Musani, A.I., Haas, A.R., Seijo, L., Wilby, M., & Sterman, D.H. (2004). Outpatient management of malignant pleural effusions with small-bore, tunneled pleural catheters. Respiration; International Review of Thoracic Diseases, 71(6), 559-566.

The objective of the study was to retrospectively examine whether recurrent malignant pleural effusions (MPEs) could be managed on an outpatient basis using small-bore tunneled pleural catheters (PCs) and without the use of sclerosing agents.

The study was a retrospective analysis of 24 patients who underwent placement of PCs to manage recurrent dyspnea symptoms due to MPEs.

Patients chosen were experiencing symptomatic MPEs and

• Had an advanced primary malignancy
• Had a predicted life expectancy of at least three months
• Had prior experience with dyspnea symptom relief post-thoracentesis
• Had radiographic evidence of an accessible, free-flowing pleural effusion.

PC placement took place in an outpatient clinic under local anesthesia or conscious sedation. Written and oral instructions were given to the patients and caregivers, including details on how to care for the catheter and perform drainage at home. Patients and their caregivers also received home visits from a home health nurse to reinforce these instructions. Patients were evaluated in the outpatient center weekly for the first two weeks and then as needed clinically. In each post-placement visit, patients were evaluated for subjective findings such as dyspnea, chest discomfort, and exercise intolerance. Objective evaluations included pulse oximetry, blood pressure, heart rate, respiratory rate, and weight measurement. In addition, patients were evaluated for pulmonary and/or catheter complications, including chest radiographs and computed tomography scans (if indicated).

Once the PC output was less than 50 mL on three consecutive days, the PC was removed using only local anesthesia in the Pulmonary Outpatient Center, and patients were periodically followed by the Interventional Pulmonology outpatient practice for evaluation of symptom recurrence or effusion.

• The study reported on a sample of 24 patients aged 47–89 years.
• Of the sample, 33% were males and 67% were females.
• Key disease characteristics were breast (11), lung (5), colon (1), mesothelioma (3), renal (1), melanoma (1), and adenocarcinoma of unknown primary (2).
• Patients who were extremely ill and had the potential to be admitted for the treatment of MPEs were excluded from this study.
   

This single-site study was conducted in an outpatient clinic in Philadelphia, PA, for both insertion and removal of the PC catheter.

• Patients were undergoing multiple phases of care.
• The study has clinical applicability for end of life, palliative care, and quality of life . 
   

The study was a retrospective chart analysis.

The dyspnea assessment instrument was not identified, but the presence and absence of dyspnea was implied.

A total of 27 PCs were placed. Three patients had bilateral PC placement, and one patient had two ipsilateral catheter placements (accounting for the extra catheter placements). All catheters were placed in an outpatient setting, and patients were sent home on the same day without any immediate complications. Five patients died during the study; four of these patients had fully functioning and patent catheters. The fifth patient developed cardiac tamponade, and the PC was removed and replaced by a chest tube. The indwelling time for these five patients prior to passing was 26.3 days.

Complications related to catheter placement included cellulitis, bacterial super-infection, and incisional tumor growth. These complications were managed with antibiotics, removal of the PC, and increases in anti-neoplastic medication.

Nineteen patients survived to catheter removal or to the time the analysis took place. Out of the 19 patients, 10 patients reached spontaneous pleurodesis after using daily PC drainage over a median time of 39 days. One patient achieved pleurodesis in 15 days after PC placement for a total of 11 out of 19 (58%) patients achieving either complete or partial pleurodesis without chest tubes or the use of sclerosing agents.

Small-bore tunneled pleural catheters are offered as an alternative, more palliative, less invasive treatment for MPEs. The number of patients in this study that reported relief of dyspnea symptoms and were able to achieve complete or partial pleurodesis after PC placement is comparable to those who undergo more invasive procedures.

•  The study had no appropriate control group
•  The study had a small sample size.
• The authors themselves recognized the potential bias of the study by excluding those patients who were extremely ill with a significant risk of being admitted for the management of MPEs.

The outpatient small-bore tunneled catheter method does not seem to be an appropriate method for patients with recurrent, symptomatic MPEs  who have weeks or days to live.