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Point and Counterpoint |

POINT: Should Small-Bore Pleural Catheter Placement Be the Preferred Initial Management for Malignant Pleural Effusions? YesSmall Pleural Catheter First Choice to Manage? Yes FREE TO VIEW

Hans J. Lee, MD, FCCP; David J. Feller-Kopman, MD, FCCP
Author and Funding Information

From the Section of Interventional Pulmonology, Division Pulmonary and Critical Care, Johns Hopkins University.

CORRESPONDENCE TO: Hans J. Lee, MD, FCCP, The Johns Hopkins Hospital, 1800 Orleans St, Zayed Bldg 7125L, Baltimore, MD 21287; e-mail: hlee171@jhmi.edu


FINANCIAL/NONFINANCIAL DISCLOSURES: The authors have reported to CHEST the following conflicts: Dr Feller-Kopman has received consulting fees from CareFusion Inc. This editorial reflects Dr Feller-Kopman’s independent thoughts regarding the use of small-bore catheters in the treatment of pleural effusions. Dr Lee reports no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2015;148(1):9-10. doi:10.1378/chest.15-0424
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The ultimate goal for the management of malignant pleural effusion (MPE) is to relieve dyspnea and avoid multiple procedures that would interfere with a patient’s quality of life. Therapeutic options include the use of oxygen and morphine for patients with an extremely limited life expectancy, repeat thoracentesis, placement of a tunneled pleural catheter (TPC), and pleurodesis. Because nearly 100% of MPEs will recur within 1 month, repeat thoracentesis often is used for patients with an expected survival < 4 weeks. It stands to reason that the least invasive methods that will provide long-term relief should be used for patients expected to survive > 1 month. Not surprisingly, a small-bore TPC is recommended by British Thoracic Society guidelines1 for the management of MPE.

There are two key questions when managing patients with MPE: (1) Is the dyspnea improved after drainage of pleural fluid, and (2) does the lung fully expand. Dyspnea in patients with MPE can be multifactorial; thus, it is important to demonstrate improvement of symptoms with pleural fluid evacuation. If the dyspnea improves after a therapeutic thoracentesis, an excellent chance exists for pleural palliation. Full lung expansion following a therapeutic thoracentesis allows for either TPC placement or pleurodesis; however, complete pleural fluid evacuation may not be completed due to either patient discomfort or concern for reexpansion pulmonary edema. If there is nonexpandable lung, TPC is undoubtedly the treatment of choice because of the unacceptable high failure rate from pleurodesis.

Pleurodesis can be performed via either poudrage or slurry. Poudrage is performed via medical/surgical thoracoscopy, whereas slurry involves instillation of a sclerosant through a chest tube. Thoracoscopy may be indicated if tissue is needed for diagnosis or molecular markers or to assess whether the lung fully expands if this has not been confirmed with a prior thoracentesis; however, thoracoscopy requires at least moderate sedation (if not general anesthesia) and at least one incision. In the largest prospective randomized trial, Dresler et al2 found no significant difference in success rates of talc poudrage vs slurry, although the poudrage group had a higher incidence of respiratory complications.

When performing pleurodesis through a chest tube, we recommend small-bore tubes (14F) or an existing TPC (previously placed). The argument for the use of a larger-bore catheter is based on Poiseuille law, which suggests better flow rates with a larger inner diameter. In an in vitro study, when draining simple fluid, the maximum flow rate plateaus with catheters smaller than 9F.3 More viscous substances (abscess fluid) would have diminishing returns starting with 12F catheters. In addition, other factors may include catheter length, material (collapsibility), number and style of fenestrations within the catheter, and requirement for a three-way stopcock, which often is smaller than the inner diameter of the catheter. Many available small-bore (14F) catheter designs allow for MPE sampling through a three-way stopcock, which also allows for flushing and instilling thrombolytic and sclerosing agents.

The literature supports pleurodesis with various sclerosing agents using small-bore catheters. Talc insufflation has been equally efficacious through small-bore catheters without occluding the catheter with fibrin plugs or residual talc. In a retrospective study using a 12F catheter compared with large-bore chest tubes, no significant difference was found when pleurodesing with various sclerosing agents, including talc.4 In a prospective study comparing large-bore (32F) vs small-bore (8F) catheters using iodopovidone for pleurodesis, the catheters were equivocal in the time to pleurodesis (3.05 and 3.29 days), total tube duration (5.6 and 5.74 days), and total response (90% and 86.9%).5 The Second Therapeutic Intervention in Malignant Pleural Effusion Trial (TIME2) used a 12F chest catheter for talc slurry pleurodesis and had an 89% success rate of pleurodesis, which is similar to other studies using larger-bore chest tubes and video-assisted thoracoscopic surgery pleurodesis.6 Although these studies were not powered for a direct comparison, they consistently do not suggest superiority of the large-bore catheters.

Small-bore catheters require a smaller incision and less tissue dissection. This again is consistent with our ultimate goal for palliation of MPE. In a prospective study, patients undergoing large-bore (24F) chest tube insertion at the time of thoracoscopy for pleurodesis had significantly more unpleasant symptoms than bedside, small-bore chest tube insertion and pleurodesis (tetracycline).7 Small-bore tubes were also found to cause significantly less pain during insertion as well as while in place compared with larger-bore tubes in patients with pleural infection.8 Other studies have found an increase in serious complications when using large-bore chest tubes compared with small-bore catheters, especially when using the trocar method of insertion.9 A review by the British Thoracic Society showed a higher postinsertion complication rate for larger-bore chest catheters in injury (0.2% vs 1.4%), with a slightly lower blockage rate (8.1% vs 5.2%).10 Part of this issue of comfort may be from using a Seldinger technique of insertion rather than blunt dissection or trocar technique. In addition, a suture is not needed for wound closure during small-bore chest catheter insertion.

TPCs are 15.5F tubes that can be placed in an outpatient setting, often with only local anesthesia. Patients are sent home with vacuum drainage bottles and typically drain every 2 to 3 days (although some centers suggest draining only when symptomatic). Some studies confirmed excellent pleural palliation, no significant difference in dyspnea, and a significant reduction in the need for further pleural intervention compared with talc slurry pleurodesis.11 Additionally, TPCs are the treatment of choice for patients with nonexpandable lung, a condition that is seen in up to 42% with MPE (S. S. Sahn, MD, personal communication, October 2011).

In conclusion, small-bore catheters and TPCs are as equally effective as large-bore tubes for the drainage and pleurodesis of MPE while requiring a smaller incision and less patient discomfort. Because they can be used in all patients with MPE (who have improvement in dyspnea following pleural drainage), their use is consistent with the overall mission of the management of MPE, which is palliation, and remains our procedure of choice for pleural palliation.

Abbreviations

BTS

British Thoracic Society

MPE

malignant pleural effusion

SBCT

small-bore chest tube

TIME2

Second Therapeutic Intervention in Malignant Pleural Effusion Trial

TPC

tunneled pleural catheter

Roberts ME, Neville E, Berrisford RG, Antunes G, Ali NJ; BTS Pleural Disease Guideline Group. Management of a malignant pleural effusion: British Thoracic Society pleural disease guideline 2010. Thorax. 2010;65(suppl 2):ii32-ii40. [CrossRef] [PubMed]
 
Dresler CM, Olak J, Herndon JE II, et al; Cooperative Groups Cancer and Leukemia Group B; Eastern Cooperative Oncology Group; North Central Cooperative Oncology Group; Radiation Therapy Oncology Group. Phase III intergroup study of talc poudrage vs talc slurry sclerosis for malignant pleural effusion. Chest. 2005;127(3):909-915. [CrossRef] [PubMed]
 
Baumann MH, Patel PB, Roney CW, Petrini MF. Comparison of function of commercially available pleural drainage units and catheters. Chest. 2003;123(6):1878-1886. [CrossRef] [PubMed]
 
Marom EM, Patz EF Jr, Erasmus JJ, McAdams HP, Goodman PC, Herndon JE. Malignant pleural effusions: treatment with small-bore-catheter thoracostomy and talc pleurodesis. Radiology. 1999;210(1):277-281. [CrossRef] [PubMed]
 
Caglayan B, Torun E, Turan D, et al. Efficacy of iodopovidone pleurodesis and comparison of small-bore catheter versus large-bore chest tube. Ann Surg Oncol. 2008;15(9):2594-2599. [CrossRef] [PubMed]
 
Davies HE, Mishra EK, Kahan BC, et al. Effect of an indwelling pleural catheter vs chest tube and talc pleurodesis for relieving dyspnea in patients with malignant pleural effusion: the TIME2 randomized controlled trial. JAMA. 2012;307(22):2383-2389. [CrossRef] [PubMed]
 
Clementsen P, Evald T, Grode G, Hansen M, Kraq Jacobsen G, Faurschou P. Treatment of malignant pleural effusion: pleurodesis using a small percutaneous catheter. A prospective randomized study. Respir Med. 1998;92(3):593-596. [CrossRef] [PubMed]
 
Rahman NM, Maskell NA, Davies CW, et al. The relationship between chest tube size and clinical outcome in pleural infection. Chest. 2010;137(3):536-543. [CrossRef] [PubMed]
 
Deneuville M. Morbidity of percutaneous tube thoracostomy in trauma patients. Eur J Cardiothorac Surg. 2002;22(5):673-678. [CrossRef] [PubMed]
 
Havelock T, Teoh R, Laws D, Gleeson F; BTS Pleural Disease Guideline Group. Pleural procedures and thoracic ultrasound: British Thoracic Society pleural disease guideline 2010. Thorax. 2010;65(suppl 2):ii61-ii76. [CrossRef] [PubMed]
 
Tremblay A, Michaud G. Single-center experience with 250 tunnelled pleural catheter insertions for malignant pleural effusion. Chest. 2006;129(2):362-368. [CrossRef] [PubMed]
 

Figures

Tables

References

Roberts ME, Neville E, Berrisford RG, Antunes G, Ali NJ; BTS Pleural Disease Guideline Group. Management of a malignant pleural effusion: British Thoracic Society pleural disease guideline 2010. Thorax. 2010;65(suppl 2):ii32-ii40. [CrossRef] [PubMed]
 
Dresler CM, Olak J, Herndon JE II, et al; Cooperative Groups Cancer and Leukemia Group B; Eastern Cooperative Oncology Group; North Central Cooperative Oncology Group; Radiation Therapy Oncology Group. Phase III intergroup study of talc poudrage vs talc slurry sclerosis for malignant pleural effusion. Chest. 2005;127(3):909-915. [CrossRef] [PubMed]
 
Baumann MH, Patel PB, Roney CW, Petrini MF. Comparison of function of commercially available pleural drainage units and catheters. Chest. 2003;123(6):1878-1886. [CrossRef] [PubMed]
 
Marom EM, Patz EF Jr, Erasmus JJ, McAdams HP, Goodman PC, Herndon JE. Malignant pleural effusions: treatment with small-bore-catheter thoracostomy and talc pleurodesis. Radiology. 1999;210(1):277-281. [CrossRef] [PubMed]
 
Caglayan B, Torun E, Turan D, et al. Efficacy of iodopovidone pleurodesis and comparison of small-bore catheter versus large-bore chest tube. Ann Surg Oncol. 2008;15(9):2594-2599. [CrossRef] [PubMed]
 
Davies HE, Mishra EK, Kahan BC, et al. Effect of an indwelling pleural catheter vs chest tube and talc pleurodesis for relieving dyspnea in patients with malignant pleural effusion: the TIME2 randomized controlled trial. JAMA. 2012;307(22):2383-2389. [CrossRef] [PubMed]
 
Clementsen P, Evald T, Grode G, Hansen M, Kraq Jacobsen G, Faurschou P. Treatment of malignant pleural effusion: pleurodesis using a small percutaneous catheter. A prospective randomized study. Respir Med. 1998;92(3):593-596. [CrossRef] [PubMed]
 
Rahman NM, Maskell NA, Davies CW, et al. The relationship between chest tube size and clinical outcome in pleural infection. Chest. 2010;137(3):536-543. [CrossRef] [PubMed]
 
Deneuville M. Morbidity of percutaneous tube thoracostomy in trauma patients. Eur J Cardiothorac Surg. 2002;22(5):673-678. [CrossRef] [PubMed]
 
Havelock T, Teoh R, Laws D, Gleeson F; BTS Pleural Disease Guideline Group. Pleural procedures and thoracic ultrasound: British Thoracic Society pleural disease guideline 2010. Thorax. 2010;65(suppl 2):ii61-ii76. [CrossRef] [PubMed]
 
Tremblay A, Michaud G. Single-center experience with 250 tunnelled pleural catheter insertions for malignant pleural effusion. Chest. 2006;129(2):362-368. [CrossRef] [PubMed]
 
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