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Alexander M, Ishisaka Y, Miyakawa L, Rothman A. Assessing Factors That May Impact Physician-based Decisions for Placing Indwelling Pleural Catheters. J Bronchology Interv Pulmonol 2024; 31:39-48. [PMID: 37185887 DOI: 10.1097/lbr.0000000000000926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Accepted: 03/27/2023] [Indexed: 05/17/2023]
Abstract
INTRODUCTION Malignant pleural effusion is a common finding in patients with advanced cancer and is a frequent cause of dyspnea. Current guidelines indicate thoracentesis for symptomatic patients, while indwelling pleural catheters (IPC) are recommended for patients who develop pleural fluid re-accumulation. IPC maintenance, however, requires a significant level of financial and social support. This study aims to analyze potential influencing factors that may play a role in the decision for placing IPCs in patients with recurrent malignant pleural effusions. METHODS This study retrospectively collected baseline sociodemographic and laboratory data in patients who underwent thoracentesis for malignant pleural effusion from August 2016 to October 2021, and selected patients who presented with re-accumulation of pleural fluid within 30 days or had a pulmonary physician's note documenting that IPC is a potential management option. Of these selected patients (IPC candidates), we stratified patients who underwent IPC placement and those who did not, and performed statistical analysis between these 2 groups. RESULTS One hundred seventy-six patients who underwent thoracentesis were regarded as IPC candidates. Almost all baseline sociodemographic characteristics, including ethnicity ( P =0.637), sex ( P =0.655), and marital status ( P =0.773) were similar between the 2 groups, but significantly higher ECOG scores ( P =0.049) were noted in the IPC group. No statistically significant differences were noted in age, body mass index, platelet, PTT, international normalized ratio, creatinine, white blood cell, red blood cells, fluid protein, or fluid lactate dehydrogenase. Fluid albumin ( P =0.057) and serum neutrophil:lymphocyte ratio ( P =0.003) were significantly higher in patients without IPC placement. CONCLUSION This study did not recognize any baseline sociodemographic factors that may contribute to the decision to place IPCs.
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Affiliation(s)
| | | | - Lina Miyakawa
- Department of Pulmonary & Critical Care Medicine, Mount Sinai Beth Israel
| | - Adam Rothman
- Department of Pulmonary & Critical Care Medicine, Mount Sinai Morningside-West, New York, NY
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Shaw JA, Louw EH, Koegelenberg CF. A practical approach to the diagnosis and management of malignant pleural effusions in resource-constrained settings. Breathe (Sheff) 2023; 19:230140. [PMID: 38125800 PMCID: PMC10729815 DOI: 10.1183/20734735.0140-2023] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 10/03/2023] [Indexed: 12/23/2023] Open
Abstract
No pleural intervention in a patient with confirmed malignant pleural effusion (MPE) prolongs life, but even the recommended interventions for diagnosis and palliation can be costly and therefore unavailable in large parts of the world. However, there is good evidence to guide clinicians working in low- and middle-income countries on the most cost-effective and clinically effective strategies for the diagnosis and management of MPE. Transthoracic ultrasound-guided closed pleural biopsy is a safe method of pleural biopsy with a diagnostic yield approaching that of thoracoscopy. With the use of pleural fluid cytology and ultrasound-guided biopsy, ≥90% of cases can be diagnosed. Cases with an associated mass lesion are best suited to an ultrasound-guided fine needle aspiration with/without core needle biopsy. Those with diffuse pleural thickening and/or nodularity should have an Abrams needle (<1 cm thickening) or core needle (≥1 cm thickening) biopsy of the area of interest. Those with insignificant pleural thickening should have an ultrasound-guided Abrams needle biopsy close to the diaphragm. The goals of management are to alleviate dyspnoea, prevent re-accumulation of the pleural effusion and minimise re-admissions to hospital. As the most cost-effective strategy, we suggest early use of indwelling pleural catheters with daily drainage for 14 days, followed by talc pleurodesis if the lung expands. The insertion of an intercostal drain with talc slurry is an alternative strategy which is noninferior to thoracoscopy with talc poudrage. Educational aims To provide clinicians practising in resource-constrained settings with a practical evidence-based approach to the diagnosis and management of malignant pleural effusions.To explain how to perform an ultrasound-guided closed pleural biopsy.To explain the cost-effective use of indwelling pleural catheters.
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Affiliation(s)
- Jane A. Shaw
- Division of Pulmonology, Department of Medicine, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa
- DSI-NRF Centre of Excellence for Biomedical Tuberculosis Research, South African Medical Research Council Centre for Tuberculosis Research, Biomedical Research Institute, Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Elizabeth H. Louw
- Division of Pulmonology, Department of Medicine, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa
| | - Coenraad F.N. Koegelenberg
- Division of Pulmonology, Department of Medicine, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa
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Davidson R, Carling M, Jackson K, Aujayeb A. Indwelling pleural catheters: evidence for and management. Postgrad Med J 2023; 99:416-422. [PMID: 37294731 DOI: 10.1136/postgradmedj-2021-141200] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2021] [Accepted: 12/31/2021] [Indexed: 12/13/2022]
Abstract
The incidence of pleural disease is increasing, and pleural medicine is increasingly recognised as a subspecialty within respiratory medicine. This often requires additional training time. Once underresearched, the last decade has seen an explosion in evidence related to the management of pleural disease. One of the cornerstones of pleural effusion management is the insertion of an indwelling pleural catheter. This allows patient-centred outpatient management and now has a robust evidence base. This article summarises evidence as well serves as a practical guide to the management of any complications related to an indwelling pleural catheter that might present on an acute take.
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Affiliation(s)
- Richard Davidson
- Respiratory Department, Northumbria Healthcare NHS Foundation Trust, North Shields, UK
| | - Michael Carling
- Respiratory Department, Northumbria Healthcare NHS Foundation Trust, North Shields, UK
| | - Karl Jackson
- Respiratory Department, Northumbria Healthcare NHS Foundation Trust, North Shields, UK
| | - Avinash Aujayeb
- Respiratory Department, Northumbria Healthcare NHS Foundation Trust, North Shields, UK
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Sidhu C, Davies HE, Muruganandan S, Lui MMS, Lau EPM, Lee YCG. Indwelling Pleural Catheter: Management of Complications. Semin Respir Crit Care Med 2023. [PMID: 37257836 DOI: 10.1055/s-0043-1769093] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Multiple randomized clinical trials have established the advantages of indwelling pleural catheter (IPC) in the management of malignant pleural effusions, resulting in its widespread adoption in clinical practice. Complications can occur with IPC use and must be recognized and managed effectively. This review provides a comprehensive overview of IPC complications and their best care. Pain postinsertion or during drainage of IPC is easily manageable and must be distinguished from tumor-related chest wall pain. IPC-related infections require systemic antibiotics and often intrapleural fibrinolytic/deoxyribonuclease therapy. The removal of IPC for infection is usually unnecessary. Symptomatic loculation usually responds to fibrinolytics but may recur. Catheter tract metastases are common in mesothelioma patients and usually respond to radiotherapy without inducing damages to the IPC. Less common complications include dislodgement, irreversible blockage, and fractures (upon removal) of the catheter. Recommendations on the management of IPC complications by recent consensus statement/guideline are discussed. Expert opinions on management approaches are included in areas where evidence is lacking to guide care.
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Affiliation(s)
- Calvin Sidhu
- Pleural Medicine Unit, Institute for Respiratory Health, Perth, Australia
- School of Medical and Health Sciences, Edith Cowan University, Perth, Australia
- Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, Australia
| | - Helen E Davies
- Department of Respiratory Medicine, University Hospital of Wales, Cardiff, United Kingdom
| | - Sanjeevan Muruganandan
- Department of Respiratory Medicine, Northern Health, Melbourne, Australia
- Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Parkville, Victoria, Australia
| | - Macy M S Lui
- Division of Respiratory Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong
| | - Estee P M Lau
- Pleural Medicine Unit, Institute for Respiratory Health, Perth, Australia
- School of Medical and Health Sciences, Edith Cowan University, Perth, Australia
| | - Y C Gary Lee
- Pleural Medicine Unit, Institute for Respiratory Health, Perth, Australia
- Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, Australia
- School of Medicine, University of Western Australia, Perth, Australia
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5
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Viola GM, Szvalb AD, Malek AE, Chaftari AM, Hachem R, Raad II. Prevention of device-related infections in patients with cancer: Current practice and future horizons. CA Cancer J Clin 2023; 73:147-163. [PMID: 36149820 PMCID: PMC9992006 DOI: 10.3322/caac.21756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 08/04/2022] [Accepted: 08/09/2022] [Indexed: 11/18/2022] Open
Abstract
Over the past several years, multifaceted advances in the management of cancer have led to a significant improvement in survival rates. Throughout patients' oncological journeys, they will likely receive one or more implantable devices for the administration of fluids and medications as well as management of various comorbidities and complications related to cancer therapy. Infections associated with these devices are frequent and complex, often necessitating device removal, increasing health care costs, negatively affecting quality of life, and complicating oncological care, usually leading to delays in further life-saving cancer therapy. Herein, the authors comprehensively review multiple evidence-based recommendations along with best practices, expert opinions, and novel approaches for the prevention of diverse device-related infections. The authors present many general principles for the prevention of these infections followed by specific device-related recommendations in a systematic manner. The continuous involvement and meaningful cooperation between regulatory entities, industry, specialty medical societies, hospitals, and infection control-targeted interventions, along with primary care and consulting health care providers, are all vital for the sustained reduction in the incidence of these preventable infections.
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Affiliation(s)
- George M Viola
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Ariel D Szvalb
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Alexandre E Malek
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Anne-Marie Chaftari
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Ray Hachem
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Issam I Raad
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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Sundaralingam A, Bedawi EO, Harriss EK, Munnavar M, Rahman NM. The Frequency, Risk Factors and Management of Complications from Pleural Procedures. Chest 2021; 161:1407-1425. [PMID: 34896096 DOI: 10.1016/j.chest.2021.11.031] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 11/11/2021] [Accepted: 11/14/2021] [Indexed: 10/19/2022] Open
Abstract
Pleural disease is a common presentation and spans a heterogenous population across broad disease entities but a common feature is the requirement for interventional procedures. Despite the frequency of such procedures, there is little consensus on rates of complications and risk factors associated with such complications. Here follows a narrative review based on a structured search of the literature. Searches were limited to 2010 onwards, in recognition of the sea-change in procedural complications following the mainstream use of thoracic ultrasound (US). Procedures of interest were limited to thoracocentesis, intercostal drains (ICD), indwelling pleural catheters (IPC) and local anaesthetic thoracoscopy (LAT). 4308 studies were screened, to identify 48 studies for inclusion. Iatrogenic pneumothorax (PTX) remains the commonest complication following thoracocentesis: 3.3% (95% CI, 3.2-3.4), though PTX requiring intervention was rare: 0.3% (95% CI, 0.2-0.4) when the procedure was US guided. Drain blockage and displacement are the commonest complications following ICD insertion (6.3%, and 6.8%, respectively). IPC related infections can be a significant problem: 5.8% (95% CI, 5.1-6.7), however most cases can be managed without removal of the IPC. LAT has an overall mortality of 0.1% (95% CI, 0.03-0.3). Data on safety and complication rates in procedural interventions are limited by methodological problems and novel methods to study this topic bears consideration. Whilst complications remain rare events, once encountered, they have the potential to rapidly escalate. It is of paramount importance for operators to prepare and have in place plans for such events, to ensure high quality and above all, safe care.
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Affiliation(s)
- Anand Sundaralingam
- Oxford Pleural Unit, Oxford Centre for Respiratory Medicine, Churchill Hospital.
| | - Eihab O Bedawi
- Oxford Pleural Unit, Oxford Centre for Respiratory Medicine, Churchill Hospital
| | | | | | - Najib M Rahman
- Oxford Pleural Unit, Oxford Centre for Respiratory Medicine, Churchill Hospital; University of Oxford, NIHR Oxford Biomedical Research Centre
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7
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Abstract
Malignant pleural effusions have a significant burden on patients and the health care system. Diagnosis is typically via thoracentesis, although other times more invasive procedures are required. Management centers around relief of dyspnea and patient quality of life and can be done via serial thoracentesis, indwelling pleural catheter, or pleurodesis. This article focuses on the diagnosis and management of malignant pleural effusion.
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Affiliation(s)
- Christopher M Kapp
- Department of Medicine, Division of Pulmonary, Critical Care, Sleep and Allergy Medicine, University of Illinois at Chicago, 840 South Wood Street, Room 920-N, Chicago, IL 60612, USA.
| | - Hans J Lee
- Section of Interventional Pulmonology, Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, USA
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Abstract
Recurrent, symptomatic pleural effusions are common and can contribute to significant morbidity in affected patients. Various management options are available and indwelling pleural catheter placement is becoming more commonplace and is the preferred option in certain clinical scenarios. The body of literature pertaining to indwelling pleural catheter use has grown substantially over the last decade and the purpose of this review is to summarize the best available evidence.
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Affiliation(s)
- Audra J Schwalk
- Division of Pulmonary and Critical Care, The University of Texas Southwestern Medical Center, Professional Office Building II, 5939 Harry Hines Boulevard, Dallas, TX 75390, USA.
| | - David E Ost
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Unit 1462, 1515 Holcombe Boulevard, Houston, TX 77030, USA
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Association between Tunneled Pleural Catheter Use and Infection in Patients Immunosuppressed from Antineoplastic Therapy. A Multicenter Study. Ann Am Thorac Soc 2021; 18:606-612. [PMID: 33026887 DOI: 10.1513/annalsats.202007-886oc] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Rationale: Patients with malignant or paramalignant pleural effusions (MPEs or PMPEs) may have tunneled pleural catheter (TPC) management withheld because of infection concerns from immunosuppression associated with antineoplastic therapy.Objectives: To determine the rate of infections related to TPC use and to determine the relationship to antineoplastic therapy, immune system competency, and overall survival (OS).Methods: We performed an international, multiinstitutional study of patients with MPEs or PMPEs undergoing TPC management from 2008 to 2016. Patients were stratified by whether or not they underwent antineoplastic therapy and/or whether or not they were immunocompromised. Cumulative incidence functions and multivariable competing risk regression analyses were performed to identify independent predictors of TPC-related infection. Kaplan-Meier method and multivariable Cox proportional hazards modeling were performed to examine for independent effects on OS.Results: A total of 1,408 TPCs were placed in 1,318 patients. Patients had a high frequency of overlap between antineoplastic therapy and an immunocompromised state (75-83%). No difference in the overall (6-7%), deep pleural (3-5%), or superficial (3-4%) TPC-related infection rates between subsets of patients stratified by antineoplastic therapy or immune status was observed. The median time to infection was 41 (interquartile range, 19-87) days after TPC insertion. Multivariable competing risk analyses demonstrated that longer TPC duration was associated with a higher risk of TPC-related infection (subdistribution hazard ratio, 1.03; 95% confidence interval [CI], 1.00-1.06; P = 0.028). Cox proportional hazards analysis showed antineoplastic therapy was associated with better OS (hazard ratio, 0.84; 95% CI, 0.73-0.97; P = 0.015).Conclusions: The risk of TPC-related infection does not appear to be increased by antineoplastic therapy use or an immunocompromised state. The overall rates of infection are low and comparable with those of immunocompetent patients with no relevant antineoplastic therapy. These results support TPC palliation for MPE or PMPEs regardless of plans for antineoplastic therapy.
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10
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Aujayeb A. A note in indwelling pleural catheter infections. THE CLINICAL RESPIRATORY JOURNAL 2021; 15:244. [PMID: 33113281 DOI: 10.1111/crj.13299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Accepted: 10/23/2020] [Indexed: 06/11/2023]
Affiliation(s)
- Avinash Aujayeb
- Northumbria HealthCare NHS Foundation Trust, Care of Tracy Groom, Cramlington, UK
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11
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Akram MJ, Khalid U, Ashraf MB, Bakar MA, Butt FM, Khan F. Predicting the survival in patients with malignant pleural effusion undergoing indwelling pleural catheter insertion. Ann Thorac Med 2020; 15:223-229. [PMID: 33381237 PMCID: PMC7720744 DOI: 10.4103/atm.atm_289_20] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Accepted: 07/03/2020] [Indexed: 11/05/2022] Open
Abstract
CONTEXT Malignant pleural effusion (MPE) is a common comorbid condition in advanced malignancies with variable survival. AIMS The aim of this study was to predict the survival in patients with MPE undergoing indwelling pleural catheter (IPC) insertion. SETTINGS AND DESIGN This was a cross-sectional study conducted at Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, Pakistan. METHODS One hundred and ten patients with MPE who underwent IPC insertion from January 2011 to December 2019 were reviewed. Kaplan-Meier method was used to determine the overall survival (OS) of the patient's cohort with respect to LENT score. STATISTICAL ANALYSIS USED The IBM SPSS version 20 was used for statistical analysis. RESULTS We retrospectively reviewed 110 patients who underwent IPC insertion for MPE, with a mean age of 49 ± 15 years. 76 (69.1%) patients were females, of which majority 59 (53.6%) had a primary diagnosis of breast cancer. The LENT score was used for risk stratification, and Kaplan-Meier survival curves were used to predict the OS. The proportion of patients with low-risk LENT score had 91%, 58%, and 29% survival, the moderate-risk group had 76%, 52%, and 14% survival, and in the high-risk group, 61%, 15%, and 0% patients survived at 1, 3, and 6 months, respectively. In addition, there was a statistically significant survival difference (P = 0.05) in patients who received chemotherapy pre- and post-IPC insertion. CONCLUSIONS LENT score seems to be an easy and attainable tool, capable of predicting the survival of the patients with MPE quite accurately. It can be helpful in palliating the symptoms of patients with advanced malignancies by modifying the treatment strategies.
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Affiliation(s)
- Muhammad Junaid Akram
- Department of Internal Medicine, Shaukat Khanum Memorial Cancer Hospital and Research Center, Lahore, Pakistan
| | - Usman Khalid
- Department of Internal Medicine, Shaukat Khanum Memorial Cancer Hospital and Research Center, Lahore, Pakistan
| | | | - Muhammad Abu Bakar
- Department of Cancer Registry and Clinical Data Management, Shaukat Khanum Memorial Cancer Hospital and Research Center, Lahore, Pakistan
| | - Faheem Mahmood Butt
- Department of Internal Medicine, Shaukat Khanum Memorial Cancer Hospital and Research Center, Lahore, Pakistan
| | - Faheem Khan
- Royal Blackburn Teaching Hospital, East Lancashire Hospitals, NHS Trust, England, UK
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Miller RJ, Chrissian AA, Lee YCG, Rahman NM, Wahidi MM, Tremblay A, Hsia DW, Almeida FA, Shojaee S, Mudambi L, Belanger AR, Bedi H, Gesthalter YB, Gaynor M, MacKenney KL, Lewis SZ, Casal RF. AABIP Evidence-informed Guidelines and Expert Panel Report for the Management of Indwelling Pleural Catheters. J Bronchology Interv Pulmonol 2020; 27:229-245. [PMID: 32804745 DOI: 10.1097/lbr.0000000000000707] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND While the efficacy of Indwelling pleural catheters for palliation of malignant pleural effusions is supported by relatively robust evidence, there is less clarity surrounding the postinsertion management. METHODS The Trustworthy Consensus-Based Statement approach was utilized to develop unbiased, scientifically valid guidance for the management of patients with malignant effusions treated with indwelling pleural catheters. A comprehensive electronic database search of PubMed was performed based on a priori crafted PICO questions (Population/Intervention/Comparator/Outcomes paradigm). Manual searches of the literature were performed to identify additional relevant literature. Dual screenings at the title, abstract, and full-text levels were performed. Identified studies were then assessed for quality based on a combination of validated tools. Appropriateness for data pooling and formation of evidence-based recommendations was assessed using predetermined criteria. All panel members participated in development of the final recommendations utilizing the modified Delphi technique. RESULTS A total of 7 studies were identified for formal quality assessment, all of which were deemed to have a high risk of bias. There was insufficient evidence to allow for data pooling and formation of any evidence-based recommendations. Panel consensus resulted in 11 ungraded consensus-based recommendations. CONCLUSION This manuscript was developed to provide clinicians with guidance on the management of patients with indwelling pleural catheters placed for palliation of malignant pleural effusions. Through a systematic and rigorous process, management suggestions were developed based on the best available evidence with augmentation by expert opinion when necessary. In addition, these guidelines highlight important gaps in knowledge which require further study.
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Affiliation(s)
- Russell J Miller
- Department of Pulmonary Medicine, Naval Medical Center San Diego
- Department of Medicine, University of California San Diego, San Diego
| | - Ara A Chrissian
- Department of Medicine, Division of Pulmonary and Critical Care, Loma Linda University Medical Center, Loma Linda
| | - Y C Gary Lee
- Centre for Respiratory Research, School of Medicine
- Institute for Respiratory Health, University of Western Australia
- Department of Respiratory Medicine, Sir Charles Gairdner Hospital
- Edith Cowan University, Perth, WA, Australia
| | - Najib M Rahman
- Oxford Respiratory Trials Unit, Nuffield Department of Experimental Medicine, University of Oxford, Oxford, UK
| | - Momen M Wahidi
- Department of Internal Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, Duke University Medical Center, Durham
| | - Alain Tremblay
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - David W Hsia
- Harbor-University of California Los Angeles Medical Center
- Los Angeles Biomedical Research Institute at Harbor-University of California Los Angeles, Torrance
| | | | - Samira Shojaee
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, Virginia Commonwealth University, Richmond, VA
| | - Lakshmi Mudambi
- Section of Pulmonary & Critical Care Medicine, VA Portland Health Care System
- Department of Medicine, Division of Pulmonary & Critical Care Medicine, Oregon Health & Science University, Portland, OR
| | - Adam R Belanger
- Section of Interventional Pulmonology, Department of Medicine, University of North Carolina, Chapel Hill, NC
| | - Harmeet Bedi
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Stanford University School of Medicine, Stanford
| | - Yaron B Gesthalter
- Department of Pulmonary, Critical Care, Allergy and Sleep Medicine, University of California San Francisco, San Francisco, CA
| | | | - Karen L MacKenney
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - Roberto F Casal
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
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13
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Akram MJ, Khalid U, Bakar MA, Butt FM, Ashraf MB, Khan F. Indications and clinical outcomes of indwelling pleural catheter placement in patients with malignant pleural effusion in a cancer setting hospital. CLINICAL RESPIRATORY JOURNAL 2020; 14:1040-1049. [PMID: 32750225 DOI: 10.1111/crj.13239] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 07/11/2020] [Accepted: 07/27/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND The placement of indwelling pleural catheters (IPC) is an effective outpatient approach for the management of malignant pleural effusions (MPE). AIMS The indications and outcome of IPC in patients with MPE. Risk stratifications, prevention and management of IPC-related complications. METHODS We retrospectively reviewed the clinical data of patients with MPE who underwent IPC insertion from July 2011 to July 2019. The multivariable logistic regression model was used to identify the independent risk factors associated with IPC infection and the Kaplan-Meier method to determine the overall survival. RESULTS A total of 102 patients underwent IPC insertion during the stipulated period and the mean age was 50.49 ± 14.36 years. Seventy-one (69.6%) were females. The indications were Trap Lung in 38 (37.3%), failed talc pleurodesis in 28 (27.5%) and as a primary intervention in 36 (35.3%). The infection rate was 25.5%, of which 65.4% patients had nosocomial infections. Post-IPC overall median survival time was 9.0 ± 2.50 weeks with highest in patients with trap lung (18 ± 1.50 weeks). In multivariable analysis, following variables were identified as a significant independent risk factor for IPC infection: Multiloculated MPE (AOR 2.80; 95%CI (1.00-9.93), 0.04), trap lung (AOR 7.57; 95%CI (1.39-41.25), 0.01), febrile neutropenia (FN) (AOR 28.55; 95%CI (4.23-19.74), 0.001), IPC domiciliary education (AOR 0.18; 95%CI (0.05-0.66), 0.001) and length of hospital stay (AOR 1.16; 95%CI (1.01-1.33), 0.03). CONCLUSION IPC insertion is an effective management for MPE with reasonable survival benefits. Infection is the most common complication, of which mostly are nosocomial infections with higher incidence in multiloculated effusions, trap lung, FN and with lack of domiciliary IPC care education.
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Affiliation(s)
- Muhammad Junaid Akram
- Fellow College of Physicians and Surgeons Pakistan (Internal Medicine), Member of Royal College of Physician United Kingdom, Fellow Pulmonology, Department of Internal Medicine, Shaukat Khanum Memorial Cancer Hospital and Research Center, Lahore, Pakistan
| | - Usman Khalid
- Fellow College of Physicians and Surgeons Pakistan (Internal Medicine), Fellow Pulmonology, Department of Internal Medicine, Shaukat Khanum Memorial Cancer Hospital and Research Center, Lahore, Pakistan
| | - Muhammad Abu Bakar
- BS (Hons), M.Sc. Epidemiology and Biostatistics (South Africa) Biostatistician and Cancer Epidemiologist, Department of Cancer Registry and Clinical Data Management, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, Pakistan
| | - Faheem Mahmood Butt
- Diplomate American Board of Internal Medicine and Pulmonology. Consultant Pulmonology, Department of Internal Medicine, Shaukat Khanum Memorial Cancer Hospital and Research Center, Lahore, Pakistan
| | - Mohammad Bilal Ashraf
- Diplomate American Board of internal medicine, Pulmonology and Critical Care, Consultant Pulmonology & Critical Care Medicine, Shaukat Khanum Memorial Cancer Hospital and Research Center, Lahore, Pakistan
| | - Faheem Khan
- Fellow of College of Chest Physicians, Member Royal College of Physicians Ireland, Consultant Pulmonology, Shaukat Khanum Memorial Cancer Hospital & Research Center, Lahore, Pakistan
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14
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Management of Indwelling Tunneled Pleural Catheters: A Modified Delphi Consensus Statement. Chest 2020; 158:2221-2228. [PMID: 32561437 DOI: 10.1016/j.chest.2020.05.594] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Revised: 04/04/2020] [Accepted: 05/17/2020] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND The management of recurrent pleural effusions remains a challenging issue for clinicians. Advances in management have led to increased use of indwelling tunneled pleural catheters (IPC) because of their effectiveness and ease of outpatient placement. However, with the increase in IPC placement there have also been increasing reports of complications, including infections. Currently there is minimal guidance in IPC-related management issues after placement. RESEARCH QUESTION Our objective was to formulate clinical consensus statements related to perioperative and long-term IPC catheter management based on a modified Delphi process from experts in pleural disease management. STUDY DESIGN AND METHODS Expert panel members used a modified Delphi process to reach consensus on common perioperative and long-term management options related to IPC use. Members were identified from multiple countries, specialties, and practice settings. A series of meetings and anonymous online surveys were completed. Responses were used to formulate consensus statements among panel experts, using a modified Delphi process. Consensus was defined a priori as greater than 80% agreement among panel constituents. RESULTS A total of 25 physicians participated in this project. The following topics were addressed during the process: definition of an IPC infection, management of IPC-related infectious complications, interventions to prevent IPC infections, IPC-related obstruction/malfunction management, assessment of IPC removal, and instructions regarding IPC management by patients and caregivers. Strong consensus was obtained on 36 statements. No consensus was obtained on 29 statements. INTERPRETATION The management of recurrent pleural disease with IPC remains complex and challenging. This statement offers statements for care in numerous areas related to IPC management based on expert consensus and identifies areas that lack consensus. Further studies related to long-term management of IPC are warranted.
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15
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Abstract
Malignant pleural effusion frequently complicates both solid and hematologic malignancies and is associated with high morbidity, mortality, and health care costs. Although no pleura-specific therapy is known to impact survival, both pleurodesis and indwelling pleural catheter (IPC) placement can significantly alleviate symptoms and improve quality of life. The optimal choice of therapy in terms of efficacy and particularly cost-effectiveness depends on patient preferences and individual characteristics, including lung expansion and life expectancy. Attempting chemical pleurodesis through an IPC in the outpatient setting appears to be a particularly promising approach in the absence of a nonexpandable lung.
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Affiliation(s)
- Majid Shafiq
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
| | - David Feller-Kopman
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, 1800 Orleans Street, Suite 7-125, Baltimore, MD 21287, USA.
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16
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Pleural effusions in hematologic malignancies and their management with indwelling pleural catheters. Curr Opin Pulm Med 2019; 24:384-391. [PMID: 29629920 DOI: 10.1097/mcp.0000000000000490] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
PURPOSE OF REVIEW Pleural effusions in patients with hematologic malignancy may represent malignant pleural effusion (MPE) or occur secondary to infection, treatment effects, and other common causes. The impact of MPE on prognosis in this cohort remains unclear. Indwelling pleural catheters (IPCs) are routinely placed for palliation of recurrent symptomatic MPEs, but perceived concerns over infection and bleeding may limit their use in patients with hematologic malignancies. However, recent evidence suggests IPCs are both well tolerated and effective in this cohort. In this review, the evaluation of pleural effusions in hematologic malignancies and their management with an IPC are outlined. RECENT FINDINGS Two retrospective studies have been published regarding the use of IPCs in hematologic malignancies. Lymphomatous effusions are the most common cause of MPE in this cohort. The rates of complications and pleurodesis with IPC in hematologic malignancies are similar to those with solid organ tumors. SUMMARY Pleural effusions in patients with hematologic malignancies may be managed safely with an IPC. Sterile technique, barrier protection, standardized algorithms for placement and removal, and quality assurance initiatives are crucial to centers that place IPCs for all patients. The safety of IPC in hematologic malignancies warrants a paradigm shift in the management of pleural disease for this cohort.
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17
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Feller-Kopman DJ, Reddy CB, DeCamp MM, Diekemper RL, Gould MK, Henry T, Iyer NP, Lee YCG, Lewis SZ, Maskell NA, Rahman NM, Sterman DH, Wahidi MM, Balekian AA. Management of Malignant Pleural Effusions. An Official ATS/STS/STR Clinical Practice Guideline. Am J Respir Crit Care Med 2018; 198:839-849. [DOI: 10.1164/rccm.201807-1415st] [Citation(s) in RCA: 192] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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18
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Evison M, Blyth KG, Bhatnagar R, Corcoran J, Saba T, Duncan T, Hallifax R, Ahmed L, West A, Pepperell JCT, Roberts M, Sivasothy P, Psallidas I, Clive AO, Latham J, Stanton AE, Maskell N, Rahman N. Providing safe and effective pleural medicine services in the UK: an aspirational statement from UK pleural physicians. BMJ Open Respir Res 2018; 5:e000307. [PMID: 30116537 PMCID: PMC6089266 DOI: 10.1136/bmjresp-2018-000307] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2018] [Revised: 07/05/2018] [Accepted: 07/06/2018] [Indexed: 12/30/2022] Open
Abstract
Physicians face considerable challenges in ensuring safe and effective care for patients admitted to hospital with pleural disease. While subspecialty development has driven up standards of care, this has been tempered by the resulting loss of procedural experience in general medical teams tasked with managing acute pleural disease. This review aims to define a framework though which a minimum standard of care might be implemented. This review has been written by pleural clinicians from across the UK representing all types of secondary care hospital. Its content has been formed on the basis of literature review, national guidelines, National Health Service England policy and consensus opinion following a round table discussion. Recommendations have been provided in the broad themes of procedural training, out-of-hours management and pleural service specification. Procedural competences have been defined into descriptive categories: emergency, basic, intermediate and advanced. Provision of emergency level operators at all times in all trusts is the cornerstone of out-of-hours recommendations, alongside readily available escalation pathways. A proposal for minimum standards to ensure the safe delivery of pleural medicine have been described with the aim of driving local conversations and providing a framework for service development, review and risk assessment.
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Affiliation(s)
- Matthew Evison
- Manchester University NHS Foundation Trust, Wythenshawe Hospital, Manchester, UK
| | - Kevin G Blyth
- Pleural Disease Unit, Queen Elizabeth Hospital, Glasgow, UK.,Institute of Infection, Immunity of Inflammation, University of Glasgow, Glasgow, UK
| | - Rahul Bhatnagar
- Academic Respiratory Unit, University of Bristol, Bristol, UK.,North Bristol Lung Centre, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - John Corcoran
- Interventional Pulmonology Service, Plymouth Hospitals NHS Trust, Plymouth, UK
| | - Tarek Saba
- Respiratory Medicine, Blackpool Victoria Hospital, Blackpool, UK
| | - Tracy Duncan
- Pleural Service, North Manchester General Hospital, Pennine Acute Hospitals NHS Trust, Manchester, UK
| | - Rob Hallifax
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Trust, Churchill Hospital, Oxford, UK
| | - Liju Ahmed
- Respiratory Medicine, Guys and St. Thomas NHS Foundation Trust, London, UK.,Respiratory Medicine, Kings College School of Medicine, London, UK
| | - Alex West
- Respiratory Medicine, Guys and St. Thomas NHS Foundation Trust, London, UK
| | | | - Mark Roberts
- Respiratory Medicine, Sherwood Forest Hospitals NHS Foundation Trust, Nottingham, UK
| | | | - Ioannis Psallidas
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Trust, Churchill Hospital, Oxford, UK
| | - Amelia O Clive
- Academic Respiratory Unit, University of Bristol, Bristol, UK.,North Bristol Lung Centre, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | | | | | - Nick Maskell
- Academic Respiratory Unit, University of Bristol, Bristol, UK.,North Bristol Lung Centre, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - Najib Rahman
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Trust, Churchill Hospital, Oxford, UK.,Oxford NIHR Biomedical Research Centre, Oxford, UK
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19
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Chalhoub M, Saqib A, Castellano M. Indwelling pleural catheters: complications and management strategies. J Thorac Dis 2018; 10:4659-4666. [PMID: 30174919 DOI: 10.21037/jtd.2018.04.160] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Indwelling pleural catheters (IPCs) are increasingly being used for patients with recurrent malignant pleural effusions. They are simple to place and can be done on an outpatient basis under local anesthesia. IPCs uniformly relieve dyspnea and improve quality of life of patients with malignant pleural effusions. In some patients with recurrent non-malignant pleural effusions, IPCs proved to be effective as well. With increasing use of IPCs, physicians and patients are faced with complications related to the presence of an indwelling catheter for extended periods of time. The purpose of this review is to describe the various complications of IPCs and to present the available data on how to best treat and potentially prevent these complications.
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Affiliation(s)
- Michel Chalhoub
- Department of Medicine, Staten Island University Hospital, Staten Island, NY, USA
| | - Amina Saqib
- Department of Medicine, Staten Island University Hospital, Staten Island, NY, USA
| | - Michael Castellano
- Department of Medicine, Staten Island University Hospital, Staten Island, NY, USA
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20
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Indwelling Pleural Catheters for Patients with Hematologic Malignancies. A 14-Year, Single-Center Experience. Ann Am Thorac Soc 2018; 14:976-985. [PMID: 28326798 DOI: 10.1513/annalsats.201610-785oc] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
RATIONALE Placement of an indwelling pleural catheter is an established modality for symptom relief and pleurodesis in the treatment of malignant pleural effusion. Concerns remain regarding possible infectious complications, risk of hemorrhage, and the rate of pleurodesis with the use of pleural catheters in the treatment of hematologic malignancies. OBJECTIVES The goals of our study were: (1) to evaluate the safety and cumulative incidence of pleurodesis with indwelling pleural catheters for patients with hematologic malignancies, and (2) to evaluate overall survival of this cohort of patients with pleural effusions. METHODS We performed a retrospective review of 172 patients with a hematologic malignancy who underwent placement of an indwelling pleural catheter between September 1997 and August 2011 at the University of Texas MD Anderson Cancer Center in Houston, Texas. A competing risk model analysis was used for complications and pleurodesis. Analysis was based on each patient's first intrapleural catheter. RESULTS There were 172 patients with lymphoma (58%), acute (16%) or chronic leukemia (16%), or multiple myeloma (10%). The effusions were characterized as malignant (85.5%), infectious (4.1%), volume overload (4.7%), or therapy-related (4.7%). Chylothorax was found in 20.1%. Pleural biopsies were obtained from 13 patients. The cumulative incidence of all complications was 13.6%, and the cumulative incidence of all significant catheter-related complications was 9.5%. The incidence of empyema was 2.9%, and major bleeding (requiring transfusion or intervention) was 1.7%. Thirty-day procedure-associated mortality was 0.6%. The cumulative incidence of pleurodesis at 180 days was 50%, with a median time to pleurodesis of 81 days for the entire cohort. CONCLUSIONS Indwelling pleural catheters appear to be safe for patients with hematologic malignancies. Complications and the cumulative incidence of pleurodesis are comparable to those reported for patients with solid organ malignancies.
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21
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Lui MMS, Thomas R, Lee YCG. Complications of indwelling pleural catheter use and their management. BMJ Open Respir Res 2016; 3:e000123. [PMID: 26870384 PMCID: PMC4746457 DOI: 10.1136/bmjresp-2015-000123] [Citation(s) in RCA: 76] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2015] [Accepted: 01/05/2016] [Indexed: 11/23/2022] Open
Abstract
The growing utilisation of indwelling pleural catheters (IPCs) has put forward a new era in the management of recurrent symptomatic pleural effusions. IPC use is safe compared to talc pleurodesis, though complications can occur. Pleural infection affects <5% of patients, and is usually responsive to antibiotic treatment without requiring catheter removal or surgery. Pleural loculations develop over time, limiting drainage in 10% of patients, which can be improved with intrapleural fibrinolytic therapy. Catheter tract metastasis can occur with most tumours but is more common in mesothelioma. The metastases usually respond to analgaesics and/or external radiotherapy. Long-term intermittent drainage of exudative effusions or chylothorax can potentially lead to loss of nutrients, though no data exist on any clinical impact. Fibrin clots within the catheter lumen can result in blockage. Chest pain following IPC insertion is often mild, and adjustments in analgaesics and drainage practice are usually all that are required. As clinical experience with the use of IPC accumulates, the profile and natural course of complications are increasingly described. We aim to summarise the available literature on IPC-related complications and the evidence to support specific strategies.
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Affiliation(s)
- Macy M S Lui
- Division of Respiratory and Critical Care Medicine, Department of Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong; Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Rajesh Thomas
- Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia; Pleural Medicine Unit, Institute of Respiratory Health, Perth, Western Australia, Australia; Centre for Respiratory Health, School of Medicine & Pharmacology, University of Western Australia, Perth, Western Australia, Australia
| | - Y C Gary Lee
- Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia; Pleural Medicine Unit, Institute of Respiratory Health, Perth, Western Australia, Australia; Centre for Respiratory Health, School of Medicine & Pharmacology, University of Western Australia, Perth, Western Australia, Australia
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