Introduction
Recurrent pleural effusions (RPEs) are defined as pleural effusions that recur despite optimal therapy for the underlying etiology of the effusions and typically require multiple thoracenteses or a more definitive therapeutic modality to prevent a recurrence. Indwelling pleural catheters (IPCs) have emerged in the past decade as a very effective modality to treat and control RPEs. They have also been shown to be associated with fewer hospitalization days from treatment to death when compared to talc pleurodesis.
Additional advantages of IPCs include a low failure rate, improved quality of life, lower initial cost, and a shorter initial admission time. The procedure is usually done on an ambulatory basis under a local anesthetic.
Procedure-related complications
Procedure-related complications are usually acute and similar in frequency to those observed with any other pleural intervention. These include pneumothorax, subcutaneous emphysema, bleeding, and overlying skin infections. Pneumothorax is seen more commonly in patients with trapped lungs. The early complications are reported to occur at a rate of 2.8% to 6%. Procedure-related complications are usually managed in a manner similar to when they occur during any other pleural intervention and will not be discussed in this review.
Catheter tract metastases are uncommon, occurring in less than 5% of cases. Over half of the cases in reported studies have been associated with mesothelioma.
Symptomatic loculations occur in up to 14% of patients with IPCs. The etiology is related to the accumulation of fibrinous material that forms septations leading to multiple loculations. These septations and loculations lead to impaired fluid removal causing fluid accumulation that causes dyspnea and discomfort.
Chest pain is frequently encountered after IPC placement. It occurs in 36% of patients but is usually mild and resolves within 3 days after insertion. This pain can be usually easily managed with analgesics. The negative pressure that develops during drainage of the IPC may result in pain. This type of pain occurs more commonly and is usually more intense when the IPC is placed in the setting of a trapped lung.
Persistent long-term drainage of pleural fluid can result in significant nutritional material and cellular losses. It is estimated that one liter of exudative pleural fluid contains up to 30 grams of protein. Patients with malignant pleural effusions may already be immunosuppressed, cachectic, and malnourished and they may be unable to compensate for the extra nutritional losses that occur from draining their pleural fluid on a regular basis. Jimenez et al. reported a decline in serum albumin level in patients with IPCs placed for malignant chylothoraces.
Catheter blockage is an uncommon complication and occurs in less than 5% of cases. Partial blockage is generally more common than complete blockage. Blockage of IPCs can result from accumulation of fibrinous exudates inside as well as around the catheter lumen. This complication can be usually managed by flushing the catheter with saline solution using aseptic technique.
Peri-catheter leakage has been reported in up to 13% of patients, it is usually self-limited and rarely requires surgical intervention.
Fracture of an IPC catheter usually occurs at the time of removal. Catheter removal may be indicated in cases of spontaneous pleurodesis and resolution of the pleural effusion or a serious complication such as empyema or intractable pain. Breakage can occur while attempting to release the cuff from the surrounding tissue. When the catheter has been in place for a longer period, adhesions may form making it difficult to remove the catheter without inadvertently breaking it.
An IPC is a specially designed small tube used to drain pleural fluid from around your lungs easily and painlessly, whenever needed. It avoids the need for repeated uncomfortable injections and chest tubes every time the fluid needs to be drained.
IPC Indwelling Pleural & Peritoneal Catheter Insertion Set with Metal Tunneller is indicated for intermittent, long term drainage of symptomatic, recurrent, pleural effusion. Including malignant pleural effusions that do not respond to medical treatment of underlying disease.
The system features
Silicone Catheter
Soft, kink resistant material approved for long use, giving increased patient comfort.
16Fg x 40cm catheter with 24cm fenestrated section, large diameter holes to maximise drainage and reduce occlusion risk.
Polyester cuff to promote rapid tissue in-growth, minimising infection risk and aiding catheter security.
Insertion Kit
A complete kit with metal tunneler for optimum catheter positioning and improve patient comfort
Simple, cost effective, long term treatment for pleural effusion.
Conclusion
As the use of IPCs is becoming widespread, more patients and physicians will possibly be faced with increasing likelihood of complications related to the long-term presence of a pleural catheter. Most of these complications are usually managed conservatively. Some complications, however, require catheter removal, and sometimes more aggressive surgical interventions. To date, evidence-based data on how to manage IPC related complications is scarce. More studies are needed to guide physicians and health care providers on how to avoid, recognize, and effectively treat IPC-related complications. Regardless of all potential complications, IPC remains the best modality to control recurrent malignant as well as non-malignant pleural effusions. It provides a very effective therapeutic modality on an outpatient basis with a seemingly low complication rate.
References
J Thorac Dis. 2018 Jul; 10(7): 4659–4666.
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