Use of Indwelling Pleural Catheters for Cardiogenic Pleural Effusions

doi:10.1378/chest.13-0331

Chest

Volume 144, Issue 5, November 2013, Pages 1603-1608

https://doi.org/10.1378/chest.13-0331 Get rights and content

Background

Cardiogenic pleural effusions are rarely refractory to treatment of the underlying disease. Few options are available in these cases. Indwelling pleural catheter (IPC) insertion has been well described for the management of malignant pleural effusions. We present our experience with using IPCs for cardiogenic pleural effusion management.

Methods

We prospectively constructed a cohort of patients who underwent IPC insertion for cardiogenic pleural effusions. Patients were carefully selected, and the IPCs were inserted as a palliative measure or while awaiting cardiac transplantation.

Results

There were 43 IPCs inserted in 38 patients. Patients had significant dyspnea, with a mean baseline dyspnea index of 2.24 (95% CI, 1.53–2.94). There was significant improvement in dyspnea 2 weeks after IPC insertion, with a mean transitional dyspnea index of 6.19 (95% CI, 5.56–6.82). There was no occurrence of empyema. Pneumothorax, mostly ex vacuo, occurred in 11.6% of procedures but did not require further intervention. IPCs were removed in 18 patients (47.4%), and successful spontaneous pleurodesis occurred in 11 patients (29.0%) after a median of 66 days (interquartile range, 34–242 days). Patients who eventually had their catheters removed had better performance status (P = .008) and were less dyspneic (P = .005) at baseline and had longer survival (P < .0001).

Conclusions

IPC insertion for cardiogenic pleural effusion is a feasible option in carefully selected patients. Further research is needed to confirm the results and to assess the impact of IPC insertion on the quality of life of these patients.

Section snippets

Study Design and Setting

We conducted a prospective cohort study of patients who underwent IPC insertion (PleurX; CareFusion Corporation) for a pleural effusion due to cardiac disease at The Ottawa Hospital. The investigational protocol was reviewed and approved by The Ottawa Hospital Research Ethics Board (protocol number 2011873-01H).

Participants

Data on patients who underwent IPC insertion were collected prospectively in the CARE (Chronic Ascites and Recurrent Effusion) clinic database since the program started in 2006. Patients

Results

There were 43 IPCs inserted in 38 patients, including two patients who had subsequent ipsilateral IPC insertion and three who had a subsequent contralateral IPC insertion. One additional patient was not included in this analysis because of subsequent pleurodesis. First-time IPCs were inserted during admission in 18 patients (47.4%) and during pleuroscopy in 12 patients (31.6%) (Table 1). Six patients had pleuroscopy as outpatients. Patients were elderly, with a mean age of 78.7 years (95% CI,

Discussion

The results illustrate that IPC insertion for cardiogenic benign pleural effusions is feasible. When performed in selected patients, it is safe and effective in relieving symptoms, with few subsequent procedures required. There was successful spontaneous pleurodesis in 29.0% of patients. Those who eventually had their IPC removed had better performance status and were less dyspneic at baseline, and their survival was much longer.

Few options are available for cardiogenic pleural effusion when

Acknowledgments

Author contributions: Dr Srour had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Dr Srour: contributed to the study concept and design; data acquisition, analysis, and interpretation; drafting of the manuscript; and final approval of the version to be published.

Dr Potechin: contributed to the data acquisition, revision of the manuscript for important intellectual content, and final approval of the version

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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
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There are more references available in the full text version of this article.

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Pleural effusion (PE) is a common yet complex disease that requires specialized, multidisciplinary management. Recent advances, novel diagnostic techniques, and innovative patient-centered therapeutic proposals have prompted an update of the current guidelines. This document provides recommendations and protocols based on a critical review of the literature on the epidemiology, etiology, diagnosis, prognosis, and new therapeutic options in PE, and addresses some cost-effectiveness issues related to the main types of PE.
Hepatic Hydrothorax and Congestive Heart Failure Induced Pleural Effusion
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Citation Excerpt :
The median time to pleurodesis ranged from 66 to 150 days.74 Although most reported studies to date are single center, retrospective with potential selection bias, these results suggest that IPC use in refractory CHF-induced PEs may lead to reduced length of hospital stay and provide symptomatic palliation to patients who would otherwise undergo frequent thoracenteses (Table 2).46,47,51,72,75–77 Literature on chemical pleurodesis in CHF-induced PE is scant and often includes single-center retrospective studies with heterogeneous population of nonmalignant etiology.
Bilateral Asymmetrical Pleural Effusion Due to Congestive Heart Failure
2021, Pleural Diseases: Clinical Cases and Real-World Discussions
An 80-year-old man presented with worsening dyspnea. His medical history included chronic heart failure and right pleural effusion that recurred after a large-volume thoracentesis. The cardiologist intensified the medical therapy by increasing the dosage of the loop diuretic and adding an angiotensin-converting enzyme (ACE) inhibitor, and an aldosterone receptor blocker. However, arterial hypotension developed, urine output decreased, the pleural effusion increased, and small symmetrical lower limb edema appeared. The patient was admitted with prerenal acute kidney injury and hypoxemic respiratory failure. Chest ultrasonography demonstrated a large area of right pleural effusion without fibrin, vertical pulmonary artifacts (B-lines), and increased size and decreased respiratory variability of the inferior vena cava. The ACE inhibitor was stopped, and the patient received dopamine and intravenous furosemide. Despite resumption of adequate urine output and improvement of renal function, the pleural effusion persisted, and the patient continued to experience shortness of breath and to require supplemental oxygen. He underwent additional large-volume thoracentesis, resulting in significant alleviation of his dyspnea. The right pleural effusion recurred 4 weeks later, and an indwelling pleural catheter (IPC) was placed. This chapter discusses pleural effusions due to cardiovascular diseases and the use of IPCs in nonmalignant diseases.
A case of hemothorax secondary to intrapleural fibrinolytic therapy: Considerations for use of fibrinolytics in high-risk patients
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Citation Excerpt :
The PleurX catheter (CareFusion, Vernon Hills, IL, USA) approved by the US Food and Drug Administration (FDA) in 1997 for management of malignant pleural Effusion and further licensed in 2011 for nonmalignant pleural effusion, is being frequently used for the outpatient management of RPEs [4,5]. The average time for pleurodesis is reported to be 95 days, although the rate of pleurodesis can be variable [6]. Recent studies have evaluated the effectiveness of IPC instillation of tPA in restoring the flow of non draining IPC when the saline flush fails.
Indwelling Pleural Catheters (IPC) are increasingly being used for management of recurrent pleural effusions (RPEs). Use of IPC for management of both malignant and non-malignant recurrent pleural effusions has been associated with complications such as dysfunctional or nonfunctioning IPCs. Alteplase, a tissue plasminogen activator (tPA) is often used to restore flow of non-draining IPC in symptomatic patients.
We present a case of a sixty-eight-year old patient with life-threatening pleural hemorrhage following intrapleural catheter instillation of tPA that was managed successfully by thoracotomy. Our case describe the importance of individualizing the fibrinolytic dose, frequency and the indwelling time in high risk patients. We have reviewed the current literature and recommendations for use of fibrinolytic therapy for IPC in high risk patients on anticoagulation.
Indwelling Pleural Catheters for Nonmalignant Effusions: Evidence-Based Answers to Clinical Concerns
2017, American Journal of the Medical Sciences
Citation Excerpt :
Fourteen catheters were eventually removed because of spontaneous pleurodesis. Similar results were reported by Srour et al25 in 2013, with all 38 patients who received catheters experiencing significant relief of dyspnea and 11 patients experiencing spontaneous pleurodesis. In 2014, Freeman et al26 published a propensity-matched comparison of 40 patients with heart failure receiving TPCs with 40 similar patients undergoing thoracoscopic pleurodesis.
Pleural effusions occur in 1.5 million patients yearly and are a common cause of dyspnea. For nonmalignant effusions, initial treatment is directed at the underlying cause, but when effusions become refractory to medical therapy, palliative options are limited. Tunneled pleural catheters (TPCs) are commonly used for palliation of malignant effusions, but many clinicians are reluctant to recommend these devices for palliation of nonmalignant effusions, citing concerns of infection, renal failure, electrolyte disturbances and protein-loss malnutrition. Based on the published experience to date, TPCs relieve dyspnea and can result in spontaneous pleurodesis in patients with nonmalignant effusions. The infection rate compares favorably to that for malignant effusions with possible increased risk in patients with hepatic hydrothorax and posttransplant patients. Renal failure, electrolyte disturbance and protein-loss malnutrition have not been observed. TPCs are a reasonable option in select patients to palliate nonmalignant effusions refractory to maximal medical therapy.
Management of Benign Pleural Effusions Using Indwelling Pleural Catheters: A Systematic Review and Meta-analysis
2017, Chest
Citation Excerpt :
From the available data, 37 catheters were removed secondary to complications. Complications that necessitated the removal of an indwelling catheter were loculation (three cases),8,27 pleural fluid leakage (one case),13 IPC dislodgement (one case),12 and, as described earlier, empyema (three cases). Detailed information was reported from only eight of 37 catheter removals secondary to complications, leaving 29 catheters that were removed because of unspecified complications.
The indwelling pleural catheter (IPC), which was initially introduced for the management of recurrent malignant effusions, could be a valuable management option for recurrent benign pleural effusion (BPE), replacing chemical pleurodesis. The purpose of this study is to analyze the efficacy and safety of IPC use in the management of refractory nonmalignant effusions.
We conducted a systematic review and meta-analysis on the published literature. Retrospective cohort studies, case series, and reports that used IPCs for the management of pleural effusion were included in the study.
Thirteen studies were included in the analysis, with a total of 325 patients. Congestive heart failure (49.8%) was the most common cause of BPE requiring IPC placement. The estimated average rate of spontaneous pleurodesis was 51.3% (95% CI, 37.1%-65.6%). The estimated average rate of all complications was 17.2% (95% CI, 9.8%-24.5%) for the entire group. The estimated average rate of major complications included the following: empyema, 2.3% (95% CI, 0.0%-4.7%); loculation, 2.0% (95% CI, 0.0%-4.7%); dislodgement, 1.3% (95% CI, 0.0%-3.7%); leakage, 1.3% (95% CI, 0.0%-3.5%); and pneumothorax, 1.2% (95% CI, 0.0%-4.1%). The estimated average rate of minor complications included the following: skin infection, 2.7% (95% CI, 0.6%-4.9%); blockage and drainage failure, 1.1% (95% CI, 0.0%-3.5%); subcutaneous emphysema, 1.1% (95% CI, 0.0%-4.0%); and other, 2.5% (95% CI, 0.0%-5.2%). One death was directly related to IPC use.
IPCs are an effective and viable option in the management of patients with refractory BPE. The quality of evidence to support IPC use for BPE remains low, and high-quality studies such as randomized controlled trials are needed.

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Funding/Support: The authors have reported to CHEST that no funding was received for this study.

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Chest

Original ResearchPulmonary ProceduresUse of Indwelling Pleural Catheters for Cardiogenic Pleural Effusions

Background

Methods

Results

Conclusions

Section snippets

Study Design and Setting

Participants

Results

Discussion

Acknowledgments

Chest

Ann Thorac Surg

Transudative effusions

Eur Respir J

Case of cardiac effusion treated by pleuroscopic talc spray [in French]

Mars Med

The use of pleurodesis for intractable pleural effusion due to congestive heart failure

Postgrad Med J

Recurring pleural effusion in congestive heart failure treated by pleurodesis

J Ir Med Assoc

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

Original Research
Pulmonary Procedures
Use of Indwelling Pleural Catheters for Cardiogenic Pleural Effusions