The insertion of an indwelling pleural catheter into the pleural space to drain fluid is an approach to relieve dyspnea due to pleural effusion. With an indwelling catheter, the patient/caregiver performs catheter care and drainage. One consideration in the decision to use an indwelling catheter to drain fluid in the pleural space is the patient/caregiver’s ability to perform ongoing catheter care. Catheter-related infection is a complication of this approach.
Van Meter, M.E., McKee, K.Y., & Kohlwes, R.J. (2011). Efficacy and safety of tunneled pleural catheters in adults with malignant pleural effusions: A systematic review. Journal of General Internal Medicine, 26(1), 70-76.
The objective of this systematic review was to review published data on the efficacy and safety of tunneled indwelling pleural catheters (TIPCs).
Databases searched were MEDLINE, EMBASE, and ISI Web of Science through 2009. A manual search was conducted of reference lists for relevant additional studies.
Search keywords were malignant pleural effusion (MPE), tunneled indwelling pleural catheter (TIPC), and palliative care.
Studies were included if they reported on
Studies with and without control were included.
Studies were excluded if they reported on non-malignant effusions, empyema, chylothoras, long-bore chest tubes, or non-tunneled catheters. Studies in which all patients underwent thorascopy, video-assisted thorascopic surgery (VATS), or pleurodesis were excluded. Studies were excluded if they weren't published in English. Studies without primary data also were excluded.
This systematic review pertains to the dyspnea Putting Evidence Into Practice topic in that one outcome of the review evaluated “symptomatic improvement” with emphasis, although not exclusive focus, on dyspnea.
Symptom relief was variably defined in the studies. Three studies reported symptom improvement without further delineation. One study rated dyspnea improvement on a three-point scale. The remaining studies reported symptomatic relief as “relief of dyspnea” or “improvement in respiratory performance,” “increased exercise tolerance,” “ improvement of pain,” and “catheter was useful.” When combined, 628 of the 657 patients (95.6%) experienced some degree of improvement in their symptoms, although the magnitude of improvement cannot be determined. Serious complications were rare. The most common complications were cellulitis (32 of 935, 3.4%) and obstruction or clogging (33 of 895, 3.7%) or unspecified malfunction of the catheter (11 of 121, 9.1%). The quality of the studies was low, as evaluated by the GRADES system.
Authors suggest that TIPC may improve symptoms for patients with MPE.
Based on the low-quality evidence in the form of the case studies, evidence is insufficient to demonstrate the effectiveness of TIPCs.
More rigorous studies need to be conducted to establish evidence with respect to dyspnea.
Davies, H.E., Mishra, E.K., Kahan, B.C., Wrightson, J.M., Stanton, A.E., Guhan, A., . . . Rahman, N.M. (2012). Effect of an indwelling pleural catheter vs chest tube and talc pleurodesis for relieving dyspnea in patients with malignant pleural effusion: The TIME2 randomized controlled trial. JAMA : The Journal of the American Medical Association, 307(22), 2383-2389.
The objective of the study was to determine if indwelling pleural catheters (IPCs) are more effective than talc slurry pleurodesis via chest tube for relief of dyspnea.
Patients with symptomatic malignant pleural effusion requiring pleurodesis were randomized to either IPC or talc pleurodesis. IPCs were inserted, initial large-volume drainage was performed, and caregivers were trained in IPC management. Drainage was advised to be done three times weekly. The IPC was removed if significant drainage stopped for at least four weeks, with no evidence of fluid reaccumulation. Patients in the talc group were hospitalized and had percutaneous chest tube insertion and talc slurry pleurodesis with 4 g sterile high-grade talc, following published treatment guidelines. Patients were followed up for 12 months after randomization. Dyspnea measurement was recorded daily for 42 days and then at 10, 14, 18, 22, and 26 weeks, and at 9 and 12 months.
The study was conducted in multiple settings in the United Kingdom.
The study was an unblinded, randomized controlled trial.
Because it was unblinded, the study had the risk of bias.
Demmy, T.L., Gu, L., Burkhalter, J.E., Toloza, E.M., D'Amico, T.A., Sutherland, S., . . . Cancer and Leukemia Group B. (2012). Optimal management of malignant pleural effusions (results of CALGB 30102). Journal of the National Comprehensive Cancer Network, 10(8), 975-982.
The objective of the study was to compare tunneled pleural catheter drainage (TCD) to bedside talc pleurodesis (TP) via chest catheter for efficacy in controlling symptomatic unilateral malignant pleural effusions (MPE).
Randomized patients received one of two methods (TP or TCD) for pleural drainage then were followed up for 60 days. For the TP procedure, a single dose of 4–5 g of sterile talc slurry in 100 mL of saline was infused into the pleural space with a chest catheter. Placement was confirmed on a chest x-ray. Talc was administered within 36 hours of tube placement. The tube remained clamped for two hours for talc distribution. When the chest drainage decreased to 150 mL/24 hours, pleurodesis was assumed and the tube was removed. TP was performed on an inpatient basis. For TCD, catheters were drained daily with drainage bottles. No more than 1,000 mL were drained at a time, other than during the initial drainage. A chest x-ray was taken within 36 hours of initial drainage and the patient, a caregiver, or a visiting nurse drained the catheter daily after that. The catheter was removed when the drainage volume was less than 30 mL each day over three consecutive days. TCD is generally an outpatient procedure.
The study was conducted in 21 comprehensive cancer centers—17 cases were conducted at one instution, and 1–7 cases were conducted at each of the other institutions.
The study was a prospective, randomized phase III trial.
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
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.
This single-site study was conducted in an outpatient clinic in Philadelphia, PA, for both insertion and removal of the PC catheter.
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 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.
Pollak, J.S., Burdge, C.M., Rosenblatt, M., Houston, J.P., Hwu, W.J., & Murren, J. (2001). Treatment of malignant pleural effusions with tunneled long-term drainage catheters. Journal of Vascular and Interventional Radiology: JVIR, 12(2), 201-208.
The objective of the study was to assess the effectiveness of tunneled pleural catheters in the treatment of malignant pleural effusions.
Initial enrollment of the first one-third of patients (n = 9) involved 2:1 randomization to the newly available and not U.S. Food and Drug Administration (FDA)-licensed PleurX® catheter or chest tube-administered chemical pleurodesis with doxycycline. The remaining 19 patients after October 1997 all were treated with the PleurX® catheter.
The study had a prospective convenience sample, with randomization of the initial one-third of patients. The study for the remaining two-thirds of the patients had a nonrandomized prospective design.
This small, single-site, prospective study of the effectiveness of tunneled pleural catheters showed effective pleural drainage, spontaneous pleurodesis equivalent to chest catheter pleurodesis, reduced days of hospitalization (as the procedure can be safely performed outpatient), reduced distressing symptoms, and rare complications.
Its use in patients with refractory effusions could be advantageous, as it represents patients who have received other therapies prior to catheter insertion. The average life expectancy of patients with malignant pleural effusions is only 6–12 months, with as many as half of patients dying within 30 days. Patients with malignant pleural effusions represent a group who experience significant symptoms that affect quality of life. Interventions that are low-intensity, can be performed quickly and with limited recovery time, and can be managed in the ambulatory or home setting are optimal. Nurses can act as advocates for innovative management of malignant pleural effusions that enhance patient independence. Nurses are key patient and family educators who provide guidance, support, and hands-on instruction in management of tunneled pleural catheters. Their follow-up with patients and caregivers assist in the detection of complications, as well as evaluation of efficacy. Follow-up nursing assessment for symptom relief and spontaneous pleurodesis or the need for additional interventions may be especially important for these patients receiving end-of-life care with limited contact with physicians.
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.
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.
The study was a retrospective analysis.
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.
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.
Suzuki, K., Servais, E.L., Rizk, N.P., Solomon, S.B., Sima, C.S., Park, B.J., . . . Adusumilli, P.S. (2011). Palliation and pleurodesis in malignant pleural effusion: The role for tunneled pleural catheters. Journal of Thoracic Oncology: Official Publication of the International Association for the Study of Lung Cancer, 6(4), 762-767.
The objective of the study was to evaluate tunneled pleural catheters for efficacy of palliation and the rate and predictors for spontaneous pleurodesis.
The study was a retrospective review of all patients (no matter who or where inserted) with at least tunneled pleural catheter inserted at a single institution from September 2007 to September 2009. Catheters were placed by pulmonologists, interventional radiologists, and thoracic surgeons in interventional radiology or bedside. All catheters were placed by Seldinger technique, unless during a video-assisted thoracoscopic procedure (VATs).
A total of 418 tunneled pleural catheters were placed. Forty-two patients had additional contralateral pleural catheters, 13 patients had an additional ipsilateral pleural catheter, and 4 patients had both a contralateral and secondary ipsilateral catheter.
The single-site study was conducted in both the inpatient and outpatient settings. Two hundred sixty-one patients (62%) were treated in interventional radiology, 107 patients (26%) were treating in the operating room, 37 patients (9%) were treated at the bedside, and 13 patients (3%) were treated in a clinic.
The study was a retrospective review.
Median survival in this series from the time of the first catheter insertion was 3.7 months (range 2.9-4.5 months, confidence interval 95%). Median follow-up was 2.4 months, with a range of 1.0-6.4 months. Three hundred eighty of 418 catheters inserted (91%) did NOT need additional effusions-directed therapies. The successful palliation rate in patients who lived longer than 30 days was 89% (28 of 322 insertions). Spontaneous pleurodesis was achieved in 110 catheters (26%), and accounting for those who died, the probability of successful pleurodesis during the study time was 34%. The catheter complication rate was 4.8% (20 catheters; 5 grade II, 15 grade III).
Tunneled pleural catheters offer an alternative method of pleural drainage and may even induce spontaneous pleurodesis in patients with symptomatic malignant pleural effusions. The process of placing the catheter is minimally invasive, is associated with a low complication rate, and allows for rapid recovery of patients with limited life expectancy. More than 90% of patients receiving this therapy experienced symptomatic relief that did not require additional interventions for treatment of pleural effusions. This therapy option for management of symptomatic pleural effusions may be suggested by nurses familiar with the management of malignant pleural effusions. Studies addressing specific symptom relief would be valuable to validate the effectiveness of this intervention.
Thornton, R.H., Miller, Z., Covey, A.M., Brody, L., Sofocleous, C.T., Solomon, S.B., & Getrajdman, G.I. (2010). Tunneled pleural catheters for treatment of recurrent malignant pleural effusion following failed pleurodesis. Journal of Vascular and Interventional Radiology: JVIR, 21(5), 696-700.
The objective of the study was to review the effectiveness of the use of single tunneled, valved pleural catheters in the treatment of symptomatic recurrent malignant pleural effusion following failed chemical pleurodesis.
Two hundred seventy patients who underwent placement of a tunneled pleural catheter between January 2002 and December 2006 were identified after reviewing interventional radiology billing records. After subsequent review of inpatient and outpatient medical reports for each case, 63 were reportedly treated for dyspnea associated with recurrent malignant pleural effusion following failed pleurodesis. In the incidence of suboptimal drainage post-procedure, fibrinolytic therapy with tissue-type plasminogen activator (tPA) dissolved in saline was administered into the catheter to dwell for two hours in the pleural space prior to drainage and was repeated at one- or two-day intervals, if clinically required for optimal drainage and symptom relief. Catheters were drained every other day until the volume decreased to 50 mL, in which case it was drained every three days. Catheters were subsequently removed from patients who achieved durable symptom relief on three consecutive drainages during the three-day intervals with less than 50 mL of drainage and who had no radiographic evidence of re-accumulation. For those with larger drainage volumes, however, catheters were left in place for continued use.
This single-site study was conducted in both inpatient and outpatient settings in Interventional Radiology.
The study was a retrospective review.
Dyspnea was measured, but the scale or instrument used was not defined.
The large majority of patients (95%) experienced prompt symptom relief and clinical improvement following tunneled pleural catheter insertion. Parynchymal lung disease or rapid progression of disease was reported among the patients who did not improve from catheter placement.
Use of tunneled pleural catheters for the treatment of recurrent malignant pleural effusion appears to be an appropriate and beneficial intervention for patients suffering from dyspnea following failed pleurodesis. The majority experienced immediate symptomatic relief of their dyspnea following catheter placement, although one-third of cases may necessitate transcatheter fibrinolytic therapy for adequate drainage. As noted by the authors, it is less invasive and more cost-effective than more successful, though high-risk interventions such as decortication (which is 100% effective but associated with high morbidity and mortality and not recommended for this population), thoracentesis (which offers immediate symptomatic relief but is associated with 98%-100% recurrence within 30 days), or thoracoscopy with talc poudrage (which has a high success rate but is more invasive and requires general anesthesia). It is also worth noting the short hospitalization period reported for 43% of the patient population, who were discharged within two days of catheter placement and symptom relief. However, effectiveness for patients with progressive disease remains questionable.
Walker, S., Zubrinic, M., Massey, C., Shargall, Y., Bedard, E., & Darling, G. (2016). A prospective study of patient-centred outcomes in the management of malignant pleural effusions. International Journal of Palliative Nursing, 22, 351–358.
To evaluate patient-reported satisfaction with treatment, quality of life (QoL), and dyspnea outcomes for four treatment strategies for malignant pleural effusion.
Four treatment regimens (indwelling pleural catheter [IPC] alone, video-assisted thoracic surgery [VATS] and IPC, bedside chest tube and talc slurry; and VATS with talc poudrage) for malignant pleural effusion (MPE) were evaluated using patient-reported outcome tools. The primary outcome of treatment satisfaction was measured immediately after treatment, as well as two and six weeks post-completion using the Functional Assessment of Chronic Illness Therapy-Treatment Satisfaction (FACIT-TS) tool. Secondary outcomes of improvement in dyspnea and QoL were measured at baseline, two, and six weeks post-treatment. Functional Assessment of Chronic Illness Therapy-Palliative (FACIT-Pal) was used to measure QoL; the London Chest Activity of Daily Living scale was used to measure dyspnea.
Prospective cohort study
Functional Assessment of Chronic Illness Therapy-Palliative (FACIT-Pal) was used to measure health-related QoL; the London Chest Activity of Daily Living scale was used to measure dyspnea; Functional Assessment of Chronic Illness Therapy-Treatment Satisfaction (FACIT-TS) was used to measure treatment satisfaction. Post-treatment pain measured on 0-10 scale, and ECOG performance status measurement was added mid-study.
No statistical difference in patient-reported outcomes was identified when comparing results for each of the four treatment modalities: indwelling pleural catheter (IPC), video assisted thoracic surgery (VATS), chest tube and talc slurry; and VATS talc poudrage. There was a statistically significant trend of improvement in overall FACIT-PAL score (p < 0.0001) and trend in decreasing breathlessness measured with both London Chest Activity Daily Living scale (p = 0.003) and FACIT-Pal shortness of breath score (p = 0.0007) when evaluating all study participants as a whole; there was no statistical difference between groups. Treatment satisfaction at six-week point was highest with VATS plus pleurodesis group and lowest with chest tube group; however, difference was NOT statistically significant.
Each of the treatment options for treating malignant pleural effusions are efficacious in improving health-related QoL and decreasing breathlessness with no statistically significant difference in patient-reported satisfaction when comparing each intervention.
Nurses educating individuals living with symptomatic malignant pleural effusions need to understand and share data regarding the experience of other patients; patients will benefit from knowledge that other individuals with MPE report an improvement in health-related QoL and a decrease in breathlessness regardless of MPE treatment option utilized. More research is needed in development of measurement tools for breathlessness in individuals with MPE. Additional studies with larger sample sizes are needed to evaluate treatment of dyspnea in patients with cancer because dyspnea is commonly experienced by individuals with advanced disease.