Schneider, T., Reimer, P., Storz, K., Klopp, M., Pfannschmidt, J., Dienemann, H., & Hoffmann, H. (2009). Recurrent pleural effusion: Who benefits from a tunneled pleural catheter? The Thoracic and Cardiovascular Surgeon, 57(1), 42-46.

The objective of this study was to report on the effectiveness of tunneled indwelling pleural catheters (TIPC) in patients with recurrent malignant pleural effusion (MPE) and impaired lung dilatability.

TIPC placement was performed on three groups of patients: those with a trapped lung who were not candidates for pleurodesis, those with recurrent pleural effusion after failed attempts at pleurodesis, and those with poor physical condition/limited lifespan who were not candidates for VATS procedure. Prior to TIPC placement, diagnostic or therapeutic interventions (i.e., pleuracenteses or pleurodesis) were performed on 54 patients to treat the pleural effusion. TIPC placement was performed by a thoracic surgeon as an inpatient procedure for 98 patients in an operating room via local anesthesia or VATS procedure. Following placement, patients and relatives or home care nursing staff were instructed in TIPC care and drainage through specific training, and subsequent drainage of the catheter system was performed three times weekly and afterward based on symptoms (pain or dyspnea) or fluid volume. TIPCs ultimately were removed as an outpatient procedure under local anesthesia when volume at three sequential drainage procedures was less than 50 mL and were drained once a week in an expanded lung by x-ray. Patients were then followed up until February 2008.

• The study reported on a sample of 100 patients.
• The mean age was 64 years, with a range of 30-91 years.
• Of the sample, 52% were males and 48% were females.
• Key disease characterstics included underlying cancer disease: lung (23), breast (20), mesothelioma (11), ovarian (4), pancreatic (5), cancer of unknown primary (5), other malignant disease (19), nonmalignant due to liver cirrhosis or chronic exudative pleurisy (13).
• Of the 107 patients undergoing TIPC procedures, 88 patients had malignant disease and 12 had nonmalignant effusions. Seven additional procedures included six contralateral procedures and one ipsilateral procedure.
• Patients with malignant pleural effusion and fully expandable lungs in good clinical condition were given talc poudrage during VATS procedure instead of TIPC. Also, intraoperative suspicion of pleural empyema was a contraindication for TIPC.

This single-site study was conducted in an inpatient setting (for TIPC insertion) and outpatient setting (for TIPC removal) in an operating room in Germany.

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

The study was a retrospective analysis.

• Diagnostic VATS procedure prior to TIPC placement (54 patients)
• X-ray performed prior to TIPC removal to assess lung re-expansion
   

Median residence time of TIPC was 70 days (range 2-384 days) in all patients. In 52 procedures, TIPC remained indwelling until patients’ death (median 47 days; range 2-319 days). In these particular patients, further relief of recurrent effusion was achieved by a drainage system, such that no one required repeated investigations (via pleuracenteses or surgical interventions). Sixteen TIPCs remained at the end of the observation period with a median indwelling time of 87 days (range 30-389 days) because they still required relief for recurrent pleural effusion. Thirty-nine TIPCs were removed after a median indwelling time of 80 days after decreased drainage and lung re-expansion. Patients with carcinoma of unknown primary and pancreatic cancer had the worst outcome. Nine patients had their catheters removed following TIPC-related complications (empyema [4], pain [1], accidental dislodgement by patient [2], bronchopleural fistula [1], occlusion of drainage [1], and recurrent effusion requiring TIPC replacement [2]). Six patients died during hospitalization following TIPC placement due to rapid progressive malignant disease.

According to the authors, the three groups that appear to benefit the most are patients with an intraoperative find of a trapped lung in a diagnostic VATS procedure who are not candidates for talc pleurodesis; patients with a history of repeated pleuracenteses or past failed attempts at pleurodesis; and patients with limited life expectancy and reduced clinical condition due to underlying disease.

Tunneled indwelling catheters are useful in the palliative treatment of patients with recurrent malignant and nonmalignant pleural effusions.

• The study had no appropriate control group.
• Due to the nature of the study, authors were unable to control for patient death during the hospitalization and observation period.
• Only patients unable to tolerate VATS procedures were included, so results can only be generalized to patients with refractory pleural effusion in the setting of poor physical health.
• Authors suggest that the insertion of a “not-tunneled pleural mini-catheter” be considered as an alternative intervention. This point, however, seems to contradict the authors’ original conclusion that TIPC will be beneficial for patients with limited lifespan and reduced clinical condition due to underlying disease.
  
   

Though TIPC placement under local anesthesia is less invasive and offers the advantage of very low postoperative mortality rate, it may not be an appropriate intervention for patients with a “very limited lifespan” based on underlying disease. Hence, its use in this population should be considered cautiously, given the procedure's aggressive or semi-aggressive, invasive nature. Patient/caregiver capacity to care for the catheter and perform drainage may influence the appropriateness of this intervention.