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Interact CardioVasc Thorac Surg 2009;9:961-964. doi:10.1510/icvts.2009.211516 © 2009 European Association of Cardio-Thoracic Surgery
Malignant pleural effusion in the presence of trapped lung. Five-year experience of PleurX tunnelled cathetersDepartment of Thoracic Surgery, St James's Hospital, Level 3, Bexley Wing, Beckett Street, Leeds, LS9 7TF, UK Received 19 May 2009; received in revised form 8 July 2009; accepted 9 July 2009
*Corresponding author. Tel.: +44-113-2068760; fax: +44-113-2068824.
Malignant pleural effusions in the presence of trapped lung remain notoriously difficult to treat. Various methods exist ranging from minimally invasive procedures including repeated needle thoracocentesis to the need for a formal surgical procedure such as placement of a pleuroperitoneal shunt and even thoracotomy and decortication. Controversy exists as to what is the optimum treatment for this condition. Any planned treatment should balance the therapeutic benefit provided against convalesce for a disease with a limited life expectancy. Patients should not spend a significant proportion of their remaining life span recovering from palliative procedures. In a series of patients with malignant pleural effusion the medial survival time was 20 weeks, with 30 days and 1 year mortality rates of 12.8% and 83.6%, respectively. We describe our five-year experience with the use of indwelling PleurX catheters in patients with malignant pleural effusions in the presence of confirmed trapped lung on radiological or VATS investigation. Patient health related quality of life was investigated by telephone questionnaire. The parameters analysed were symptomatic relief, mobility and ease of management following insertion. One hundred and sixteen patients underwent PleurX catheter insertion by a single operator, 48 questionnaires were completed. Of the 48 cases analysed, improvement in all three quality of life indices was recorded following catheter insertion. Ease of mobility was recorded as moderately satisfied and very satisfied in 50% and 15% of patients, respectively. Symptomatic improvement was found to have been increased with 42% and 6% of patients responding to moderately satisfied and very satisfied, respectively. Ease of management was recorded as ‘slightly satisfied’ and moderately satisfied in 50% and 33% of patients, respectively, demonstrating a high satisfaction index in patients with chronic progressively debilitating malignancies. Complications were either transient or readily correctable. Pain was the predominant complication occurring in 35% of patients lasting <3 days. No patient required catheter removal for resolution of discomfort. Our findings support the use of PleurX catheters for palliative patients with malignant pleural effusions in the presence of trapped lung. The catheters are not only easy to insert and discrete but they can be managed effectively by patients and community nurse practitioners and prevent repeated admissions to hospital in palliative patients with compromised life expectancy.
Key Words: PleurX catheter; Pleural effusion; Decortication; Trapped lung; Palliative care
The management of malignant pleural effusions in the presence of trapped lung is extremely challenging. Since these patients generally have a poor long-term prognosis with a median survival time of seven months for mesothelioma [1] to  30 months for metastatic breast carcinoma [2], treatment offered must consider the time taken to recover from the procedure provided as the principal determinant of selection. Therefore, complex extensive or challenging operations such as decortication are not widely accepted since they require a long recuperation during the patients' weakest period and attract complications. Less aggressive and universally accepted approaches include repeated ‘pleural taps’, placement of pleuroperitoneal shunts or even attempted bedside or surgical chemical pleurodesis. However, these are not without their own inherent drawbacks. Repeated thoracocentesis whilst being a simple procedure to undertake is performed following the onset of symptoms. It requires repeated admissions to hospital placing a strain on both the patient and the health care system and is limited by reaccumulation and the formation of loculi. Pleuroperitoneal shunts on the other hand require patient compliance often in elderly frail patients. Pumping of up to 400 times a day may be necessary to ‘flush’ pleural fluid through. They frequently become obstructed and violate two body cavities with spread of cancer to the abdomen. Recently, intrapleural urokinase has also been used for the treatment of loculated malignant pleural effusions and trapped lungs in medically inoperable cancer patients [3] with good response, however, regular and therefore resource intensive flushes are required initially. PleurX drains have been systematically utilized in our department since 2002 (Fig. 1). They are indicated in patients with free flowing effusions or effusions with minimal loculations. Each PleurX drain consists of a 15.5 French silastic catheter, with a one-way airtight valve in the hub. Once tunnelled beneath the skin into the pleural cavity they can remain in place indefinitely. Intermittent drainage of pleural effusion may be performed by a health care professional or by the patient using a sealed vacuum bottle at a frequency determined by the patient's average rate of fluid production or the development of respiratory symptoms.
Between October 2002 and October 2007, 116 patients were treated with a unilateral PleurX catheter. Drain insertion was performed by a single operator. Inclusion criteria were: (1) pathologically proven diagnosis of malignancy. (2) Symptomatic pleural effusion. (3) Life expectancy >30 days. (4) VATS confirmation of trapped lung. Implantation of the PleurX device (Denver Biomedical Inc) was performed by placing a 5-mm VATS port beyond the anterior axillary line to take advantage of the increased size of each intercostal space and thickness of the overlying tissues. A VATS technique predominantly under general anaesthesia was chosen as this allowed examination for the potential of lung re-expansion under positive pressure ventilation if it was not clear from the history or radiology that the lung was indeed trapped. In such cases where lung re-expansion was established the patient underwent chemical pleurodesis with the implantation of a large bore intercostal drain. Debridement of tumour or loculations to release the lung were not performed to avoid the risk of parenchymal injury, air leak and empyema in patients with an already debilitation condition. Once visual confirmation of the presence of trapped lung was established, the catheter trocar was tunnelled from a point 6–10 cm anterior to the VATS port inline with the corresponding intercostal space. The PleurX drain was then passed through the trocar to reach the VATS port allowing it to be directed into the pleural cavity. The port site was closed in an airtight fashion to prevent peri-catheter leakage during coughing or when performing the Valsava manoeuvre. During implantation care must also be taken to avoid deep implantation of the catheter, and the tubing should not traverse multiple intercostal spaces since this may lead to pain and occlusion with respiration. The catheter should also not be anchored using a suture since this may lead to fatigue of the silastic tubing and fracture. Following catheter implantation, saline should be used to refill the drained hemithorax thereby expelling air and preventing the formation of surgical emphysema. In addition, this reduces the development of ‘dissection’ planes which could lead to peri-catheter leakage, and lessens the risk of sudden ‘preferential’ re-expansion of lung segments with the risk of visceral tears leading to chronic air leak and the possible development of an empyema. Patients were educated by staff immediately after the procedure by video presentations and illustrated leaflets. Community nurses involved in each patients' care underwent a vigorous training programme consisting of classes with trained thoracic advanced nurse practitioners as well as local support from the company representative. A health related quality of life questionnaire was then used to assess patients' response to treatment. Improvement in mobility, symptom control and ease of management were investigated. Patient satisfaction was also evaluated as were postprocedural complications.
Between 2001 and 2007, 116 patients were treated with a PleurX catheter. Forty-eight patients were alive for questioning and all responded. Median length of stay following catheter insertion was 1.8 days (95% CI: 1–22 days). Patients were operated under general anaesthetic (GA) (n=41) if systemically well. Those unfit for a GA were performed under local anaesthetic (n=7). Patients recorded an improvement in mobility following PleurX catheter insertion (Fig. 2). Fifty percent of patients recorded a moderately satisfied response and 15% of patients recorded a very satisfied response to improvement in mobility compared to their preprocedural ability.
3.2. Symptomatic improvement Symptomatic relief was gained in a substantial proportion of patients following PleurX catheter insertion. Forty-two percent of patients were moderately satisfied with improvement in symptom control while 6% of patients responded very satisfied to the symptomatic benefit achieved after treatment (Fig. 3).
3.3. Ease of management On questioning patients to the ease of management of PleurX catheters, 50% of patients responded ‘slightly satisfied’, 33% of patients were moderately satisfied while 8% of patients were very satisfied demonstrating a high satisfaction index experienced in patients with chronic and progressively debilitating malignancies (Fig. 4).
3.4. Patient satisfaction Feedback from palliative patients regarding potential improvements in therapy is valuable. Support in the community and information provided following treatment was therefore assessed. Forty-two percent of patients questioned were moderately satisfied with support offered in the community by our walk in nurse led clinic, general practitioners and district nurses (Fig. 5), while 33% of patients were moderately satisfied with information provided in the form of ward posters, illustrated leaflet and DVD provided following treatment (Fig. 6).
3.5. Complications Complications in the setting of limited life expectancy are potentially catastrophic. No reports of emergency treatment or infection were reported and of the complications recorded the majority were either transient or readily correctable (Fig. 7). Pain was the predominant complication occurring in patients. Thirty-five percent of patients recorded transient pain lasting <3 days. No patient required catheter removal for resolution of discomfort. Peri-catheter leakage was recorded in 13% of patients, however, this was self-limiting and required no surgical intervention. Occlusion and catheter displacement requiring PleurX replacement occurred in 4% of patients, respectively.
The management of malignant pleural effusion in the presence of inoperable disease and trapped lung remains challenging. Not only is the overall prognosis of each patient poor but the condition leads to a progressive and debilitating deterioration in respiratory function caused by a variety of factors including chest wall involvement, pulmonary infiltration and the presence of significant pleural effusions. Surgical options for the treatment of symptomatic pleural effusions are limited. Parietal pleurectomy should not be performed on patients with an expected survival of <6 months. Short-term chest tube drainage has variable results and is therefore not recommended, and pleuroperitoneal shunts disseminate tumour into the abdominal cavity which can result in further discomfort caused by ascites. Chemical pleurodesis is not feasible without the potential of parietal and visceral pleural apposition, while repetitive needle throracocentesis is not without inherent risks and morbidity. Our study investigated the use of indwelling PleurX catheters over a period of five years as a palliative procedure for the treatment of malignant pleural effusions in the presence of trapped lung. This method of treatment was chosen as it was felt to be safe yet offers the greatest improvement in quality of life for the shortest recuperation period. Data revealed that patients treated using the PleurX catheter system perceived an improvement in quality of life provided by a substantial increase in mobility and symptomatic improvement. The precise reason for this is difficult to postulate since lung re-expansion did not occur as was not the aim of the therapy. It is, however, thought that reduced distension of the affected thoracic cavity with reversal of mediastinal shift and compression of the unaffected lung occurs following the drainage of large unilateral pleural effusions leading to the relief of symptoms of dyspnoea. Physiological improvements may not be the only factor involved, the psychological effects of draining large volumes of effusion should also not be ignored. Patients questioned confirmed that management of their condition had greatly benefited while adverse effects were either transient or readily correctable. These results support the findings of recent studies [4–7] suggesting that symptomatic benefit is gained from the use of indwelling pleural catheters. The PleurX device enabled the provision of symptomatic relief from a progressive malignant process. Furthermore, implantation of the device is simple and can be performed without the need of a general anaesthetic, thus preventing the exclusion of high-risk patients. Complication rates were low and predominantly transient, comparing favourably with other treatment modalities. Following catheter insertion patients were swiftly discharged home to the care of community nurses. In some cases, patients themselves managed their treatment regime once appropriate training had been performed. Thus, we conclude that, in our practice, the use of the PleurX catheter device is an extremely valuable resource in the treatment of a debilitating, distressing and often difficult to manage condition, thereby improving quality of life for cancer patients.
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Abstract
1. Introduction
