Indwelling pleural catheters for non-malignant pleural effusions: report on a single centre's 10 years of experience

Indwelling pleural catheter infection and colonisation: a clinical practice review

Indwelling pleural catheters (IPCs) are used in the management of malignant pleural effusions, but they can become infected in 5.7% of cases. This review aims to provide a summary of the development of IPC infections and their microbiology, diagnosis and management. IPC infections can be deep, involving the pleural space, or superficial. The former are of greater clinical concern. Deep infection is associated with biofilm formation on the IPC surface and require longer courses of antibiotic treatment. Mortality from infections is low and it is common for patients to undergo pleurodesis following a deep infection. The diagnosis of pleural infections is based upon positive IPC pleural fluid cultures, changes in pleural fluid appearance and biochemistry, and signs or symptoms suggestive of infection. IPCs can also become colonised, where bacteria are grown from pleural fluid drained via an IPC but without evidence of infection. It is important to distinguish between infection and colonisation clinically, and though infections require antibiotic treatment, colonisation does not. It is unclear what proportion of IPCs become colonised. The most common causes of IPC infection and colonisation are Staphylococcus aureus and Coagulase-negative Staphylococci respectively. The management of deep IPC infections requires prolonged antibiotic therapy and the drainage of infected fluid, usually via the IPC. Intrapleural enzyme therapy (DNase and fibrinolytics) can be used to aid drainage. IPCs rarely need to be removed and patients can generally be managed as outpatients. Work is ongoing to study the incidence and significance of IPC colonisation. Other topics of interest include topical mupirocin to prevent IPC infections, and whether IPCs can be designed to limit infection risk.

Cardiac related pleural effusions: a narrative review

Background and Objective

Pleural effusions (PEs) are commonly seen in various pathologies and have a significant impact on patient health and quality of life. Unlike for malignant PEs, non-malignant PEs (NMPEs) do not have well-established guidelines. Much of the evidence base in this field is from a handful of randomised controlled trials (RCTs) and the majority are from retrospective cohort analyses and cases series. Cardiac related PEs fall within the entity of NMPEs and the aim of this narrative review is to gather the existing evidence in the field of congestive heart failure (CHF), pericarditis and post-cardiac injury syndrome (PCIS). This narrative review investigates the pathophysiology, diagnostic criteria and treatment options for the various cause of cardiac related PEs.

Methods

This narrative review is based on a comprehensive literature search analysing RCTs, prospective and retrospective cohort analyses and published case series.

Key Content and Findings

CHF related PEs have a substantial mortality rate and carry a worse prognosis if the PEs are bilateral and transudative in nature. Light's criteria have often shown to misclassify transudative effusions in CHF (pseudo-exudates) and hence measuring serum-pleural albumin gradient is an invaluable tool to accurately identify transudates. Elevated serum and pleural N-terminal pro-B type natriuretic peptide (NT-proBNP) has shown increasing evidence of correctly identifying PEs secondary to CHF. However, they should be considered with the pre-test probability of CHF. Therapeutic thoracentesis and indwelling pleural catheter (IPC) placement may be necessary if medical management has failed. PEs can also occur secondary to pericarditis and are often small, bilateral and exudative. PCIS also results in PEs and are commonly seen in post-coronary artery bypass graft (CABG) surgery. Both entities need management of the underlying cause first, but in cases where PEs are refractory, individualised pleural interventions may be necessary.

Conclusions

This comprehensive narrative review provides valuable insights into the aetiology, diagnosis and management of PEs secondary to CHF, pericarditis and PCIS. The aim is to enhance the clinicians' knowledge of this complex and controversial topic to improve patient care of cardiac-related PEs. Ongoing trials in this field will be able to provide valuable insights.

Hepatic hydrothorax

Hepatic hydrothorax (HH) refers to the presence of a pleural effusion that develops in the context of underlying liver cirrhosis and portal hypertension. It carries a high risk of morbidity and mortality, with a median survival of 8-12 months. Diagnosis is usually confirmed by pleural aspiration, demonstrating typical features of a transudative effusion in the absence of co-existent cardio-pulmonary or renal pathology. The clinical presentation is quite variable, with some patients remaining relatively asymptomatic in the presence of small or incidental effusions, while others present with frank respiratory failure requiring pleural intervention. The development of spontaneous bacterial empyema (SBEM) is a significant and not infrequent complication, requiring prompt recognition and treatment. While the mainstay of management is focused on optimising fluid balance through dietary salt restriction and diuretic therapy, liver transplantation remains the definitive treatment option. As such, it is crucial to adopt a multi-disciplinary approach-involving pulmonologists, hepatologists, dieticians, and palliative care physicians-in order to optimise care for this often complex group of patients. This review will discuss the basic pathophysiology of HH, its clinical presentation and diagnosis, as well as the approach to management of HH in clinical practice, focussing on both interventional and non-interventional treatment modalities.

Medical thoracoscopy for pleural diseases

PURPOSE OF REVIEW

The purpose of this review is to elaborate on the role of medical thoracoscopy for various diagnostic and therapeutic parietal pleural interventions. The renewed interest in medical thoracoscopy has been boosted by the growth of the field of interventional pulmonology and, possibly, well tolerated and evolving anesthesia.

RECENT FINDINGS

Medical thoracoscopy to obtain pleural biopsies is established largely as a safe and effective diagnostic procedure. Recent data suggest how a pragmatic biopsy-first approach in specific cancer scenarios may be patient-centered. The current scope of medical thoracoscopy for therapeutic interventions other than pleurodesis and indwelling pleural catheter (IPC) placement is limited. In this review, we discuss the available evidence for therapeutic indications and why we must tread with caution in certain scenarios.

SUMMARY

This article reviews contemporary published data to highlight the best utility of medical thoracoscopy as a diagnostic procedure for undiagnosed exudative effusions or effusions suspected to be secondary to cancers or tuberculosis. The potentially therapeutic role of medical thoracoscopy in patients with pneumothorax or empyema warrants further research focusing on patient-centered outcomes and comparisons with video-assisted thoracoscopic surgery.

Modern view on the problem of acute pleural empyema surgical treatment

OBJECTIVE

Aim: data study on the results of treatment of acute non-specific purulent-destructive pleura diseases with the purpose of further improvement of its results on the basis of improvement of diagnostics, identification of factors of disease prognosis and by implementing differential tactics of surgical treatment with the use of minimally invasive interventions.

PATIENTS AND METHODS

Materials and Methods: We have studied modern literary sources on the topic of current trends in the treatment of acute pleural empyema and its complications. The studied material is summarized and presented in the form of a literature review in this article.

CONCLUSION

Conclusions: These issues cannot be considered to be completely solved and require further study. Everything mentioned above dictates the search of new effective methods of the treatment of the mentioned pathology and proves the relevance of the theme. The outlined information highlights the necessity of improvement of surgical tactics in patients with pleural empyema.

Indwelling Pleural Catheter: Management of Complications

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.

Transudative chylothorax and frailty: a diagnostic and therapeutic challenge

Transudative chylothoraces are a rare entity and their management in the presence of multiorgan dysfunction and frailty is complex. A woman in her 90s was investigated during acute hospital admission and found unexpectedly to have a transudative chylothorax secondary to cryptogenic cirrhosis. Not all chylothoraces have the classically described milky appearances and a high index of suspicion is vital in determining appropriate investigation and management. Our patient required repeated thoracocentesis and subsequently chose to be discharged from hospital with comfort care. Management of non-malignant pleural effusions can be challenging. Case reports surrounding the management of transudative chylothoraces in particular are scarce. Establishing patient priorities and openly explaining the uncertainty regarding prognosis and potential therapeutic options is paramount in this complex and changing field.

Indwelling pleural catheters for benign pleural effusions: a concise review

PURPOSE OF REVIEW

Benign pleural effusions (BPEs) are more common than malignant effusions and their treatment involves treating the underlying disease process. However, in cases refractory to medical management, pleural interventions might be necessary. Use of indwelling pleural catheters (IPCs) has been gaining popularity for patients with refractory effusion. In this review, we will focus on reviewing the data assessing safety and efficacy of IPC in patients with BPE related to congestive heart failure (CHF), hepatic hydrothorax, end-stage renal disease (ESRD) and chylothorax.

RECENT FINDINGS

Several small studies including the most recent randomized control trial have looked into the efficacy and safety of IPC in BPE. Majority of data come from patients having CHF and hepatic hydrothorax as the underlying cause of the effusion. Limited data are available in patients with ESRD and chylothorax. Time to pleurodesis varies but is relatively higher in this patient population. Caution must be addressed in patients with immunocompromised status given a high risk of infection.

SUMMARY

IPCs are increasingly being used in patients with BPE refractory to medical management. They can be used both for palliation and to achieve pleurodesis in some cases. Further data in the form of randomized control trials are still needed to evaluate the efficacy and safety of its use in this patient population.

Hepatic Hydrothorax: A Narrative Review

Hepatic hydrothorax (HH) represents a distinct clinical entity within the broader classification of pleural effusion that is associated with significant morbidity and mortality. The median survival of patients with cirrhosis who develop HH is 8-12 months. The diagnosis is typically made in the context of advanced liver disease and ascites, in the absence of underlying cardio-pulmonary pathology. A multi-disciplinary approach to management, involving respiratory physicians, hepatologists, and palliative care specialists is crucial to ensuring optimal patient-centered care. However, the majority of accepted therapeutic options are based on expert opinion rather than large, adequately powered randomized controlled trials. In this narrative review, we discuss the epidemiology, pathophysiology, clinical characteristics, and management of HH, highlighting the use of salt restriction and diuretic therapy, porto-systemic shunts, and liver transplantation. We include specific sections focusing on the role of pleural interventions and palliative care, respectively.

Hepatic Hydrothorax and Congestive Heart Failure Induced Pleural Effusion

Pleural effusions (PEs) are frequently encountered in routine clinical practice, affecting more than 3000 people per million population every year. Heart and liver failures are two of the most common causes of transudative PE. Because these effusions have nonmalignant etiologies, they are commonly referred to as benign effusions despite of the poor prognosis they foretell in their refractory stages. Like malignant effusions, symptom management is important and plays a significant role in palliation when these effusions become refractory to medical therapy.

[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.