Indwelling Pleural Catheters, Chest Tubes and Trapped Lung

Quality Gaps and Comparative Effectiveness of Management Strategies for Recurrent Malignant Pleural Effusions

https://www.ncbi.nlm.nih.gov/pubmed/28864054

Clinical Trial 

Reference: Ost DE, Niu J, Zhao H, Grosu HB, Giordano SH. Quality Gaps and Comparative Effectiveness of Management Strategies for Recurrent Malignant Pleural Effusions. Chest. 2018;153(2):438-452.

Background: There are several guidelines for the management of MPE which recommend definitive procedures over repeat thoracentesis. This study sought to evaluate whether not patients received guideline consistent care and how this affected number of procedures and complications.

PICO:

Populations:

  • Patients 66 to 90 years of age with a primary cancer diagnosis and MPE being evaluated for a second pleural procedure within 2 weeks of the first thoracentesis

Intervention:

  • Guideline consistent care:
  • Definitive pleural procedure

Comparison:

  • Guideline inconsistent care:
  • Repeat thoracentesis

Outcome:

  • Primary outcome:
  • Whether or not patients received guideline consistent care for the management of a recurrent MPE – 24% of patients alive after 30 days that experienced a recurrence requiring a second intervention prior to 14 days received a definitive procedure
  • Secondary outcomes:
  • Number of subsequent pleural procedures – patients receiving a definitive procedure required fewer repeat pleural procedures when compared to repeat thoracentesis group
  • Pneumothorax related to pleural procedures – total incidence of pneumothoraces per patient was lower in the definitive procedure group when compared to repeat thoracentesis group
  • Site of service – patients receiving a definitive procedure required fewer subsequent inpatient and ED procedures than patients receiving a repeat thoracentesis
  • Inpatient days associated with pleural procedures – patients with IPC or repeat thoracentesis as the second procedure had fewer inpatient days than patients receiving chest tube or thoracoscopic pleurodesis

Take Home: This study determined performing a definitive procedure in accordance with guideline consistent care rather than repeating a thoracentesis was associated with fewer subsequent procedures and complications in patients with recurrent MPE.


 Quality-adjusted survival following treatment of malignant pleural effusions with indwelling pleural catheters

https://www.ncbi.nlm.nih.gov/pubmed/24480929

Clinical Trial 

Reference: Ost DE, Jimenez CA, Lei X, et al. Quality-adjusted survival following treatment of malignant pleural effusions with indwelling pleural catheters. Chest. 2014;145(6):1347-1356.

Background: This study evaluated quality adjusted survival following IPC placement in patients with a recurrent MPE

PICO:

Populations:

  • Adult patients undergoing IPC placement for management of a symptomatic MPE
  • Excluded patients with: previously attempted pleurodesis, previous IPC placement, chylous effusions, pleural space infection, bilateral effusions requiring interventions or respiratory failure requiring mechanical ventilation

Intervention:

  • IPC placement

Comparison:

  • None

Outcome:

  • Quality-adjusted survival expressed in quality-adjusted life days – Median was 95.1 QALDs
  • Self-reported global quality of life measured by the SF-6D
  • Utilities calculated with the SF-6D – No significant difference in utility at 1 month after IPC placement compared to baseline
  • Dyspnea measured by the Borg score – Significantly improved at 1 month when compared to baseline
  • Performance status measured by the ECOG
  • Complications – 9.7% of patients had a complication with median time to complication being 1.4 months. No factor had a significant impact on time to any complication or catheter removal
  • Reasons for catheter removal

Take Home: This study showed IPC placement significantly improves dyspnea in patients with recurrent, symptomatic MPE, but the improvement in utility was not as significant. Patients receiving chemotherapy or radiation after IPC placement and those with worse baseline shortness of breath experience greater improvements in utility.


 Use of an implantable pleural catheter for trapped lung syndrome in patients with malignant pleural effusion

https://pubmed.ncbi.nlm.nih.gov/11399685/

Case Series 

Reference: Pien GW, gant M, Washam C, et al. Use of an Implantable Pleural Catheter for Trapped Lung Syndrome in Patients with Malignant Pleural Effusion. CHEST 2001; 119:1641-1646.

Summary: This case series retrospectively reviewed the outcomes of 11 patients with trapped lung that underwent IPC placement for symptomatic, refractory MPE. Ten out of the 11 patients reported symptomatic benefit after IPC placement. Ten of the 11 patients had the IPC in place until death with the mean length being 115 days. One patient required IPC revision after catheter occlusion and other complications included catheter infection, localized skin breakdown and cellulitis. IPC placement appears to be a good option for treatment of symptomatic, recurrent MPE in patients with trapped lung.