Use of pleural catheters in the management of MPE
My case study is based on a 74 year old man who came into the hospital for elective admission for the insertion of a pleurex chest drain after several recurrent episodes of malignant pleural effusions. The patient was admitted in a respiratory ward by a nurse with increased shortness of breath and was found to have right pleural effusion after a chest X-ray. A pleurex chest drain was inserted and 2000mls of pleural fluid was drained. Although a number of treatment modalities are available, pleurex chest drainage was the modality being used to manage this specific patient, as such it is necessary to determine whether it is the best management option for malignant pleural effusion. This paper will therefore focus on the issue of the use of pleurex chest drainage in the management of malignant pleural effusions and specifically on the use of pleurex chest catheters. In this regard, issues to do with the background, scientific evidence, the merits and demerits of pleural catheters and those relating to the cost and reimbursements, medical and nursing care, support in the community and self management of patients with pleurex chest catheters in-situ will be explored.
Malignant pleural effusion (MPE), defined as the presence of malignant cells in the pleural space comprise an important complication as well as source of morbidity for patients with intrathoracic and/or extrathoracic malignancies. The median survival following the diagnosis of MPE is 3 to 12 months. MPE can present as the first manifestation of an underlying malignancy or as a complication in late cancer disease. Nearly all the tumor types can cause MPE but lymphomas, carcinomas and mesotheliomas of the lungs, breasts, ovaries and GIT are the most common causes of MPEs. Almost all patients with MPEs present with chronic shortness of breath. Other debilitating symptoms include cough and pain. The aforementioned symptoms impact negatively on the quality of life in the final phase of cancer. A number of cytologic, histologic techniques as well as imaging modalities like X –rays and CT-scans are used in the evaluation of patients suspected to have MPEs (Muduly et al., 2011; Heffner and Klein, 2008).
The goals of management for MPE patients are focused on the relief or total elimination of dyspnea, reestablishment of normal function and activity, reduction or elimination of hospitalization and finally, the efficient use of medical resources. The management of MPE particularly in regard to dyspnea remains palliative and entails the removal of the fluid from the pleural space through the least invasive procedure possible and which in addition must have minimal associated morbidity (Muduly et al., 2011). Thoracentesis, tube thoracostomy or video-assisted thoracoscopic surgery and pleuroperitioneal shunting are the methods used to remove fluid from the pleural space. Thoracentesis entails the installation of pleural tap to drain accumulated pleural fluid. It provides rapid immediate but transient relief of symptoms. It can be performed on an outpatient basis. However, it has a high recurrence rate and is thus recommended for patients with limited expected survival and poor functional status since it avoids the need for hospitalization. VATS and tube-thoracostomy can be followed by pleurodesis, the process of obliterating the pleural space via chemically or mechanically induced inflammation. Pleurodesis is meant to achieve definitive long-term pleural apposition with fibrosis. The aggressiveness of management depends on the functional status of the patient and the severity of MPE symptoms (Muduly et al., 2011; Heffner and Klein, 2008).
As mentioned previously, pleurex/ambulatory chest drainage is also amongst the modalities used to remove fluid accumulated in the pleural space. Large bore (24-36F) and small (7-16F) bore tubes and catheters have been used to drain fluid. Accumulating evidence from a number of studies however supports the use of small bore tubes or catheters because they have been shown to reduce the number of hospitalization days and to reduce the incidence of recurrence. In one such study by Putnam et al. (2000 as cited in Heffner and Klein, 2008) the number of hospitalization days for patients and rate of recurrence for patients on pleurex catheter was 1.5 days and 13% respectively as opposed to 6.5 days and 21% for patients on a standard chest tube. Both large and small bore tubes and catheters have been shown to have almost equal results in the relief of symptoms, enhancing the quality of life and reducing the incidence of complications. Findings from a myriad of studies in addition indicate that small bore tubes cause less discomfort to patients with MPE. As such, they do not limit the patients’ activities. Large bore tubes were used initially because they were thought to be less likely to be obstructed by clots, however there is no evidence from studies so far to support this presumption. As such, small bore tubes are recommended (Muduly et al., 2011; Heffner and Klein, 2008).
Regardless of the size, pleurex chest drainage catheters or tubes are normally inserted at the bedside in the triangle of safety, anterior to the mid-axillary line in the fifth intercostals space under local anaesthesia, with or without ultrasonographic guidance. These tubes or catheters allow the intermittent drainage of about 1000ml of pleural fluid two to three times a week for prolonged periods of time. Studies that have investigated the utility of ultrasonographic guidance during chest catheter insertion and subsequent pleurodosis have reported high success rates because ultrasonographic guidance ensures proper positioning as well as enables the confirmation of the absence of fluid in the pleural space before sclerosants can be instilled (Heffner and Klein, 2008).
Accumulating evidence from a number of studies shows that pleurex chest drainage provides immediate relief of shortness of breath in 94 to 100% of patients and persistent relief for about 30days in 90% of patients. In one such study by Qureshi et al. (2008), 94.2% of the 54 patients who participated in the study had symptomatic relief and a significant reduction in the MRC (Medical Research Council) dyspnea score (p<0.001). In a similar study by Bazerbashi et al. (2009), the mean duration of the plurex catheters used was 87.0 days while the mean survival length following the insertion of the catheter was 84.1days. This particular study had 125 MPE patients, the pleurex catheters were inserted via thorascopic approach for 77 patients and Seldinger approach for 48 patients. The rate of complication was relatively high at 22% and the mortality rate was 7.2%. In another study by van de Toorn et al. (2005), the mean duration for the pleurex catheters used was 2.3 months, 70-80% of the patients who participated in the study experienced symptomatic relief although the complication rates for catheter dislocation and infection was 29.4%. Pien et al. (2001) also conducted a similar study but on MPE patients with trapped lung syndrome, the mean duration of the catheters after placement was 115 days, the mean survival rate on the other hand was 125 days although the complication rate was quite high at 45.4%. Of the patients who participated in the study, 90.9% experienced symptomatic relief. Sioris et al (2009) also conducted a study on MPE patients with trapped lung syndrome and those whom pleural fluid secretion rates was more than 300ml/24h and hence were not ideal candidates for talc pleurodesis. In this particular study, 71% of the participants were discharged home on the same day as the catheter implantation while the mean survival length for these patients was 3 months. Other evidence suggests that a majority of the patients tolerate the procedure well if close follow-up for complications such as infection of the catheter, breakdown of the skin at the site of insertion, obstruction of the tube or catheter, cellulitis, empyema and metastasis of the tumor along the track of the catheter is provided. In addition, findings from an array of studies indicate that spontaneous pleurodesis occurs after 2 to 6 weeks of pleurex chest drainage in about 40 to 58% of patients on long-term catheter drainage. However, the rate of recurrence of MPE within 30 days of removal of the drainage catheters or tubes is estimated to be 80%. As such, it is recommended for patients whose expected survival is 1 to 3 months. This implies that other measures in addition to pleurex chest drainage need to be explored for patients with a longer expected survival (Muduly et al., 2011; Heffner and Klein, 2008). If spontaneous pleurodesis fails to occur after several weeks of drainage, the chemicals used to cause pleurodesis otherwise called sclerosants can be instilled into the pleural cavity via the catheter. Long-term indwelling catheter drainage is been strongly advocated for by many experts as the primary therapy for MPE particularly for patients who can manage home drainage because these catheters have higher rates of spontaneous pleurodesis and they allow the instillation of sclerosants. Pleurex chest drainage in addition to use in patients with a short survival rate is also recommended for patients with trapped lung syndrome because the latter condition is known to respond poorly to chemical pleurodosis due to scarring and adhesions that render the lungs incapable of dilating fully. In case of loculated MPE, multiple pleurex drains are used (Heffner and Klein, 2008; Muduly et al., 2011). Tunneled pleural catheters (TPCs) on the other hand allow long-term drainage on an outpatient basis hence permit the control of pleural effusion and its related symptoms in about 80 to 90% of patients in a cost-effective manner. They are therefore indicated for MPE patients expected to be treated for a significant time as outpatients. Spontaneous pleurodesis occurs in over 40% of patients with TPCs. TPCs are also effective in the treatment of large locules and trapped lungs. In addition, they can be used for the instillation of sclerosants (Pollack, 2002; Heffner and Klein, 2008). As previously mentioned, chemical pleurodesis can be performed in patients on pleurex chest drainage and in whom pleurodesis fails to occur spontaneously after 2 weeks and their expected survival rates exceeds 3 months. Basically, it is recommended that the sclerosant be instilled via the pleurex catheter when the latter drains less than 150ml per day. The chest drainage catheter should be removed once the drainage returns to less than 150ml/day after sclerosant instillation. Studies have however been conducted to compare this practice with pleurodesis accelerated protocols. In one such study by Yildrim et al. (2005) patients were randomized to a standard protocol which required diminished PF drainage and others to an accelerated protocol whereby sclerosants were instilled immediately after catheter insertion. The rate at which pleurodesis occurred in both groups did not differ, however the inpatient stay for the patients randomized to the accelerated protocol was shorter. In addition, a clinical trial by Goodman and Davies (2006) reported similar pleurodesis success rates for patients whose catheters were removed 24 and 72 hours following the instillation of talc slurry. Meanwhile, a study by Spielger et al. (2003) reported a pleurodesis success rate of 79%, for this study, sclerosants were instilled 2 hours after catheter insertion and the catheters removed 2 hours after the sclerosing agent had been instilled. There is no general consensus on the sclerosant that is most ideal for chest-catheter pleurodesis hence extensive practice variations exist. However, a number of literature review based studies such as the Cochraine review have concurred that talc is by far the most the efficacious sclerosant agent as far as the prevention of recurrence of MPE is concerned. Majority of contemporary studies have also arrived at a similar conclusion reporting a 71% to 96% pleurodesis success rate when talc was instilled via a chest-catheter tube (Muduly et al., 2011; Heffner and Klein, 2008). Some studies have focused on evaluating the effectiveness of pluerex chest drainage versus other MPE management modalities. One such study by Zahid et al (2011) concluded that chemical pluerodesis is so far the best treatment modality for MPE with long-term catheter use being reserved for those patients in whom talc pleurodesis is not possible. Thoracentesis on the other hand is less effective than plurex catheter drainage because of their inherent disadvantages. For one, they require repeated hospital admissions and they provide only transient relief due to high recurrence rates. On pleuroperitoneal shunts, they require patient compliance which may be a daunting task for the elderly frail patients who comprise the largest portion affected by the disease. For instance, they require a lot of pumping to flush the pleural fluid through. Further, they are easily obstructed and pose the risk of spreading the cancer to the abdomen (Efthymiou et al., 2009). Another study by Qureshi et al. (2008) concluded that best treatment option for MPE in patients with trapped lung syndrome is long-term pleurex drainage catheters. A study that investigated the utility of using TPCs for MPE patients with trapped lung syndrome strongly recommended their use in this condition. According to the findings of this particular study, the patients reported improved quality of life after catheter insertion on three indices; ease of mobility, relief of symptoms and ease of management. Pain was the major complication reported (Efthymiou et al., 2009). On the home and community care of pleural chest drainage, drainage is performed everyday or intermittently using a vacuum bottle and clean technique. Patients are normally admitted overnight for drainage of pleural effusion. Education on the care of the catheter is provided to the patients and family members by Oncology nurse educator. Instructional videos are also used to supplement this education. The patients are discharged after the appropriate catheter care, drainage of fluid, change of dressing and proper documentation of drainage on the drainage log has been demonstrated to them (Robert Wood Johnson University Hospital, 2011; Brubacher and Gobel, 2003). Pertaining to the issue of cost, pleurex chest drainage may seem expensive considering the cost of purchasing the catheter, paying for its insertion and the single-use vacuum bottles as well as charges related to regular follow-up by a physician and frequent nursing care services to monitor for catheter related problems amongst other aspects of care. However, despite these factors, pleural chest drainage catheters have been shown to be cost effective even when the number of inpatient days has been accounted for (Sioris et al., 2009). Medical insurance companies normally reimburse for the inpatient days, catheter insertion as well as for drainage supplies (Robert Wood Johnson University Hospital, 2011).
In conclusion therefore, MPE is a major cause of morbidity in patients with advanced cancer. It presents with amongst other symptoms shortness of breath. Pleuroperitoneal shunting, thoracentesis, pleurodesis and pleural chest catheters are amongst the various treatment modalities used in the management of the condition. Thoracentesis and pleural catheters are the modalities commonly employed to remove accumulated pleural fluid. Thoracentesis provides rapid and immediate relief of symptoms particularly shortness of breath. However, this benefit is shadowed by its high rates of recurrence and complications. Pleural chest catheters drain about 1000ml of pleural fluid in a week and hence achieve relief of dyspnea. In addition, they promote spontaneous pleurodesis. They can be easily managed at home although they require close follow-up by community nurses as well as by physicians. Therefore, pleural chest catheters provide a cost-effective measure for improving the quality of life for advanced cancer patients who normally have a limited life expectancy.
Patients and their relatives are normally educated on home care of the plural chest catheter by an oncology nurse educator before they are discharged. Pleural chest catheters are normally inserted under local anaesthesia with or without ultrasonographic guidance. Ultrasonographic guidance during insertion is however recommended because amongst other merits it ensures appropriate positioning. A specific kind of pleural catheter called the tunneled pleural catheter is highly recommended because for one, it allows for sclerosants to be instilled, two, it promotes spontaneous pleurodesis and three it is effective in managing MPE patients with trapped lung syndrome. Trapped lung syndrome is a condition which has been shown to be very complicated to manage.
If pleurodesis fails to occur spontaneously two weeks after insertion of the pleural chest catheter, sclerosants can be instilled to promote pleurodesis. The decision on whether to instill sclerosants is influenced by amongst other factors the functional status of the patient as well as the expected survival rate. For patients with a relatively short expected survival duration period of about 1 to 3 months, it is recommended that they be managed using pleural chest catheters. Sclerosants are recommended for patients with a longer expected survival period. Although there is no general consensus on the most appropriate sclerosant, a number of literature review based studies have concluded that talc is by far the most effective.
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