Complications of indwelling pleural catheter use and their management

Our plain-English summary of Complications of indwelling pleural catheter use and their management, by M.M. Lui, R. Thomas, Y.C. Lee (BMJ Open Respiratory Research, 2016).

The study

• Authors: M.M. Lui, R. Thomas, Y.C. Lee
• Journal: BMJ Open Respiratory Research
• Published: 2016;3(1):e000123
• Cited by: 87 articles, as counted by NIH iCite
• Read it: PubMed · Publisher · Free full text

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.

In plain English

This article was a review, not a new study. The authors summarised published research on complications of indwelling pleural catheters. These are tubes left in the chest to drain fluid that keeps building up around the lung, mostly fluid caused by cancer, including mesothelioma. In the studies reviewed, infection rates in the pleural space ranged from 0% to 12%. One multicentre review of 1021 patients found an infection rate of 4.8%; deaths from pleural infection equalled 0.29% of all catheter-treated patients. Tumour growth along the catheter tract affected up to 10% of patients in one cohort in which 60% had mesothelioma. Mesothelioma accounted for most such cases in two studies. Symptomatic fluid pockets (loculations) that caused breathlessness and would not drain through a working catheter were reported in 5–14% of catheter-treated patients. In one study of 66 patients, clot-dissolving drugs improved symptoms in 83%. Other reported problems included catheter breakage on removal, blockage and chest pain. Data on nutrient loss were described as scant. The authors concluded that many knowledge gaps existed and that robust evidence to guide management was lacking.

We wrote this plain-English summary from the full article with the help of AI, and a second AI model checked each sentence against the article. It is not the authors' wording; the abstract and the article are their own account.

What the study did and found

• Design: Narrative review of published literature (commissioned, externally peer reviewed)
• Who was studied: Published studies of patients treated with indwelling pleural catheters for recurrent symptomatic pleural effusions, mostly malignant pleural effusion (including mesothelioma), with some studies of benign effusions
• Main results:
  • In the studies the authors reviewed (usually small series), rates of catheter-related pleural infection ranged from 0% to 12%
  • A cited multicentre review of 1021 catheter patients from 11 centres found an infection rate of 4.8%
  • In a cited study, overall mortality from pleural infection was 0.29% of all catheter-treated patients, not of the infected patients only
  • Catheter tract metastasis affected up to 10% of patients in a cited cohort in which 60% were patients with mesothelioma
  • Mesothelioma accounted for most cases of catheter tract metastasis in the two cited studies on this complication
  • According to the reviewed literature, catheter tract metastases could usually be treated with simple pain relief and external beam radiotherapy
  • Symptomatic loculation was defined as residual fluid that would not drain through a working catheter, with related breathlessness and no evidence of infection. It was reported in 5–14% of catheter-treated patients
  • A cited four-centre retrospective study looked at 66 patients with malignant pleural effusion who received intrapleural fibrinolytic therapy for symptomatic loculations. Symptoms improved in 83% and drainage improved in 93%. Pleural bleeding occurred in 2 patients (3%), and loculation recurred in 40%
  • In a cited two-centre series of 61 catheter removals, 10% (6 cases) involved catheter fracture or deliberate severing
  • Complete catheter blockage was reported at an incidence of less than 5%
  • Severe pain requiring catheter removal was reported as rare (0.6%) in the published literature
  • Data on the effects of catheter drainage on nutrition and immunity were described as scant
• The authors' conclusion: The authors concluded that knowledge gaps and differences in practice between centres reflect a lack of robust evidence to guide prevention and management of catheter-related complications. They said future studies should identify risk factors
• Limitations the authors state:
  • The authors noted that the low incidence of pleural infection, and so the small number of patients, had prevented multivariate analysis of risk factors
  • The authors noted many knowledge gaps and differences in management among centres
  • The authors noted that most cost-analysis studies were retrospective

Topics

Medical terms in this study, explained in our Lexicon: Indwelling Pleural Catheter, Pleural Effusion, Talc Pleurodesis, Tract Metastasis, Mesothelioma.

Related studies

• The use of indwelling pleural catheters for the management of malignant pleural effusion--direct costs in a Dutch hospital — R.C. Boshuizen, S. Onderwater, et al. (2013)
• Australasian Malignant PLeural Effusion (AMPLE)-3 trial: study protocol for a multi-centre randomised study comparing indwelling pleural catheter (±talc pleurodesis) versus video-assisted thoracoscopic surgery for management of malignant pleural effusion — D.B. Fitzgerald, C. Sidhu, et al. (2022)
• Protocol of the Australasian Malignant Pleural Effusion-2 (AMPLE-2) trial: a multicentre randomised study of aggressive versus symptom-guided drainage via indwelling pleural catheters — M. Azzopardi, R. Thomas, et al. (2016)
• Histopathology of removed indwelling pleural catheters from patients with malignant pleural diseases — C.L. Tobin, R. Thomas, et al. (2016)
• Aggressive versus symptom-guided drainage of malignant pleural effusion via indwelling pleural catheters (AMPLE-2): an open-label randomised trial — S. Muruganandan, M. Azzopardi, et al. (2018)
• Intrapleural Fibrinolysis for the Treatment of Indwelling Pleural Catheter-Related Symptomatic Loculations: A Multicenter Observational Study — R. Thomas, F. Piccolo, et al. (2015)

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