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Use of Indwelling Pleural Catheters for Chronic Pleural Infection* FREE TO VIEW

Helen E. Davies, MBBS; Najib M. Rahman, BMBCh, MA (Oxon); Robert J. Parker, MSc; Robert J. O. Davies, DM
Author and Funding Information

*From the Oxford Pleural Unit, Oxford Centre for Respiratory Medicine, University of Oxford and Oxford Radcliffe NHS Trust, Oxford, UK.

Correspondence to: Helen E. Davies, MBBS, Oxford Pleural Unit, Oxford Centre for Respiratory Medicine, Churchill Hospital, Oxford Radcliffe NHS Trust, Oxford, OX3 7LJ, UK; e-mail: hedavies@doctors.net.uk



Chest. 2008;133(2):546-549. doi:10.1378/chest.07-1742
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Recurrent, chronic pleural infection creates difficult management issues. Surgical drainage is currently recommended for patients who have failed initial “medical treatment” (ie, tube thoracostomy and antibiotic therapy), but the options for patients not fit for surgery are limited. Prolonged closed tube drainage may be an option in this group, although concerns exist regarding the efficacy and risk of catheter blockage. Long-term indwelling pleural catheters are increasingly used for the treatment of recurrent malignant pleural effusion. Pleural infection is recognized as a complication and is cited as a contraindication to insertion of an indwelling pleural drain within the product literature. We report two patients with empyema in a fixed pleural space in whom the insertion of an ambulatory catheter produced successful drainage. Long-term indwelling pleural catheters may have a role in maintaining the drainage of a chronically infected pleural space that is not readily treated in other ways.

Figures in this Article

A 54-year-old man with seropositive erosive rheumatoid arthritis, controlled with long-term therapy with methotrexate and steroids, and a chronic right bronchopleural fistula presented with a right-sided empyema. Chest radiography showed a right hydropneumothorax (Fig 1 ) and purulent pleural aspirate cultured coliforms.

Initial treatment was with tube drainage (12F Portex chest drain; SIMS Portex Ltd; Hythe, Kent, UK) and broad-spectrum antibiotic therapy. Surgery was considered, but the residual lung was severely damaged and fibrotically contracted, and it was thought that lung expansion could not be achieved. The pyopneumothorax recurred on removal of the chest tube. A 15.5F indwelling pleural catheter (Pleurx; Denver Biomedicals; Golden, CO) was inserted to maintain a dry pleural space, and alternate-day drainage was commenced, with up to 400 mL of fluid obtained on each occasion. Clinical and radiographic improvement subsequently occurred with significant lung reexpansion (Fig 2 ) and closure of the bronchopleural fistula. Pleural fluid production correspondingly reduced, and the pleural catheter was removed 21 months after insertion.

A 31-year-old Indian man was referred for management of his pleural empyema. He had a 6-month history of productive cough, weight loss, and night sweats. His chest radiograph showed a large left pleural effusion (Fig 3 , top left). Thoracentesis yielded lymphocytic exudative fluid, and closed pleural biopsies showed necrotizing granulomatous inflammation and were culture positive for acid-fast bacilli. He started quadruple antituberculous chemotherapy with rifampicin, isoniazid, pyrazinamide, and ethambutol. After initial complete chest tube drainage (12F Seldinger chest drain; Rocket Medical PLC; Washington, Tyne & Wear, UK), the effusion recurred and when resampled was turbid with a pleural fluid pH of 6.97, a glucose concentration of 1.0 mmol/L, and a lactate dehydrogenase concentration of 5,476 IU/L. The patient remained febrile.

Thoracic ultrasound demonstrated a multiloculated, echogenic collection (Fig 3, top right), and CT scanning showed a residual left pleural effusion with right upper lobe nodularity and necrotic mediastinal lymphadenopathy consistent with active tuberculosis. Mediastinal air was also visible, and oral contrast administration confirmed esophageal perforation due to necrotizing tuberculous lymphadenopathy (Fig 3, bottom left). Tuberculous pleurisy with superadded bacterial empyema was diagnosed, and treatment with broad-spectrum antibiotics was added to the antituberculous therapy.

Upper GI endoscopy demonstrated the presence of a 1.5-cm opening in the distal esophagus due to erosion by tuberculous lymph nodes; laparotomy, omental biopsy (which showed multiple epithelioid granulomata with caseous necrosis), and insertion of a feeding jejunostomy tube was subsequently performed. Despite these measures, his fever persisted, and the pleural collection reaccumulated. An ambulatory long-term tunneled pleural catheter (15.5F Pleurx catheter; Denver Biomedicals) was inserted. This was initially drained three times per week by the patient, with aspiration of up to a total of 1,250 mL each week. He was discharged to home on day 52 and steadily recovered, requiring less frequent pleural drainage. The drain was removed when no pleural fluid had been obtained for 6 weeks. At 8 months, his chest radiograph findings were nearly normal (Fig 3, bottom right).

Long-term indwelling pleural catheters are increasingly used for the treatment of recurrent pleural effusion. Pleural infection is recognized as a complication13 and is cited as a contraindication to insertion of an indwelling pleural drain. The use of ambulatory indwelling pleural catheters in our two cases illustrates a novel strategy for the treatment of a persistently infected pleural space, in one case with a bronchopleural fistula, and in the other with an esophagopleural fistula. Previously, the standard care for these patients has been rib resection and long-term open drainage, which is unpleasant for the patient, substantially reducing quality of life.4

Rib excision with associated large-bore chest tube insertion into the residual infected cavity often takes > 6 months to heal and, in patients already debilitated by chronic pleural infection, may be poorly tolerated. The use of a more permanent “open” drainage system, introduced initially by Eloesser in 193556 and subsequently modified by Symbas et al7and Thourani et al,8 provides an alternative approach; however, it is only an option in a select cohort of this patient population (ie, those fit for operative intervention) and still leaves the patient with an unpleasant open draining fistula.

Our cases suggest that outcomes as successful as those seen with open drainage can be achieved with small-bore indwelling catheters that allow the patient a better quality of life during sustained pleural drainage. Thus, just as short-term fine-bore pigtail catheter drainage can be useful during the acute phase of care,9 long-term drainage can be effective for chronic pleural infection, without the problems of catheter blockage or tract infection. This strategy warrants exploration in larger patient samples and randomized trials.

The authors have reported to the ACCP that no significant conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Figure Jump LinkFigure 1. Chest radiographs showing a large right pyopneumothorax.Grahic Jump Location
Figure Jump LinkFigure 2. Series of radiographs showing gradual resolution of the right pyopneumothorax and resultant development of pleural thickening. Top left: following insertion of indwelling pleural catheter. Top right: at 3 months. Bottom left: at 6 months. Bottom right: at 21 months prior to drain removal.Grahic Jump Location
Figure Jump LinkFigure 3. Top left: chest radiograph on presentation. Top right: thoracic ultrasound image demonstrating multiple septations (arrows) within pleural collection. Bottom left: CT image showing pockets of mediastinal air and extraluminal leak of oral contrast (arrow). Bottom right: chest radiograph at 8 months.Grahic Jump Location
Pien, GW, Gant, MJ, Washam, CL, et al (2001) Use of an implantable pleural catheter for trapped lung syndrome in patients with malignant pleural effusion.Chest119,1641-1646. [PubMed] [CrossRef]
 
Putnam, JB, Jr, Light, RW, Rodriguez, RM, et al A randomized comparison of indwelling pleural catheter and doxycycline pleurodesis in the management of malignant pleural effusions.Cancer1999;86,1992-1999. [PubMed]
 
van den Toorn, LM, Schaap, E, Surmont, VF, et al Management of recurrent malignant pleural effusions with a chronic indwelling pleural catheter.Lung Cancer2005;50,123-127. [PubMed]
 
Davies, CW, Gleeson, FV, Davies, RJ BTS guidelines for the management of pleural infection.Thorax2003;58(suppl),ii18-ii28
 
Eloesser, L An operation for tuberculous empyema.Surg Gynecol Obstet1935;60,1096-1097
 
Eloesser, L Of an operation for tuberculous empyema.Ann Thorac Surg1969;8,355-357. [PubMed]
 
Symbas, PN, Nugent, JT, Abbott, OA, et al Nontuberculous pleural empyema in adults: the role of a modified Eloesser procedure in its management.Ann Thorac Surg1971;12,69-78. [PubMed]
 
Thourani, VH, Lancaster, RT, Mansour, KA, et al Twenty-six years of experience with the modified Eloesser flap.Ann Thorac Surg2003;76,401-405. [PubMed]
 
Crouch, JD, Keagy, BA, Delany, DJ “Pigtail” catheter drainage in thoracic surgery.Am Rev Respir Dis1987;136,174-175. [PubMed]
 

Figures

Figure Jump LinkFigure 1. Chest radiographs showing a large right pyopneumothorax.Grahic Jump Location
Figure Jump LinkFigure 2. Series of radiographs showing gradual resolution of the right pyopneumothorax and resultant development of pleural thickening. Top left: following insertion of indwelling pleural catheter. Top right: at 3 months. Bottom left: at 6 months. Bottom right: at 21 months prior to drain removal.Grahic Jump Location
Figure Jump LinkFigure 3. Top left: chest radiograph on presentation. Top right: thoracic ultrasound image demonstrating multiple septations (arrows) within pleural collection. Bottom left: CT image showing pockets of mediastinal air and extraluminal leak of oral contrast (arrow). Bottom right: chest radiograph at 8 months.Grahic Jump Location

Tables

References

Pien, GW, Gant, MJ, Washam, CL, et al (2001) Use of an implantable pleural catheter for trapped lung syndrome in patients with malignant pleural effusion.Chest119,1641-1646. [PubMed] [CrossRef]
 
Putnam, JB, Jr, Light, RW, Rodriguez, RM, et al A randomized comparison of indwelling pleural catheter and doxycycline pleurodesis in the management of malignant pleural effusions.Cancer1999;86,1992-1999. [PubMed]
 
van den Toorn, LM, Schaap, E, Surmont, VF, et al Management of recurrent malignant pleural effusions with a chronic indwelling pleural catheter.Lung Cancer2005;50,123-127. [PubMed]
 
Davies, CW, Gleeson, FV, Davies, RJ BTS guidelines for the management of pleural infection.Thorax2003;58(suppl),ii18-ii28
 
Eloesser, L An operation for tuberculous empyema.Surg Gynecol Obstet1935;60,1096-1097
 
Eloesser, L Of an operation for tuberculous empyema.Ann Thorac Surg1969;8,355-357. [PubMed]
 
Symbas, PN, Nugent, JT, Abbott, OA, et al Nontuberculous pleural empyema in adults: the role of a modified Eloesser procedure in its management.Ann Thorac Surg1971;12,69-78. [PubMed]
 
Thourani, VH, Lancaster, RT, Mansour, KA, et al Twenty-six years of experience with the modified Eloesser flap.Ann Thorac Surg2003;76,401-405. [PubMed]
 
Crouch, JD, Keagy, BA, Delany, DJ “Pigtail” catheter drainage in thoracic surgery.Am Rev Respir Dis1987;136,174-175. [PubMed]
 
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