in the pathogenesis of MPE and MA, the Regional Immuno-Oncology Trial 2 (RIOT-2) clinical protocol was developed to explore intra-cavitary delivery of tocilizumab, an IL-6 receptor antagonist, as treatment for these conditions. MethodsThis phase I clinical trial (NCT 06016179) is being conducted to assess the safety and pharmacokinetics of intra-cavitary tocilizumab administration to patients with MPE and MA. Eligible patients are those with pleural effusion or peritoneal ascites due to metastatic cancer who are scheduled to undergo standard-of-care catheter placement for pleural or peritoneal drainage. Following catheter placement, patients will receive a starting dose of tocilizumab 0.5 µg/mL via intra-pleural or intra-peritoneal implantable catheters. Weekly escalating doses of tocilizumab will be given over four weeks. Primary endpoints are frequency and type of adverse events, while secondary endpoints include pharmacokinetic and immunological parameters. This single-center study will proceed until 12 patients have been treated. DiscussionInhibition of the IL-6 signaling pathway with tocilizumab is hypothesized to be a rational mitigating treatment strategy for the maladaptive intra-cavitary immune environment in patients with MPE and MA. The RIOT-2 study aims to assess the safety of intra-cavitary tocilizumab therapy, administered via indwelling catheters. Pharmacologic and translational immunologic findings generated by this study could pave the way for future research into clinical applications of intra-cavitary immunotherapy. Trial registrationThe trial is registered at ClinicalTrials.gov; NCT06016179 (registered on August 29th, 2023).

Developments in Postoperative Analgesia in Open and Minimally Invasive Thoracic Surgery Over the Past Decade

Whether through minimally invasive or conventional open techniques, thoracic surgery is often reported to be one of the most painful surgical procedures due to the incision of intercostal and respiratory muscles, rib injury or resection, and placement of surgical drains. Some of the more severe complications related to poor analgesia include prolonged intensive care unit stay, mechanical ventilation, pneumonia, and the development of chronic postoperative pain syndromes. Over the past few decades, much progress has been made in recognizing the importance of multimodal analgesic techniques. These may include a variety of regional anesthetic techniques such as epidural anesthesia, fascial plane blocks, and intrapleural catheters, as well as the utilization of opioid and opioid-sparing oral regimens. This article provides an up-to-date review of pain management following thoracic surgery, emphasizing multimodal techniques and enhanced recovery pathways. In our review, we included articles published between 2010 and 2022. PubMed and Google Scholar were researched using the keywords thoracic, cardiac, pain control, thoracic epidural analgesia, fascial plane blocks, multimodal analgesia, and Enhanced Recovery after Surgery in thoracic surgery. Over 100 articles were then reviewed. We excluded articles not in English and articles that were not pertinent to cardiac or thoracic surgery. Eventually, 53 articles were included in the review, composed of clinical trials, case series, and retrospective cohort studies. A variety of pain control methods employed in thoracic and cardiac surgery range from opioids and opioid-sparing medications, such as acetaminophen and gabapentin, to regional techniques, such as fascial plane blocks to epidural anesthesia. Multimodal anesthesia combining regional and opioid-sparing analgesics and their combination in enhanced recovery protocols were shown to provide adequate pain control, decrease opioid consumption and lead to shorter lengths of stay. Postoperative pain control remains one of the biggest challenges in the care of thoracic surgery patients. Analgesic plans must be individualized for each patient. Multimodal analgesia remains the gold standard; however, more studies are still warranted. Finding the optimal combination of opioid and non-opioid pain medication and local anesthetic delivered via suitable regional technique will improve the outcomes and lead to successful patient recovery.

Efficacy of Small versus Large-Bore Chest Drain in Pleural Infection: A Systematic Review and Meta-Analysis

Background: Pleural infection represents a significant clinical challenge worldwide. Although prompt drainage of pleural fluid is thought to play a key role in pleural infection management, the optimal size of intrapleural catheter has yet to be defined. Objectives: The aim of this systematic review and meta-analysis was to summarize data on efficacy and complications of small-bore drain (SBD), defined as ≤14F, in comparison to large-bore drain (LBD) in patients with pleural infection. Method: We searched MEDLINE and Embase for all studies reporting outcomes of interest published up to October 2021. Two authors reviewed selected full text to identify studies according to predefined eligibility criteria. Summary estimates were derived using the random-effects model. Results: Twelve original studies were included for qualitative analysis and 7 of these for quantitative analysis. The surgical referral rate of SBD and LBD were, respectively, 0.16 (95% confidence interval [CI], 0.12–0.21) and 0.20 (95% CI, 0.10–0.32), the pooled mortality were 0.12 (95% CI, 0.05–0.21) and 0.20 (95% CI, 0.10–0.32), and the length of hospital stay was 24 days in both groups. Data on complications suggest similar proportions of tube dislodgement. Intensity of pain was evaluated in one study only, reporting higher scores for LBD. Conclusions: This systematic review and meta-analysis provide the first synthesis of data on performance of SBD and LBD in management of pleural infection, and, overall, clinical outcomes and complications did not substantially differ, although the limited number of studies and the absence of dedicated randomized trials does limit the reliability of results.

A Strangulated Congenital Diaphragmatic Bochdalek Hernia Diagnosed in an Adult

Although Bochdalek hernias are uncommon in adults and difficult to diagnose, such congenital diaphragmatic hernias (CDHs) are some of the most serious malformations among newborns. In particular, CDHs are accompanied by high mortality and marked disability later in life due to concomitant morbidity (i.e., caused by pulmonary lung hypoplasia and persisting pulmonary hypertension of neonates) and require long-lasting neonatal treatment in an intensive care unit. Late-diagnosed CDHs are extremely rare and always show small defects that justify a better prognosis than CDHs with large defects. In most cases, such CDHs go undiagnosed due to their mild, delayed symptoms. In the case described here, an 18-year-old Asian male presented with abdominal pain and a bowel contour in the epigastric region and left upper quadrant. A chest X-ray and thoracoabdominal computerized tomography scan confirmed the diagnosis of bowel obstruction due to a left diaphragmatic hernia. Moreover, a defect was revealed in the posterolateral left diaphragm, and the transverse colon, spleen, and half of the stomach had herniated through it. A segmentectomy was performed on the transverse colon, followed by an end-to-end anastomosis, a diaphragmatic plasty, and the placement of an intrapleural catheter. In conclusion, diagnosing a diaphragmatic hernia before surgery can be difficult due to its rarity and wide range of symptoms. Although prenatal diagnosis using ultrasonography is possible in up to 80% of fetuses, that method may not be available in all regions in Indonesia or in all countries, where doctors thus continue to face a diagnostic challenge when dealing with CDHs.

Pleural Effusions in Patients With Congestive Heart Failure: Frequency, Pathogenesis, Diagnosis, and Implications.

Patients with cardiac disease frequently develop pleural effusions; the incidence is approximately 500,000 cases per year in the United States. These effusions often represent important clinical events for patients, indicating that either there has been an acute change in the patient's clinical status or the patient's chronic management program needs review. These effusions usually develop in both the right and left hemithorax but can be unilateral. The pathogenesis involves increased fluid transfer from parietal pleural capillaries into the pleural space and possibly decreased pleural fluid uptake into parietal pleural lymphatic structures. The increased fluid transfer develops due to increased capillary pressure secondary to elevated venous outflow pressure and secondary to decreased lymphatic flow into central vessels secondary to heart failure. Most pleural effusions associated with heart failure are transudates, but 20% to 25% have increased protein and lactate dehydrogenase levels suggesting an exudative process. Additional testing can clarify the situation and requires calculation of the serum albumin to pleural fluid albumin gradient or measurement of N-terminal pro-brain natriuretic peptide in the pleural fluid. An albumin gradient of greater than 1.2 g/dL suggests that the fluid is a transudate. The presence of a pleural effusion in a hospitalized patient at discharge is associated with an increased likelihood of rehospitalization and mortality within the next year. Patients with large symptomatic pleural effusions may require therapeutic thoracentesis. Recurrence of symptomatic effusions presents a management dilemma that might require repeated thoracenteses, indwelling intrapleural catheter placement, or other management steps used in advanced chronic heart failure.

YELLOW NAIL SYNDROME PLEURAL ENTRAPMENT SUCCESSFULLY TREATED WITH INTRAPLEURAL CATHETER PLACEMENT FOLLOWED BY PLEURODESIS

TOPIC: Disorders of the Pleura TYPE: Fellow Case Reports INTRODUCTION: Yellow Nail Syndrome (YNS) is a rare cause of pleural effusions. The etiology of YNS remains unknown and treatment focuses on symptomatic management [1]. Therapies for YNS pleural effusions include thoracentesis, tunneled intrapleural catheters (IPC), pleurodesis, and pleurectomy [1,2,3]. Here we present a patient with YNS and bilateral pleural effusions successfully treated with staged IPC followed by video-assisted thoracoscopic surgery (VATS) pleurodesis. CASE PRESENTATION: A 79 year old woman who is a lifelong nonsmoker with a history of type one diabetes mellitus, hyperlipidemia, and hypothyroidism presented with chronic cough, bilateral lower extremity edema, and yellow nail discoloration. Chest computed tomography (CT) scan revealed bilateral lower lobe bronchiectasis and bilateral pleural effusions. A diagnosis of YNS was made recognizing the triad of yellow nails, lymphedema, and pulmonary disease. Thoracentesis revealed a clear-yellow, exudative pleural effusion with a lymphocytic predominance, normal triglyceride level, and negative cultures. Per patient preference, she underwent serial therapeutic thoracenteses. Over the following two years, her pleural effusions progressed requiring increased frequency of drainage, and she developed evidence of bilateral lung entrapment on manual pleural manometry with residual pleural fluid. She then opted to pursue VATS pleurodesis. Her right VATS pleurodesis was preceded by IPC placement, and her lung entrapment improved with serial IPC drainage over two months. She then underwent right VATS mechanical and doxycycline pleurodesis. This same staged procedure was performed on the left side. She has had successful resolution of her pleural effusions without evidence of recurrence at greater than 18 months of follow up. DISCUSSION: YNS is a rare diagnosis with less than 400 cases described and an estimated prevalence of <1:1,000,000 [1]. It is characterized by the triad of yellow discoloration of the nails, lymphedema, and respiratory system involvement [1]. The cause of YNS is unknown, but an anatomic or functional abnormality of lymphatic drainage is proposed as the cause of its clinical manifestations [1]. There are currently no guidelines for the management of YNS, and an individualized approach to the management of YNS pleural effusions should be taken [2,3]. As with other recurrent exudative pleural effusions, serial thoracenteses for YNS may be complicated by pleural entrapment and progression to trapped lung, limiting the efficacy of future pleurodesis. CONCLUSIONS: Our patient's case suggests a role for staged IPC placement followed by VATS pleurodesis in patients with YNS pleural effusions complicated by pleural entrapment. This may also suggest a role for IPC placement in patients who are not currently surgical candidates without sacrificing the potential for more definitive treatment in the future. REFERENCE #1: Vignes S, Baran R. Yellow nail syndrome: a review. Orphanet J Rare Dis. 02 2017;12(1):42. doi:10.1186/s13023-017-0594-4 REFERENCE #2: Kurin M, Wiesen J, Mehta AC. Yellow nail syndrome: a case report and review of treatment options. Clin Respir J. Jul 2017;11(4):405-410. doi:10.1111/crj.12354 REFERENCE #3: Valdés L, Huggins JT, Gude F, et al. Characteristics of patients with yellow nail syndrome and pleural effusion. Respirology. Oct 2014;19(7):985-92. doi:10.1111/resp.12357 DISCLOSURES: No relevant relationships by Peter Le, source=Web Response No relevant relationships by Eric Sumner, source=Web Response

Use of Medical Thoracoscopy for Retrieval of Broken Intrapleural Catheter.

Small-bore pleural catheters are used to drain simple effusions effectively. They are less invasive and more comfortable than tube thoracostomy. As with any other intervention, these small catheters have their associated complications. Herein, we report a case of a young woman who was diagnosed with tuberculous pleural effusion. Easydrain pleural catheter was inserted to drain the effusion; it broke in situ because of improper insertion and was later removed using medical thoracoscopy. We emphasize on the need for proper training for doctors and staff regarding these procedures to avoid undue complications. We have also highlighted the importance of medical thoracoscopy in the removal of retained intrapleural foreign bodies.

Bronchopleural Fistula in the Mechanically Ventilated Patient: A Concise Review

To describe the physiology of air leak in bronchopleural fistula in mechanically ventilated patients and how understanding of its physiology drives management of positive-pressure ventilation. To provide guidance of lung isolation, mechanical ventilator, pleural catheter, and endobronchial strategies for the management of bronchopleural fistula on mechanical ventilation. Online search of PubMed and manual review of articles (laboratory and patient studies) was performed. Articles relevant to bronchopleural fistula, mechanical ventilation in patients with bronchopleural fistula, independent lung ventilation, high-flow ventilatory modes, physiology of persistent air leak, extracorporeal membrane oxygenation, fluid dynamics of bronchopleural fistula airflow, and intrapleural catheter management were selected. Randomized trials, observational studies, case reports, and physiologic studies were included. Data from selected studies were qualitatively evaluated for this review. We included data illustrating the physiology of driving pressure across a bronchopleural fistula as well as data, largely from case reports, demonstrating management and outcomes with various ventilator modes, intrapleural catheter techniques, endoscopic placement of occlusion and valve devices, and extracorporeal membrane oxygenation. Themes related to managing persistent air leak with mechanical ventilation were reviewed and extracted. In case reports that demonstrate different approaches to managing patients with bronchopleural fistula requiring mechanical ventilation, common themes emerge. Strategies aimed at decreasing peak inspiratory pressure, using lower tidal volumes, lowering positive end-expiratory pressure, decreasing the inspiratory time, and decreasing the respiratory rate, while minimizing negative intrapleural pressure decreases airflow across the bronchopleural fistula. Mechanical ventilation and intrapleural catheter management must be individualized and aimed at reducing air leak. Clinicians should emphasize reducing peak inspiratory pressures, reducing positive end-expiratory pressure, and limiting negative intrapleural pressure. In refractory cases, clinicians can consider lung isolation, independent lung ventilation, or extracorporeal membrane oxygenation in appropriate patients as well as definitive management with advanced bronchoscopic placement of valves or occlusion devices.

Oncolytic herpesvirus therapy for mesothelioma – A phase I/IIa trial of intrapleural administration of HSV1716

ObjectivesMalignant Pleural Mesothelioma (MPM) remains a major oncological challenge with limited therapeutic options. HSV1716 is a replication restricted oncolytic herpes simplex virus with anti-tumor effects in multiple cell lines including MPM. Intrapleural treatment appeals because MPM is typically multifocal but confined to the pleura, and distant metastases are uncommon. We assessed the safety and possible efficacy of intrapleural HSV1716 for inoperable MPM. Materials and methodsPatients with MPM received 1 × 107iu HSV1716 injected via an indwelling intrapleural catheter (IPC) on one, two or four occasions a week apart. The primary endpoint was the safety and tolerability of HSV1716. Secondary endpoints were assessment of HSV1716 replication, detection of immune response and evaluation of tumor response. ResultsOf thirteen patients enrolled, five had received previous pemetrexed-cisplatin chemotherapy, and eight were chemotherapy naïve. Three patients were enrolled to receive one dose, three patients to two doses and seven patients to four doses. The treatment was well-tolerated with few virus-related adverse events and no dose limiting toxicities. Twelve patients were evaluable for response, as one patient withdrew early after a catheter fracture. There was evidence of viral replication/persistence in pleural fluid in seven of the twelve patients. Induction of Th1 cytokine responses to HSV1716 treatment occurred in eight patients and four patients developed novel anti-tumor IgG. No objective responses were observed but disease stabilization was reported in 50 % of patients at 8 weeks. ConclusionsIntrapleural HSV1716 was well-tolerated and demonstrated an anti-tumor immune response in MPM patients. These results provide a rationale for further studies with this agent in MPM and in combination with other therapies.

Efficacy of talc pleurodesis for malignant and paramalignant pleural effusion: a retrospective analysis of 61 cases

Introduction: Malignant-paramalignant effusions are common after malignancies. Treatment of malign-paramalignant pleural effusion is directed towards palliation of symptoms and improvement in quality of life. Chemical pleurodesis has been widely used to control malignant and para-malignant pleural effusion. The present study aims to reveal the effects of chemical pleurodesis on malignant and paramalignant pleural effusions commonly coexisting with malignant diseases.Methods: 61 patients were retrospectively examined between October 2017 and December 2019. Drainage with 8F intrapleural catheter and chemical pleurodesis (sterile talc powder) were employed in 61 patients with malignant and/or paramalignant effusion. The patient group consisted of patients treated at the thoracic surgery service or consulted from other services. The patients demographics and data on their operated side (left/right), recurrence rate, length of postoperative hospital stay, and complications were extracted from their files.Results: The sample consisted of 48 male (78.6%) and 13 female (21.3%) patients. The patients were between 22 and 82 years and the average age was 60.0 ± 13.2 years. 33 patients (54.0%) were operated on the right side, while 7 (11.4%) and 21 (34.4%) were operated bilaterally or on the left side, respectively. The most common cause of malignant and paramalignant pleural effusion was found to be lung cancer, accounting for 38 (62.2%) of the patients. Postoperative recurrence was observed in 15 (24.5%) patients. The ‎Mann-Whitney U test was used for skewed variables, and the Chi-Square test (or Fisher’s exact test) was used for ‎categorical variables. No significant difference was observed in terms of surgery side (p=0.676), gender (p=0.156) and malignant disease (p=0.979).The average length of hospital stay was 5.3 days.Conclusions: The primary principle is to control the symptoms by removing the intrapleural effusion in the cases of malignant and paramalignant effusions. When recurrence rates were evaluated, intrapleural catheter drainage and chemical pleurodesis are an effective and safe method in selected patients.

AN UNCOMMON MALIGNANT PLEURAL EFFUSION

SESSION TITLE: Tuesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/22/2019 01:00 PM - 02:00 PM INTRODUCTION: Malignant pleural effusions (MPE) are usually related to metastatic disease, most commonly from lung cancer and breast cancer. We present a case of primary pleural low-grade B-cell lymphoma, presenting with a right pleural effusion, which management defers from other etiologies of MPE. CASE PRESENTATION: An 84-year-old man with a past medical history of laryngeal cancer and atrial fibrillation, who presented to the emergency department with progressive exertional shortness of breath associated with dry cough and onset of right-sided pleuritic chest pain the past 3 days. Review of Systems was otherwise negative. Social history was non-contributory. On physical examination he was in mild-to-moderate respiratory distress, tachycardic, tachypneic and afebrile, with decreased breath sounds and dullness to percussion over the right hemithorax. Chest radiograph revealed a large right-sided pleural effusion (Fig. 1). Thoracentesis was performed and one and a half liters of cloudy exudative fluid was drained. Repeat radiograph showed adequate interval lung re-expansion (Fig. 2). Cytology analysis demonstrated low grade B cell lymphoma with CD20 positive. Staging CT/PET scan and bone marrow biopsy were normal. The patient was started on rituximab and bendamustine with no intrapleural catheter (IPC) placement after the oncologist and pulmonologist were consulted. There were no immediate complications or recurrence of pleural effusion and the patient was discharged home with outpatient follow up. DISCUSSION: Malignant pleural effusions are the second leading cause of exudative effusions. Pleural involvement by metastatic disease, including lymphoma is common, however primary pleural lymphoma remains an extremely rare condition, representing only 7% of all lymphomas (1). From all the reported cases, low-grade B-cell lymphoma representing 1.34% (2). Recent guidelines published by the American Thoracic Society regarding management of malignant pleural effusion take in consideration lung re-expansion and life expectancy before moving forward with therapeutic interventions. Outweighing benefits and risk regarding IPC, pleurodesis and combination of both should be discussed with patients and the multidisciplinary team for the benefit of the patients. As in our case, due to the high chemotherapeutic response, he will benefit from holding any unnecessary interventional procedures, avoided increased risk for infections, periprocedural complications and limitation of daily activities. Chemotherapy was initiated with close monitoring for newly developing pleural effusion. CONCLUSIONS: We submit a unique case of primary pleural low-grade B cell lymphoma presenting with large malignant pleural effusion in which management can differ from recommended guidelines. This also outlines the importance of multidisciplinary approach to avoid unnecessary procedures with better outcomes for patients with this condition. Reference #1: Mei-Lin S, Bin S, Jian-hua G & Shu-juan J. Rare case of primary lymphoma presenting with pleural effusion. Thoracic Cancer 7. 2016. 145-150 Reference #2: Vega F, Padula A, Valbuena JR et al. Lymphomas Involving the pleura. Arch Pathol Lab Med. 2006;130.1497-1502 DISCLOSURES: No relevant relationships by Israel Acosta Sanchez, source=Web Response No relevant relationships by Kathlyn Camargo Macias, source=Web Response No relevant relationships by Abed Madanieh, source=Web Response No relevant relationships by Chirin Orabi, source=Web Response No relevant relationships by jorge otoya, source=Web Response

Pre-EDIT: A Randomized Feasibility Trial of Elastance-Directed Intrapleural Catheter or Talc Pleurodesis in Malignant Pleural Effusion

Talc slurry pleurodesis (TSP) prevents recurrence of symptomatic malignant pleural effusion (MPE) in 71%to 78%patients. Nonexpansile lung (NEL) frequently accounts for TSP failure but is often occult predrainage, impairing selection of patients. NEL is associated with high pleural elastance (PEL), but technical limitations have hampered the development of PEL as a predictive NEL marker. We performed a single-center, randomized, controlled, open-label feasibility trial of EDIT (elastance-directed indwelling pleural catheter or TSP) management, using a novel digital manometer and a new definition of high PEL. Patients with symptomatic MPE were randomized 1:1 between EDIT and standard care (TSP). EDIT involved PEL assessment during large-volume thoracentesis; patients with high PEL (maximum PEL sustained over 250mL [MaxPEL250]≥ 14.5cm H2O/L) were allocated to immediately receive an indwelling pleural catheter; the remainder underwent immediate drain placement for TSP. The primary outcome measure was recruitment feasibility, defined a priori as 30 patients over 12months. Secondary outcomes included safety, technical reliability, and the aspiration volume required to detect high PEL. The accuracy of the PEL definition for NEL was analyzed post hoc. Thirty-one patients were randomized (one allocation failure) over 12months. PEL assessment (mean duration, 33 minutes) was successful in 13 of 15 patients (87%). No directly attributable serious adverse events occurred. High PEL was detected in seven of 13 patients (54%), associated with 100%sensitivity and 67%specificity for NEL, and was first detected at a median volume of 325mL (range, 250-800mL). A phase 3 trial testing the effect of EDIT management on symptomatic MPE recurrence following TSP is feasible. ClinicalTrials.gov; No.: NCT03319186; URL: www.clinicaltrials.gov.

PENGGUNAAN KATETER INTRAPLEURA (WATER SEALED DRAINAGE, INDWELLING PLEURAL CATHETER, PIGTAIL CATHETER) PADA PENATALAKSANAAN KANKER PARU DENGAN EFUSI PLEURA MASIF

Massive pleural effusion is one of the problems in lung cancer treatment that cause death. The main treatment of cancer patient with massive pleural effusion is the placement of intrapleural catheter. This is a preliminary study which is aimed to assess tolerancies and efficacies of intrapleural catheter (WSD, IPC or pigtail catheter) in lung cancer with massive pleural effusion. This study is a retroscpective observational cohort study. Subjects are lung cancer patients with massive pleural effusion and catheterized with intrapleural catheter (WSD, IPC or pigtail catheter). The datas were taken from medical record at RSUP Persahabatan and assessed for tolerancies (acute or late complication) and efficacies ((length of hospital admission after catheter placement, duration and the reason of retraction) of intrapleural catheter. Tolerancies and efficacies of intrapleural catheter (WSD, IPC or pigtail catheter) in lung cancer patients with massive pleural effusion are quite good and safe. Prospective cohort studies are needed in the future to determine which type of intrapleural catheter is better for the treatment of massive pleural effusion in lung cancer patients.

PENGGUNAAN KATETER INTRAPLEURA (WATER SEALED DRAINAGE, INDWELLING PLEURAL CATHETER, PIGTAIL CATHETER) PADA PENATALAKSANAAN KANKER PARU DENGAN EFUSI PLEURA MASIF

Massive pleural effusion is one of the problems in lung cancer treatment that cause death. The main treatment of cancer patient with massive pleural effusion is the placement of intrapleural catheter. This is a preliminary study which is aimed to assess tolerancies and efficacies of intrapleural catheter (WSD, IPC or pigtail catheter) in lung cancer with massive pleural effusion. This study is a retroscpective observational cohort study. Subjects are lung cancer patients with massive pleural effusion and catheterized with intrapleural catheter (WSD, IPC or pigtail catheter). The datas were taken from medical record at RSUP Persahabatan and assessed for tolerancies (acute or late complication) and efficacies ((length of hospital admission after catheter placement, duration and the reason of retraction) of intrapleural catheter. Tolerancies and efficacies of intrapleural catheter (WSD, IPC or pigtail catheter) in lung cancer patients with massive pleural effusion are quite good and safe. Prospective cohort studies are needed in the future to determine which type of intrapleural catheter is better for the treatment of massive pleural effusion in lung cancer patients.

Small dose of naloxone as an adjuvant to bupivacaine in intrapleural infiltration after thoracotomy surgery: a prospective, controlled study.

BackgroundSevere pain always develops after thoracotomy; intrapleural regional analgesia is used as a simple, safe technique to control it. This study was performed to evaluate whether a small dose of naloxone with local anesthetics prolongs sensory blockade.MethodsA prospective, randomized double-blinded controlled study was conducted on 60 patients of American Society of Anesthesiologists statuses I and II, aged 18 to 60 years, scheduled for unilateral thoracotomy surgery. After surgery, patients were randomly divided into two groups: through the intrapleural catheter, group B received 30 ml of 0.5% bupivacaine, while group N received 30 ml of 0.5% bupivacaine with 100 ng of naloxone. Postoperative pain was assessed using the visual analog pain scale (VAS). Time for the first request for rescue analgesia, total amount consumed, and incidence of postoperative complications were also recorded.ResultsThe VAS score significantly decreased in group N, at 6 h and 8 h after operation (P < 0.001 for both). At 12 h after injection, the VAS score increased significantly in group N (P < 0.001). The time for the first request of rescue analgesia was significantly longer in group N compared to group B (P < 0.001). The total amount of morphine consumed was significantly lower in group N than in the bupivacaine group (P < 0.001).ConclusionsAddition of a small dose of naloxone to bupivacaine in intrapleural regional analgesia significantly prolonged pain relief after thoracotomy and delayed the first request for rescue analgesia, without significant adverse effects.

Comparision of Chest Tube and Intrapleural Catheter Applied for Benign Pleural Effusions

Comparision of Chest Tube and Intrapleural Catheter Applied for Benign Pleural Effusions

192 - Pre-EDIT: a randomised, feasibility trial of Elastance-Directed Intra-pleural catheter or Talc Pleurodesis (EDIT) in the management of symptomatic malignant pleural effusion without obvious non-expansile lung

192 - Pre-EDIT: a randomised, feasibility trial of Elastance-Directed Intra-pleural catheter or Talc Pleurodesis (EDIT) in the management of symptomatic malignant pleural effusion without obvious non-expansile lung

Intrapleural Infection Causing Pleurodesis in a Patient With Refractory Chylothorax Related to Yellow Nail Syndrome

SESSION TITLE: Disorders of the Pleura SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM INTRODUCTION: Yellow nail syndrome (YNS) is a rare cause of chylothorax, and empyema is an unusual complication in these patients. While tunneled intrapleural catheter (IPC) related infections are uncommon, they may lead to post-infectious pleurodesis. Herein we report a case of refractory chylothorax due to YNS with empyema leading to post-infectious pleurodesis. CASE PRESENTATION: A 66 year old man with YNS, manifested by chronic chylous pleural effusions managed by placement of tunneled IPCs 4 years prior, was admitted to the hospital with increasing dyspnea and oxygen requirement. Imaging revealed patchy opacities in the bases of the lungs bilaterally, and broad antibiotic coverage was initiated. Ultrasound demonstrated increased septations within the pleural fluid compared to previous imaging, and bilateral thoracenteses were performed with Enterococcus faecalis growth noted from the left effusion. Evacuation of the pleural space was accomplished via instillation of fibrinolytic agents via the left IPC, and was later repeated on the right following decrease in output with noted increase in septations on ultrasound. Antibiotic coverage was continued for a total of three weeks. On follow-up, the catheters had both stopped draining for three weeks, and ultrasound revealed small residual effusions allowing removal of both catheters. There was no recurrence of the effusions at 6 months, demonstrating pleurodesis. DISCUSSION: Yellow nail syndrome is a rare disorder characterized by thickened and yellow nails with lymphedema and multiple respiratory manifestations. The cause is unknown, but the mechanism of the clinical manifestations is thought to be acquired lymphatic dysfunction. A recent review of the literature has identified less than 400 cases with an estimated prevalence in the general population of < 1:1,000,000. While parapneumonic effusions and empyemas are quite common complications of bacterial pneumonia, empyemas appear to be uncommon within YNS, with one study documenting empyema in only 3.5% of patients (3/85). A 2013 study of over 1000 patients with malignant pleural effusions by Fysh et al. demonstrated that IPC related infections were uncommon, occurring in <5% of cases, but of these, 62% (31/50) achieved post-infectious pleurodesis. CONCLUSIONS: Our patient required long term IPC management for chronic chylothoraces; however, following treatment for empyema, achieved bilateral pleurodesis with durable response. Though infections are undesirable, pleurodesis is a positive outcome that is commonly noted in IPC related infections. Reference #1: Fysh, E. T., et al. (2013). “Clinical outcomes of indwelling pleural catheter-related pleural infections: an international multicenter study.” Chest 144(5): 1597-1602. Reference #2: Valdes, L., et al. (2014). “Characteristics of patients with yellow nail syndrome and pleural effusion.” Respirology 19(7): 985-992. Reference #3: Vignes, S. and R. Baran (2017). “Yellow nail syndrome: a review.” Orphanet J Rare Dis 12(1): 42 DISCLOSURE: The following authors have nothing to disclose: Bryan Kelly, Ryan Kern No Product/Research Disclosure Information

The effect of bilateral intrapleural infusion of lidocaine with fentanyl versus only lidocaine in relieving pain after coronary artery bypasses surgery.

Background and Objective:Pain control during surgery in order to cause analgesia and reduce the somatic and autonomic response may decrease the morbidity. Intrapleural catheter embedding during surgery under direct vision of surgeon is safe and easy and without potential risk of thoracic epidural block. The aim of this study was to investigate the effect of bilateral intrapleural infusion of lidocaine with fentanyl versus only lidocaine in relieving pain after coronary artery bypass surgery.Methods:In this prospective randomized double blind clinical trial,130 adult patients undergoing elective CABG with age range of 20 to 60 years were divided into two groups receiving either lidocaine and fentanyl (group A) or lidocaine (group B). The analgesia was evaluated every two hours in all intubated and non-intubated patients using Visual analog scale (VAS) and data were analyzed using SPSS software package.Results:Of all patients, 67 (51.5%) were males and 63 (48.5%) were females. The average age of subjects was 53.49 ± 5.099 years. Mean pain score six hours after the surgery was statistically different between the groups at all times.Conclusion:The pain in patients receiving combination of lidocaine and fentanyl is less than patients receiving only lidocaine.

OA13.07 Intrapleural Modified Vaccine Strain Measles Virus Therapy for Patients with Malignant Pleural Mesothelioma

Malignant pleural mesothelioma (MM) remains an almost universally fatal disease with limited treatment options. Preclinical models indicate the preferential oncolytic activity of the modified vaccine strain measles virus carrying the gene for the human sodium-iodine symporter (NIS) – MV-NIS. Intraperitoneal and intravenous administration of MV-NIS was recently found to be potentially effective in patients with refractory ovarian cancer and multiple myeloma. However, whether MV-NIS is directly oncolytic or triggers an anti-tumor immune response remains unclear. We conducted a phase I dose escalation study with 3+3 design and ongoing maximal tolerated dose (MTD) expansion cohort. MV-NIS was administered as first or second line therapy via a tunneled intrapleural catheter to patients with MM. MV-NIS dose ranged from 108 TICID50 to 9 x 109 TICID50. In the absence of dose limiting toxicity and disease progression, patients received up to 6 cycles of MV-NIS therapy (Phase I). Currently additional patients are being randomized between a single and multiple cycles. MV-NIS infection and replication are monitored by Iodine123 SPECT/CT (Phase I only) as well as by RT-PCR and/or plaque-assay. Anti-tumor immunity is monitored in the blood and pleural fluid and patients are followed clinically by chest CT using the modified RECIST criteria. Twelve patients (3/dose level) received MV-NIS therapy. There were no dose limiting adverse events and therapy was well tolerated. The best therapeutic response was stable disease, which was achieved at 1 month by 8/12 evaluable patients (67%). Median overall survival was 449 days (95%CI: 221, 484) (∼15 months) (4/12 patients remain alive), and median progression free survival was 63 days (95% CI: 33, 174) (∼2 months). MV infection and replication were detectable by RT-PCR and plaque assay in the pleural fluid between 24-72 hours after treatment. I123 SPECT-CT demonstrated only marginal viral gene expression in a single patient treated with the highest dose level. MV-NIS therapy effectively boosted pre-existing anti-MV neutralizing antibody responses in the plasma and pleural fluid of most patients. We observed a transient inflammatory response in the pleural space after MV-NIS administration. In addition, induction or boosting of anti-tumor antibody responses was observed. The intrapleural administration of MV-NIS is safe, resulted in stable disease for 67% of patients and may be associated with favorable overall survival in MM. While there was only transient infection and viral replication, we observed the induction of anti-tumor immune responses supportive of potential long-term therapeutic impact. The study continues with the MTD expansion cohort.