Small-bore Catheters Research Articles

Efficacy of Iodopovidone Pleurodesis and Comparison of Small-Bore Catheter Versus Large-Bore Chest Tube

To evaluate the efficacy of iodopovidone as an agent for pleurodesis in malignant pleural effusion (MPE) and to compare the efficacy of small-bore catheter (Pleuracan, Braun, Melsungen, Germany) and conventional large-bore chest tube in pleural fluid drainage and sclerotherapy. Patients with MPE were prospectively consecutively randomized into two groups between August 2004 and February 2007: pleurodesis via conventional (32F) chest tube (group 1) and small-bore catheter (group 2), both using iodopovidone. After 3 months' follow-up, response rates (complete or partial), complication rates, and duration of procedures within whole group, group 1, and group 2 were compared. Statistical analyses were performed by Mann-Whitney U, chi(2), and Fisher's exact test. Forty-three pleurodeses were performed in 41 patients. The response was complete in 26 (60.5%) and partial in 12 (27.9%), and the overall success rate was 88.4%. The response rate was not associated with the type of inserted tube (P = .750), pleural fluid pH (P = .290), or pleural fluid lactate dehydrogenase (P = .727). In group 1 (n = 20), 12 demonstrated complete and 6 demonstrated partial response, with a 90% success rate; success was 86.9% in group 2, with complete response in 14 and partial response in 6 patients. Success rates were similar in the two groups (P = 1.000). Of 43 procedures, complications were observed in 14 (32.5%), and complication rates were 35% and 30.4% in groups 1 and 2, respectively (P = .750). The most frequent complication was pain (16.2%), followed by fever, subcutaneous emphysema, dyspnea, and hypotension. Iodopovidone is an effective, inexpensive, safe, and easily available alternative in chemical pleurodesis in MPE. The success rates of pleurodesis were found to be similar regardless of the type of the tube inserted.

Predictors of talc pleurodesis outcome in patients with malignant pleural effusions

Chemical pleurodesis is an accepted palliative therapy for patients with recurrent, symptomatic, malignant pleural effusions (MPE). The purpose of the study was to determine the factors that have an effect on successful pleurodesis for MPE. Eighty-four consecutive patients with biopsy-proven malignant pleural disease and recurrent, symptomatic MPE were eligible to participate in this study. Five grams of talc mixed in 150ml of normal saline were administered via tube thoracostomy or small-bore catheters after complete drainage of the pleural effusion. Seven patients did not return for their 30-day follow-up visit and were excluded from further analysis. Successful pleurodesis was achieved in 63 of 77 eligible patients (81.8%) with MPE. In the univariate analysis, female gender, Karnofsky performance status, pleural fluid pH, cholesterol, and adenosine deaminase level showed a significant association with the probability of success. Multivariate logistic regression analysis showed that pleural fluid pH and ADA levels were independent predictors of talc pleurodesis outcome. Our results show that pleurodesis using talc as the sclerosing agent is a simple and acceptable procedure with high efficacy for controlling MPE, especially when used in appropriate patients.

Large or Small Bore, Push or Pull: A Comparison of Three Classes of Percutaneous Fluoroscopic Gastrostomy Catheters

To compare the tube performance and complication rates of small-bore, large-bore push-type, and large-bore pull-type gastrostomy catheters. A total of 160 patients (74 men, 86 women; mean age, 66.9 years, range, 22-95 y) underwent percutaneous fluoroscopic gastrostomy placement between January 2004 and March 2006. Choice of catheter was based on the preference of the attending radiologist. Data were collected retrospectively with institutional review board approval. Radiology reports provided information on the catheter, indication for gastrostomy, technical success, and immediate outcome. Chart review provided data on medical history, postprocedural complications, progress to feeding goal, and clinical outcomes. Statistical analysis was performed to compare the three classes of gastrostomy catheters. All 160 catheters were placed successfully. Patients who received small-bore catheters (14 F; n = 88) had significantly more tube complications (17% vs 5.6%) and were less likely to meet their feeding goal (P = .035) compared with patients with large-bore catheters (20 F; n = 72). No difference was observed in terms of major or minor complications. Large-bore push-type (n = 14) and pull-type catheters (n = 58) were similar in terms of complication rates. Patients who received large-bore push-type catheters achieved their feeding goals in significantly less time than those with large-bore pull-type catheters (average, 3.8 days vs 6.0 days; P = .04). Patients who received small-bore gastrostomy catheters are significantly more prone to tube dysfunction. Large-bore catheters should be preferentially used, with push-type catheters performing better with regard to the time to achieve feeding goal.

Continuous Spinal Analgesia for Labor and Delivery

Continuous Spinal Analgesia for Labor and Delivery

Devastating chest wall necrotizing fasciitis following pigtail catheter drainage

Pigtail catheter for drainage of pleural effusion has gained popularity. Complication related to the insertion of these small-bore catheter is low. In this report, we highlight two cases with devastating necrotizing fasciitis of chest wall following pigtail catheter insertion.

The Role of Simple Aspiration in the Management of Primary Spontaneous Pneumothorax

According to an American College of Chest Physicians consensus statement published in 2001, it is recommended that chest tubes should be used for the drainage of primary spontaneous pneumothoraces. However, more recent expert opinions and guidelines suggest that simple aspiration is increasingly recognized as an acceptable alternative treatment. Studies have shown that the success rates and recurrence rates of simple aspiration are comparable to, if not more favorable than, those of chest tube drainage and small-bore catheter aspiration. Simple aspiration is the least invasive modality and it has economic cost-saving benefits, particularly with respect to admission rates and hospital length of stay. Its complication rate is low. However, a larger size of pneumothorax seems to be associated with increased likelihood of failure of simple aspiration. The author reviews the available evidence relating to the use of simple aspiration as a modality for treating primary spontaneous pneumothorax.

Empyema and Effusion: Outcome of Image-Guided Small-Bore Catheter Drainage

Empyema and complicated pleural effusion represent common medical problems. Current treatment options are multiple. The purpose of this study was to access the outcome of image-guided, small-bore catheter drainage of empyema and effusion. We evaluated 93 small-bore catheters in 82 patients with pleural effusion (n = 30) or empyema (n = 52), over a 2-year period. Image guidance was with ultrasound (US; n = 56) and CT (n = 37). All patients were followed clinically, with catheter dwell times, catheter outcome, pleural fluid outcome, reinsertion rates, and need for urokinase or surgery recorded. Ninety-three small-bore chest drains (mean=10.2 Fr; range, 8.2-12.2 Fr) were inserted, with an average dwell time of 7.81 days for empyemas and 7.14 days for effusions (p > 0.05). Elective removal rates (73% empyema vs 86% effusions) and dislodgement rates (12% empyema vs 13% effusions) were similar for both groups. Eight percent of catheters became blocked and 17% necessitated reinsertion in empyemas, with no catheters blocked or requiring reinsertion in effusions (p < 0.05). Thirty-two patients (51%) required urokinase in the empyema group, versus 2 patients (6%) in the effusion group (p < 0.05). All treatment failures, requiring surgery, occurred in the empyema group (19%; n = 12; p < 0.05). In conclusion, noninfected pleural collections are adequately treated with small-bore catheters, however, empyemas have a failure rate of 19%. The threshold for using urokinase and larger-bore catheters should be low in empyema.

Preliminary Report of a Prospective, Randomized Trial of Underwater Seal for Spontaneous and Iatrogenic Pneumothorax

Management of pneumothorax has traditionally been tube thoracostomy and -20 cm H2O suction. The purpose of our study was to determine if underwater seal in iatrogenic and spontaneous pneumothoraces is safe and efficacious and if small-caliber chest tubes are appropriate for routine use in pneumothorax. From April 2001 through October 2003 patients with iatrogenic or spontaneous pneumothorax were enrolled in this prospective, randomized trial. Small-bore catheters were inserted. Initial management was 1 hour -20 cm H2O suction, chest radiography, and randomization into -20 cm H2O suction, -10 cm H2O suction, or underwater seal. Tubes were discontinued at 48 hours if there were no pneumothoraces and no air leaks. Those with air leaks and recurrent pneumothoraces persisting 5 days underwent pleurodesis. The primary end point was successful chest tube removal at 48 hours. The secondary end point was need for pleurodesis. Twenty-nine patients were analyzed. Seven were randomized to -20 cm H2O suction, 11 to -10 cm H2O suction, and 11 to underwater seal. Most (59%, 17 of 29) chest tubes were successfully removed 48 hours after placement: 57% (4 of 7) after -20 cm H2O suction, 73% (8 of 11) after -10 cm H2O suction, and 45% (5 of 11) after underwater seal (p = 0.48). Seven (24%) required pleurodesis: 29% (2 of 7) after -20 cm H2O suction, 27% (3 of 11) after -10 cm H2O suction, and 18% (2 of 11) after underwater seal (p = 0.70). Early underwater seal appears to be safe for treating iatrogenic and spontaneous pneumothoraces. It can achieve comparable frequencies of early chest tube removal and avoidance of operation compared with traditional management. A larger, multi-institutional study should be performed to demonstrate that pneumothorax treatment can effectively incorporate small-caliber tubes and underwater seal.

Pleural drain malposition

Sir: Small-bore chest drains with removable introducer needle (such as the 8-Fr Pleurocath®, Plastimed, Saint-Leu-La Foret, France) can be used to drain liquid pleural effusions or pneumothorax [1]. We report a case of severe vascular injury due to Pleurocath® malposition, with the goal of raising awareness among physicians about this life-threatening complication, and discuss methods for a safer procedure. A 67-year-old man with a recent history of trauma and hemorrhagic shock followed by postanoxic encephalopathy was admitted to a general medicine ward for investigation of left hydropneumothorax. Thoracic computed tomography confirmed the left hydropneumothorax. A Pleurocath® was inserted on the left mid-axillary line with the patient in the 45° semi-recumbent position. Blood issued through the distal end of the catheter immediately after insertion but was mistakenly taken as evidence of hemothorax. Hemorrhagic shock occurred within a few minutes and the catheter was clamped. The patient was transferred to the intensive care unit. Catheter malposition was suspected. A chest radiograph showed the tip of the catheter in the superior mediastinum, but without an accurate location. Fluid resuscitation and blood transfusion were started. Thoracic computed tomography (CT) with contrast enhancement showed that the catheter ran through the left ventricle, ascending aorta (Fig. 1), and right carotid. The patient was immediately transferred to a cardiothoracic surgery center, where the catheter was removed through a left thoracotomy. The patient was discharged from the unit 3 weeks later. Use of small-bore catheters may reduce morbidity compared with chest tubes [2]. Several cases of cardiac puncture have been reported with larger-bore drains over rigid inner trocars (e.g., Mallinckrodt®) [3] and, more rarely, with small-bore drains (e.g., Pleurocath®). However, our case report shows that small-bore catheters may be associated with life-threatening complications. In our patient, the main factors causing cardiac injury were probably insertion of the catheter low in the left chest wall, through the sixth intercostal space and the small size of the effusion. The published guidelines of the British Thoracic Society [2] recommend insertion in the “safe triangle” bordered by the anterior border of the latissimus dorsi, the lateral border of

Rapid pleurodesis with doxycycline through a small-bore catheter for the treatment of metastatic malignant effusions

The goal of the study was to evaluate the safety and efficacy of bedside pleurodesis with doxycycline using a short-term indwelling chest catheter for the palliative treatment of malignant effusions. A prospective study of 36 rapid pleurodesis procedures in 34 patients with malignant pleural effusions was conducted over a 5-year period in a university hospital. A 12F chest catheter placement was facilitated utilizing the Seldinger percutaneous entry technique. Patients received 500 mg of intrapleural doxycycline combined in half of the cases with mepivacaine. We assessed success or failure of pleurodesis in addition to the frequency of complications and survival. Chest tubes were removed within 24 h in 69% and within 48 h in 94% of the patients. Complete success of pleurodesis was achieved in 17 (55%), partial success in eight (26%), and failure in six (19%) out of 31 evaluative procedures. Thus, the overall success rate of pleurodesis was 81%. Toxicity was mild and included pain (36%), fever (8%), and pneumothorax (6%). The median survival was 105 days. There was no relationship between instillation of intrapleural anesthetics and development of pain. Rapid pleurodesis with doxycycline, which can be accomplished within 24 to 48 h, is a valid option for the symptomatic treatment of malignant effusions. This technique can be used as a first-line procedure in the majority of cases, particularly if thoracoscopic facilities are not available.

Seldinger Approach Of Pleural Effusion Drainage In Emergency Department

Previous articles confirmed high incidence of pleural effusions in Emergency Department. Aim of this prospective observational study was to avoid repeated thoracentesis and drain large effusions using an indwelling 16 G single lumen central venous catheter (CVC). 56 patients were studied prospectively from December 2005 to January 2006. Patients were included if they had large pleural effusions with clinical and radiological demonstration. Patients were excluded from this study in case of doubt of loculated pleural effusion, or coagulation abnormalities. Mean volumes drained at 1, 6 and 24 hours were 454±241 ml, 756±403 ml and 1,010±469 ml, respectively. 37 samples were classified as exudates and 16 samples as transudates. Results for one sample were not available. No patients had pneumothorax on first roentgenogram performed within 8 — 12 hours after catheter insertion. There were no instances of hemothorax or re-expansion pulmonary edema. None of the catheters slipped out and there were no accidental disconnections of drainage system. Longest duration of in situ catheter was 14 days, and drained a total of 5,050 ml over this period. Daily drainage ranged from 70 to 1,700 ml/day. There were no instances of catheter blockage despite fibrinous material being seen in the collection bag of 2 (3.57%) patients. In conclusion, this technique is useful and safe in selected individuals. Non-ultrasound guided placement of small-bore catheters such as central lines provide effective and safe drainage of pleural effusions with minimal discomfort.

Management of Recurrent Malignant Pleural Effusion with Chemical Pleurodesis

Malignant pleural effusion is a common complication of primary and metastatic pleural malignancies. It is usually managed by drainage and pleurodesis, but there is no consensus as to the best method of pleurodesis. We compared the effectiveness, side effects, and cost of different chemical pleurodesis agents used in patients with malignant pleural effusion. Between January 1990 and December 2001, 108 patients with malignant pleural effusion underwent chemical pleurodesis in our department. Thoracoscopy was performed in 64 patients (59%), a minithoracotomy in 18 (17%), tube thoracostomy in 11 (10%), and a small-bore catheter was inserted in 15 (14%). Talc was used in 68 (63%) patients, tetracycline in 26 (24%), and bleomycin in 14 (13%). Talc was instilled by insufflation during surgery after drainage, whereas tetracycline and bleomycin were instilled via tube or catheter for pleural analgesia. Talc resulted in significantly earlier tube and catheter removal, after an average 4.1 days versus 5.1 days after tetracyline, and 6.3 days after bleomycin (P = 0.026, P = 0.001, respectively). A significantly lower reaccumulation ratio in 90 days was achieved by the talc group, with nine (13.2%) patients, representing an 86.8% success rate, than in the tetracyline and bleomycin groups, with seven (26.7%) and five (35.7%) patients, respectively, representing 73.8% and 64.3% success rates (P = 0.04). Talc resulted in the earliest expansion, minimal drainage, and the earliest tube and catheter removal.

Rapid pleurodesis in symptomatic malignant pleural effusion

The objective of the study was to see whether a rapid method of pleurodesis was superior to the standard protocol in patients with symptomatic malignant pleural effusion. Between January 2000 and February 2003, a prospective randomised trial was carried out in a sequential sample of 27 patients with malignant pleural effusions documented cytopathologically. Twelve patients were allocated to group 1 (standard protocol) and 15 to group 2 (new protocol). A small-bore catheter (12 Fr) and oxytetracycline (35 mg/kg of body weight) were used in both groups. In group 1, patients had drainage until radiological evidence of lung re-expansion was obtained and the amount of fluid drained was less than 150 ml/day, before oxytetracycline was instilled. The catheter was removed when the amount of fluid drained after instillation was less than 150 ml/day. In group 2, patients had the oxytetracycline instilled in a fractionated-dose manner following frequent aspirations at 6h intervals. The catheter was removed when the total amount of fluid drained after instillation of the oxytetracycline [OT] was less than 150 ml/last three aspirations. Response was evaluated at 1, 3 and 6 months after pleurodesis. There was no statistically significant difference in the demographic features, site of the primary tumour, disease characteristics, and response rates in any evaluation period in both groups (P>0.05). However, the number of days of drainage and hospitalisation, and the cost were significantly lower in the second group (P<0.001). This new pleurodesis method provided shorter hospital stay resulting in superior cost-effectiveness and palliation without sacrificing the efficacy of pleurodesis.

Management of empyema - Role of a surgeon

Postpneumonic empyema still remains quite common in developing countries, especially during the hot and humid months. While most cases would respond to antibiotic therapy, needle aspiration and intercostal drainage, few cases require further surgical management.<br>The most common nontubercular etiological agent is Staphylococcus. Tubercular etiology is not uncommon in India, especially due to delayed presentation, multiresistant strains, mismanaged cases, and noncompliance with antitubercular treatment amidst malnutrition and anemia. Clinical symptoms, a skiagram chest followed by thoracentesis are enough for diagnosis. Pleural fluid is usually diagnostic and helps in choosing the appropriate antibiotics. Further investigations and management depends on the stage of the disease. Thoracentesis alone may be sufficient for the exudative phase. In fibrinopurulent stage, a properly sized and well-placed tube thoracostomy with underwater seal is curative in most cases. Interventional radiologists have placed small-bore catheters, specifically directed to the loculated collection and have used fibrinolytics like urokinase, streptokinase, and tissue plasminogen activator (TPA) to break loculations, ameliorate fibrous peel formation, and fibrin deposition.<br>Thoracoscopic debridement and thoracoscopic decortication is an alternative with distinct advantages over thoracotmy and are indicated if there was no response with intercostal drainage procedure. In the organizing stage, a thoracotomy (for decortication) would be required if there is a loculated empyema, underlying lung disease or persistently symptomatic effusions. Timely institution of proper management prevents the need for any surgical intervention and avoids long-term morbid complications.<br>

The Mechanical Properties of Continuous Spinal Small-Bore Catheters

Continuous spinal anesthesia (CSA) has a nearly 100-yr history. In situations of difficult removal of a CSA small-bore catheter, mechanical properties of the different catheters might be important, because breakage could occur. We compared 5 different CSA small-bore catheters, 22- to 28-gauge from 3 manufacturers, for tensile strength, tensile stress, distension, and yield strength. Maximal tensile strength is the force applied before breakage of the catheter. The material characteristics of different CSA small-bore catheters for maximal tensile strength were: 22-gauge = 29.56 +/- 1.56 (mean +/- sd) Newton (N), 24-gauge = 16.77 +/- 1.61 N, 25-gauge = 9.20 +/- 0.48 N, 27-gauge = 4.61 +/- 0.25 N, 28-gauge = 5.07 +/- 0.59 N at room temperature. A strong correlation between maximal tensile strength and the outer diameter (r = 0.957, P < 0.001) and maximal tensile strength and the wall thickness (r = 0.9, P < 0.001) was observed. Although extrapolation from experimental studies to clinical routine should be made with care, our data suggest that catheters with higher-strength characteristics may reduce the risk of catheter breakage in patients, although clinical correlations are lacking.

Pneumothorax.

Spontaneous pneumothoraces can occur without obvious underlying lung disease (primary) or in patients with known underlying lung disease (secondary). Management guidelines for spontaneous pneumothorax have been published by major professional organizations, but awareness and application among clinicians seems poor. First episodes of primary spontaneous pneumothorax can be managed with observation if the pneumothorax is small. If the pneumothorax is large or if the patient is symptomatic, manual aspiration via a small catheter or insertion of a small-bore catheter coupled to a Heimlich valve or water-seal device, should be performed. In general, definitive measures to prevent recurrence are recommended after the first recurrence of the pneumothorax, and can be achieved by medical (e.g. talc) or surgical (video-assisted thoracic surgery) pleurodesis. Secondary pneumothoraces should be treated with chest tube drainage followed by pleurodesis after the first episode to minimize any risk of recurrence. Traumatic pneumothoraces may be occult (not seen on an initial CXR) or non-occult. The majority are treated by placement of a chest tube. Selected patients may be treated conservatively, with approximately 10% of these patients eventually requiring chest tube placement. Iatrogenic pneumothoraces have a myriad of causes with transthoracic lung needle biopsy being most common. Transthoracic needle biopsy-related pneumothoraces have CT findings that can predict their occurrence and the need for chest tube placement. Iatrogenic pneumothoraces, regardless of cause, may be managed by observation or small bore chest tube placement, depending upon patient stability and the size of the pneumothorax.

Association of Tension Pneumothorax With Use of Small-Bore Chest Tubes in Patients Receiving Mechanical Ventilation

We report the case of a 46-year-old woman who came to our emergency department with generalized weakness and abdominal pain. Shortly thereafter, she became hypotensive and had a respiratory arrest that required endotracheal intubation and mechanical ventilation.The patient had a history of hypertension, migraines, and emphysema. Medications included aspirin, butalbital, and caffeine taken for headaches, and laxatives. A chest radiograph obtained after intubation revealed hyperinflated lungs with diminished vascularity and a flattened diaphragm suggestive of emphysematous lung disease.Within a few hours after intubation, the patient’s respiratory status deteriorated and her oxygen saturation decreased precipitously. Peak airway pressures were elevated and hypotension developed. Because of the potential for pneumothorax, the on-call physician placed a small-bore chest tube connected to a Heimlich 1-way valve. In order for the patient to be transferred for computed tomography, mechanical ventilation was temporarily stopped and aggressive manual ventilation was used. The nursing staff noticed significant resistance during manual ventilation. After placement of the chest tube, computed tomography revealed significant subcutaneous emphysema, a tension pneumothorax, and contralateral mediastinal shift. Multiple bullae and blebs also were present. The patient had a cardiorespiratory arrest and required placement of a conventional large-bore chest tube; resolution of the pneumothorax ensued. Eventually, she was taken to the operating room for bullectomy and repair of ruptured blebs. The postoperative course was complicated by exacerbation of respiratory failure and infection, and the patient died.In this case, placement of a small-bore chest tube did not resolve a pneumothorax. Moreover, the tube could have potentiated the problem by causing tension pneumothorax. The American College of Chest Physicians consensus statement1 supports the use of small-bore catheters (<14F) in patients with small to large pneumothoraces whose clinical status is stable. Some patients whose clinical status is unstable can be managed with a small-bore catheter attached to a Heimlich valve if the catheter can provide rapid evacuation of the pleural space. The American College of Chest Physicians recommends the use of size 24F to 28F catheters in patients who appear to be at risk for a large pleural air leak. However, until the computed tomography scan was obtained, we did not know that our patient was high risk.Small-bore chest tubes, although effective for treating small pneumothoraces, have major limitations.2 The catheter tip is easily occluded by fluid, by placement of the catheter against the chest wall, or by a kink; all these situations could create a tension pneumothorax.2–4 Tension pneumothorax could be catastrophic in a patient receiving positive-pressure ventilation. The user’s manual provided by the manufacturer of the small-bore chest tube that was used did not refer to that complication. After placement of a conventional chest tube and removal of the small-bore chest tube, the tension pneumothorax in our patient resolved.We therefore caution physicians and nurses against the use of small-bore chest tubes with a Heimlich valve in patients who are receiving positive-pressure ventilation. If possible, regular-size thoracotomy tubes should be used instead. Furthermore, nursing staff should be cautious in fervent manual overinflation in patients with severe emphysema who are receiving mechanical ventilation, especially during transportation or resuscitation efforts. Such overinflation could markedly increase intrathoracic pressure and eventually lead to excessive amounts of intrinsic positive end-expiratory pressure.5 In patients with large bullae, blebs, and poor parenchymal integrity, intrinsic positive end-expiratory pressure could cause hypotension, hypoxemia, and poor gas exchange, leading to cardiorespiratory arrest and possibly death. It is therefore recommended that ventilation via a manual resuscitation bag be done with lower tidal volumes and increased time for full exhalation between breaths.

Choosing fluids in traumatic hypovolemic shock: the role of crystalloids, colloids, and hypertonic saline.

Choosing fluids in traumatic hypovolemic shock: the role of crystalloids, colloids, and hypertonic saline.

The Value of Small-Bore Catheter Thoracostomy in the Treatment of Malignant Pleural Effusions

Background: Malignant pleural effusions can cause severe debilitating symptoms and impair the quality of life. Treatment is often palliative, usually consisting of sequential thoracenteses or tube thoracostomy with or without sclerotherapy. Large-bore thoracostomy tubes have traditionally been used for drainage and sclerotherapy. More recently, the use of small-bore catheters has been studied. Objectives: To assess the efficacy and safety of small-bore catheter (Pleuracan^®) thoracostomy combined with talc sclerotherapy for palliative treatment of malignant pleural effusions. Methods:Between May 1998 and March 2000, 24 consecutive patients presenting at our inpatient clinic were studied. Follow-up radiography at the end of the 1st month (immediate response) and 3rd month (long-term follow-up) after talc pleurodesis was performed to assess the response rates. Results: Of the 24 patients included, 2 patients did not show lung expansion after pleural drainage. Two patients died within 30 days after talc pleurodesis and 1 did not undergo 30-day postpleurodesis radiography. The remaining 19 patients made up the study group to assess the response rates (8 men, 11 women). Overall response rates of talc pleurodesis via small-bore catheter were found to be 84.2% [complete response (CR): 68.4%, partial response (PR): 15.8%] at 30-day and 78.6% (CR: 57.2%, PR:2 1.4%) at 90-day follow-up, respectively. One patient reported moderate pain during catheter placement. Four patients experienced mild to moderate pleuritic chest pain, shortness of breath, or both within 4 h after instillation. Seven of the 22 patients (31.8%) had a transient fever (≤39.0°C) 6–24 h after talc instillation that lasted less than 24 h and was successfully treated with acetaminophen. One patient had significant subcutaneous emphysema that resolved in 24 h. Four patients died because of tumor progress (2 patients in the 1st month and 2 patients between 30 and 90 days). Conclusion:Pleurodesis can successfully be performed via a small-bore catheter in patients with recurrent malignant pleural effusion. To validate the results of the study, a prospective randomized study, comparing this device (Pleuracan) and a ‘standard’ 16- to 24-french chest drain, should be performed.

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.