A single institution experience for the management of recurrent pleural effusions with tunneled pleural catheter and its evolution

Incidence of complications from indwelling pleural catheter for pleural effusion: A meta-analysis

Indwelling pleural catheter (IPC) is widely used in patients with pleural effusion (PE). This meta-analysis aimed to comprehensively summarize the clinical complication from IPC. We searched four large electronic databases (PubMed, EMBASE, MEDLINE, and Cochrane Library) for potentially relevant studies and assessed the included studies' quality using the methodological index for nonrandomized studies' criteria. Extracted data were used to pool rates, and to conduct subgroup and meta-regression analyses. Forty-one studies involving a cumulative 4983 patients with 5650 IPCs were included in this meta-analysis. The overall incidence of IPC complications was 20.3% (95% confidence interval [CI]: 15.0-26.3). The top four complications were: overall infection incidence 5.7% (95% CI: 0.7-2.4); overall catheter abnormality incidence 4.4% (95% CI: 2.8-6.3); pain incidence 1.2% (95% CI: 0.4-2.4); and overall loculation incidence 0.9% (95% CI: 0.1-2.1). Subgroup and meta-regression analyses for overall complications and infections by country, PE site, and PE type demonstrated these factors did not contribute significantly to heterogeneity. Further subgroup analyses for infection of benign PE showed that the overall infection incidence (12.6% [95% CI: 8.1-17.8] vs 0.7% [95% CI: 0.0-4.5]) and empyema incidence (9.1% [95% CI: 5.3-13.8] vs 0.0% [95% CI: 0.0-2.3]) of patients with liver-related PE were significantly higher than that of patients with heart-related PE. Our meta-analysis showed reliable pooled incidences of IPC-related complications, with infection being the most common. These results serve to remind clinicians about the incidence of IPC-related complications and emphasize the importance of taking corresponding preventive and therapeutic steps.

[Complications after Indwelling Pleural Catheter Implant for Symptomatic Recurrent Benign and Malignant Pleural Effusions]

BACKGROUND

 Implant of indwelling pleural catheters (IPC) represents an established therapy method in addition to pleurodesis for symptomatic recurrent benign and malignant pleural effusions (BPE and MPE).There are only few studies on IPC safety during follow-up, especially with regard to infection and pneumothorax rates.The aim of our investigation was to determine the complication frequency after IPC implant and its predictive factors in patients with BPE vs. MPE.

METHODS

 Retrospective analysis of all IPC implantations in the pneumology department at the University Hospital Dresden during 2015 - 2018.

RESULTS

 An IPC was implanted in 86 patients (43 m/f each; age 66.9 ± 13.3 years) with symptomatic BPE and MPE. BPE and MPE was present in 12.8 % (11/86) and 87.2 % (75/86) of the patients, respectively.A predominantly small and asymptomatic pneumothorax was detectable as an immediate complication in 43/86 (50 %) of patients; 34/43 (79 %) of patients did not require any specific therapy. For 9/43 patients, IPC suction was required for a median period of three days; 8/43 patients had a large pneumothorax with partial or complete regression after a median period of two days.Catheter infection developed in 15.1 % (13/86) of the total group and 36.4 % (4/11) of the BPE vs. 12 % (9/75) of the MPE after a median period of 87 (BPE/MPE 116/87) days. This was more common in BPE (p = 0.035), large pneumothorax (4/8 patients; p = 0.015) and longer catheter dwell times (124 ± 112 vs. 71 ± 112 days; p = 0.07).

CONCLUSION

 Small pneumothoraxes are frequent after IPC implantation, but usually do not require specific therapy. IPC infection was detected in 15.1 % of all patients after a median period of 87 days. This was more common in patients with BPE, longer catheter dwell times and large pneumothorax.

Chemical pleurodesis - a review of mechanisms involved in pleural space obliteration

Chemical pleurodesis is a therapeutic procedure applied to create the symphysis between the parietal and visceral pleura by intrapleural administration of various chemical agents (e.g. talk, tetracycline, iodopovidone, etc.). The two major clinical conditions treated with chemical pleurodesis are recurrent pleural effusion (PE) and recurrent spontaneous pneumothorax. Although the history of chemical pleurodesis began over a century ago, detailed data on the mechanisms of action of sclerosing agents are highly incomplete. The following article aims to present the state of knowledge on this subject.It is believed that mesothelial cells are the main structural axis of pleurodesis. In response to sclerosing agents they secrete a variety of mediators including chemokines such as interleukin 8 (IL-8) and monocyte chemoattractant protein (MCP-1), as well as growth factors - vascular endothelial growth factor (VEGF), platelet-derived growth factor (PDGF), basic fibroblast growth factor (bFGF) and transforming growth factor- β (TGF-β). Numerous data suggest that intact mesothelial cells and the above cytokines play a crucial role in the initiation and maintenance of different pathways of pleural inflammation and pleural space obliteration.It seems that the process of pleurodesis is largely nonspecific to the sclerosant and involves the same ultimate pathways including activation of pleural cells, coagulation cascade, fibrin chain formation, fibroblast proliferation and production of collagen and extracellular matrix components. Of these processes, the coagulation cascade with decreased fibrinolytic activity and increased fibrinogenesis probably plays a pivotal role, at least during the early response to sclerosant administration.A better understanding of various pathways involved in pleurodesis may be a prerequisite for more effective and safe use of various sclerosants and for the development of new, perhaps more personalized therapeutic approaches.

Current practice in management of exudative pleural effusions-a survey of American Association of Bronchology and Interventional Pulmonology (AABIP)

Background

With increased availability of techniques to address pleural effusions including medical thoracoscopy (MT) and tunneled pleural catheter (TPC), we anticipate there has been an evolution in the practice pattern. We sought to evaluate the current practice patterns in the management of exudative pleural effusion in the interventional pulmonary (IP) community.

Methods

A questionnaire was developed and was disseminated to all listed American Association of Bronchology and Interventional Pulmonology (AABIP) members. Survey addressed the approach to the management of recurrent exudative pleural effusions with emphasis on the roles of Semi-rigid and rigid thoracoscopy.

Results

Of 388 members who opened the survey, 165 (43%) completed it. The majority were interventional pulmonologists representing academic and private practice in the United States (US), with approximately one third of respondents from other countries. Almost two thirds (61%) of them perform thoracoscopy. For those who do perform thoracoscopy, 93% would perform thoracoscopy for recurrent undiagnosed exudate. Equal numbers perform rigid and semi-rigid thoracoscopy and 31 (44%) perform both procedures, there was no statistically significant difference. There was a slight preference for Semi-rigid thoracoscopy although opinion was skewed slightly in favor of rigid thoracoscopy when asked about diagnostic yield. TPCs play a large role in management patterns, sometimes without and sometimes after thoracoscopy, 59% of the respondents chose a TPC alone for the management of known malignant effusion, while a 16% would combine it with MT (P value <0.0001).

Conclusions

Thoracoscopy is accepted as the diagnostic procedure of choice for undiagnosed exudative effusion. TPCs play a dominant role in management even when thoracoscopy is performed.