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 Table of Contents  
Year : 2022  |  Volume : 5  |  Issue : 2  |  Page : 71-76

Review article on indwelling pleural catheter

1 Department of Respiratory Medicine, Apollo Hospitals, Chennai, Tamil Nadu, India
2 Department of Cardiothoracic and Vascular Surgery, Apollo Hospitals, Chennai, Tamil Nadu, India

Date of Submission14-Jul-2022
Date of Acceptance03-Aug-2022
Date of Web Publication23-Dec-2022

Correspondence Address:
Dr. Vignesh Ashokan
Associate Consultant, Department of Respiratory Medicine, Apollo Hospitals, Chennai - 600 006, Tamil Nadu
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/japt.japt_22_22

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Lymphomas, malignancies of the lung, breast, and ovaries, most frequently give rise to malignant pleural effusions (MPE). The prognosis is often bad when an MPE is present. Malignant cells found in the pleural fluid or tissue can be used to confirm the diagnosis of MPE. Palliative care should emphasize on symptom relief, quality-of-life enhancement, and acceptance of an initial intervention to drain an MPE or prevent recurrence and affordability. Our preferred initial treatment for the majority of patients with recurrent MPE is the placement of an IPC (also known as a tunneled pleural catheter), with intermittent outpatient drainage performed by the patient or attender. Patients with expandable lung are candidates for both IPC drainage and pleurodesis, but those with nonexpandable lung are often only eligible for IPC drainage. IPC requires interventional expertise and may not be available in some institutions. IPC can produce spontaneous pleurodesis and gives good symptom alleviation, according to many randomized trials and one meta-analysis. Effective pleurodesis occurs in up to 70% of patients.

Keywords: Indwelling pleural catheter, malignant pleural effusions, pleurodesis, recurrent pleural effusions

How to cite this article:
Rajendran SS, Ashokan V, Narasimhan R A. Review article on indwelling pleural catheter. J Assoc Pulmonologist Tamilnadu 2022;5:71-6

How to cite this URL:
Rajendran SS, Ashokan V, Narasimhan R A. Review article on indwelling pleural catheter. J Assoc Pulmonologist Tamilnadu [serial online] 2022 [cited 2023 Jan 27];5:71-6. Available from: http://www.japt.com/text.asp?2022/5/2/71/365080

  Introduction Top

Indwelling pleural catheters (IPCs) are nowadays being used for patients with recurrent pleural effusions (RPEs). Since the IPC received Food and Drug Administration's clearance in 1997, it has become the procedure of choice for treating recurrent malignant pleural effusions (MPEs) as an outpatient,[1] and it is the preferred method to treat MPEs associated with trapped lung.[2] The IPC [Figure 1] is a 66-cm long, 15.5-Fr silicone catheter with multiple side beveled holes for fluid drainage, a polyester cuff at the exit site that allows tissue ingrowth to keep the catheter in place and lower the risk of infection. It also has a one-way safety valve on the outside end to prevent unnecessary access [Figure 2].
Figure 1: Indwelling pleural catheter kit

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Figure 2: IPC vacuum bottle

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Typically, local anesthetic is used to place IPC, either with or without conscious sedation.[3],[4] The catheter must first be subcutaneously tunneled between two incisions before being inserted into the pleural cavity using a specialized introducer sheath. A special vacuum bottle [Figure 3] connected to the catheter is then used to drain the pleural fluid everyday or every other day.[5],[6] RPEs (MPEs and nonmalignant pleural effusions)[4] are defined as pleural effusions that recur despite optimal therapy for the underlying etiology of the effusions and typically require multiple thoracenteses or a more definitive therapeutic modality to prevent recurrence.
Figure 3: IPC silicon catheter

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More aggressive measures are required to ensure symptom control and to prevent recurrent effusions that are refractory to medical therapy and those that recur despite appropriate medical management of the underlying disease and repeated thoracenteses.[7],[8] Repeated thoracenteses, chest-tube thoracostomy with chemical pleurodesis, surgical pleurodesis, or placement of an indwelling tunneled pleural catheter (IPC) or PleurX catheter (PC)[1],[9] were some of the therapeutic options to manage RPEs.

The presence of the catheter inside the pleural cavity causes an inflammatory response and the creation of adhesions, which is the basic mechanism of pleurodesis. Pleural symphysis is brought on by repeated drainage, which triggers an inflammatory response to a foreign substance inside the pleural cavity.[10] The pleural catheter has a benefit over a chest tube in that it is less rigid, which allows for more free movement inside the pleural cavity and, consequently, more direct contact with more pleural surface when the catheter sweeps inside the pleural cavity.[10] The 15.5-Fr-diameter PC, manufactured by Care Fusion (McGaw Park, IL, USA), is the medical device that is used most widely throughout the world. It was initially approved for use in MPEs in 1997 to reduce dyspnea and accomplish pleurodesis. This license was extended 4 years later to include the drainage of all recurrent effusions.

  IPC Insertion and Drainage Top



  • Uncorrected coagulopathy
  • Pleural infection with evidence of ongoing sepsis
  • Pleural infection with evidence of major malignant involvement over the planned insertion location and
  • Evidence of cutaneous infection over the proposed insertion site
  • Inability for the patient, family, or health-care services to manage or tolerate the drain.

  IPC Insertion and Drainage Technique Top

Using a modified Seldinger technique, the IPC is inserted into the pleural cavity after tunneling between two tiny skin incisions. These are typically made 7–10 cm apart to allow for simple access to the drain and enough tunnel length to lower the risk of dislodgment. It is crucial to remember that the drain is not actually sutured into place. Fixation relies on both eventual fibrosis around the cuff and a tight closure of the skin incision via which the drain exits the subcutaneous tissues.[5]

An initial IPC drainage frequency of three times per week would be typical, with further adjustments based on volumes and symptoms related to drainage. Patients can maintain a high quality of life without experiencing a large disruption to their home life, with a typical drainage lasting about 15 min. IPC's drain is accomplished using a bag or bottle attached to a special one-way access valve on the drain's exterior. A vacuum is used to prime this container in order to draw out the pleural contents, often 500–1000 ml at a time.

Complications related to IPC placement for MPEs can be divided into two main categories:

Procedure-related complications

Pneumothorax, misplacement, and bleeding are those complications that occur during the placement of the catheter.[16]

Catheter-related complications

This includes the complications associated with having a pleural catheter in place for a long time,[17],[18],[19] such as infections at the site of placement, empyema, a prolonged leak at the entry site, catheter blockages, kinked catheters, dislodged catheters, chronic pain or discomfort, inadequate drainage as a result of the catheter's improper placement or loculation formation, and incomplete re-expansion of the lung.[6]

  Removal of IPCs and associated complications Top

One of the many potential causes for thinking about removing a catheter is spontaneous pleurodesis, coupled with irremediable blockage or pleural loculation, substantial pleural infection, pain either due to drainages or the presence of the drain itself, or damage to the IPC itself.[4] The longer a drain is left in place, the harder it may be to remove it because the polyester cuff linked to it is made to encourage local fibrosis.[4]

Fibrotic bands may also develop through IPC fenestrations or along its surface as a result of very severe malignant pleural processes, making extraction more difficult.[4] The careful dissection of the fibrous tissue surrounding the cuff following appropriate incisions is the most crucial step in the procedure. The proximal end of the IPC can then be subjected to gradual but firm pressure to promote dislodgment.[4]

The internal pulling feeling may be too much for some patients to handle, making it unsafe to remove the drain. In this case, removing only the proximal part of the drain provides an alternative to simply keeping it in place. To accomplish this, the IPC is severed under tension, causing the distal end to recoil back into the pleural space.[4]

  Review of literature Top

Mullon J et al. investigated the use of tunneled indwelling pleural catheters (IPCs) in 109 non-malignant pleural effusions retrospectively at Mayo Clinic, Rochester.[20] 44 (40%) were placed for heart failure, 26 (24%) for inflammatory pleuritis, 10 (9%) for chylothoraces, 6 (5%) for renal failure, 5 (5%) each for hepatic hydrothoraces and trapped lung, and 13 (12%) for other etiologies. In total, 60 (55%) were placed for transudative, and 49 (45%) for exudative processes.[20] All but 4 patients (96%) reported symptom improvement with IPCs use. Hospitalization from pleural disease one year after IPC placement was reduced when compared to one-year prior for all types of effusions (0.4 vs 1.6 admissions, p< 0.0001), with the largest reduction seen in heart failure (0.5 vs 2.4 admissions, p<0.0001). Sixty-nine (63%) catheters were removed at a median duration of 89 days, while 32 (30%) remained in place until patient death.[20] Sixty-four (59%) catheters were removed at a median of 90 days due to spontaneous pleurodesis, and there was no difference in pleurodesis time between exudative and transudative processes (89 vs 95 days, P = 0.71). Complications included empyema in 5 (5%), reversible tube occlusion in 4 (4%), pneumothorax, catheter leakage, and post-insertion pain each in 2 (2%), and tube malposition and tunnel-track infection each in 1 (1%).[20]

Putnam et al. conducted the first study to discuss the experience using the IPC in the management of MPE.[5] A total of 144 patients participated in the trial, which was published in 1999. Of those, 96 received IPC treatment, while the remaining 48 had underwent chest tube and doxycycline pleurodesis.[5] The median survival was similar between the two groups, but the IPC group's had a significantly shorter hospital stay – 1 day as opposed to 6.5 days. Nearly 46% of the IPC group and 56% of the chest tube and doxycycline sclerotherapy group experienced successful pleurodesis.[5] Recurrent significant pleural effusions appeared in 13% of those who received IPC treatment, compared to 21% of those who received doxycycline sclerotherapy.[5] Since this study, multiple studies which confirmed the utility of IPCs in the management of MPEs[18],[21],[22] were published.

In a retrospective chart review analysis of patients who developed symptomatic pleural loculations following the implantation of an IPC, 66 individuals received intra-pleural fibrinolytic therapy using tissue plasminogen activator, streptokinase, or urokinase.[4] Ninety-three percent of patients who had increased fluid drainage experienced a successful intervention. Eighty-three percent of patients saw an improvement in their dyspnea. There was substantial pleural bleeding in two cases (3%). There have been no deaths linked to intra-pleural fibrinolytic treatment so far.[4]

Ost et al. conducted the main study that addressed quality of life following IPC placement, and it was published in June 2014. In that study, 266 patients who underwent IPC for MPEs were evaluated for quality-adjusted survival.[23] After the placement of IPC, quality of life, measured by SF-6D, did not differ significantly. However, there was a higher improvement in utility at 1 month in patients who received chemotherapy or radiation following IPC placement and in those who were more dyspneic at baseline. After IPC implantation, the Borg Dyspnea Scale score for dyspnea dramatically decreased at 1 month and remained statistically significant at 12 months. At a median follow-up of 3.5 months (range 0–14.5 months), 58.6 patients had passed away.[23] Factors that predicted longer survival were older age, patients receiving chemotherapy or radiation following IPC installation, patients with less shortness of breath, and patients with higher quality of life, using multivariate analysis.

For the treatment of MPEs, Davies et al. compared IPC to chest tubes with talc pleurodesis.[7] The final data analysis included 106 patients in total, of whom 52 underwent IPCs and 54 received a chest tube with talc pleurodesis. Both groups experienced a similar improvement in dyspnea after 42 days of the intervention. But after 6 months, the IPC group's dyspnea dramatically improved in comparison to the chest tube and talc pleurodesis group.[7] There was no difference in the quality of life between both groups. The length of stay was much shorter in the IPC group compared to the chest tube and talc pleurodesis groups, with a median of 0 days in the IPC group compared to 4 days in the talc group, in a manner similar to Putnam's first study.[5] Compared to the IPC group, there were more patients in the talc group who needed further pleural intervention – 22% versus 6%, respectively. Contrarily, however, the IPC group saw more adverse side effects than the talc group; 40% versus 13%, respectively.[5],[7]

One article reviewed the IPC's application to hematologic malignancies.[22] The final analysis included 91 patients. The most prevalent cancer was lymphoma (62%), followed by leukemia (21%) and multiple myeloma (13%). There was no predilection to either side of the chest, and 7% of the patients had bilateral IPCs. The mean time to IPC removal was 89.9 days (between 2 and 867 days). The most frequent reason for IPC removal was death (58.2%), followed by spontaneous pleurodesis (23.1%). IPCs were removed in three patients (3.3%) as a result of pain. Nearly 7.7% of that cohort had empyema, with Staphylococcus aureus growing in most cultures (71.4%). In addition to the removal of the IPCs, 57% of patients with empyema required additional interventions to address the pleural infection. When extra intervention was performed (thoracotomy, video-assisted thoracoscopic surgery [VATS], and chest-tube thoracostomy), no mortality was recorded. In comparison, 66.6% of patients who did not undergo additional interventions died.[22]

MPEs related to trapped lung have also been successfully managed by using indwelling pleural catheters. A total of 116 individuals had IPC placement as part of a research that assessed the use of IPCs in trapped lung that had been surgically or radio-logically verified. Following catheter implantation, the authors reported on symptom alleviation, mobility, and ease of management.[24] Patients who responded to the surveys indicated that they were “somewhat” and “moderately” satisfied with the simplicity of care following catheter implantation as well as “moderately” and “extremely” satisfied with their mobility and symptom reduction.[24] The complications associated with a trapped lung were typically minor and self-limiting. In 35% of cases, pain developed was often minor and momentary (resolving in <3 days, on an average). No catheter was taken out because of pain. Nearly 13% of cases had pericatheter leakage, and all of these cases were self-limited, needing no active intervention to stop the leak. Only 4% of patients had catheter blockage or displacement that required replacement.[24]

IPC may have also been successful in the treatment of chronic pleural effusions that develop following lung transplantation.[25] Twelve IPCs were implanted in nine recipients of lung transplants. The target outcome, which was defined as resolution of the pleural effusion and adequate palliation of lung entrapment, was accomplished in 11 out of the 12 IPCs. The median amount of time it took to remove the catheter in the cases of lung entrapment following lung transplantation was 86 days. Catheter-related complications included one hemothorax and one empyema.[25]

Warren et al. investigated factors that can predict successful pleurodesis and catheter removal in MPEs.[8] In that study, they investigated potential predictors of catheter removal and spontaneous pleurodesis, including the initial tumor site, the existence of trapped lung, the results of a cytological examination of the pleural fluid, and prior chest irradiation. A total of 295 IPCs were implanted for 263 patients in the research. With an average indwelling time of 29.4 days, 58.6% of the catheters were eventually removed. In contrast to patients who had catheters implanted for malignancies of other sorts, those with breast cancer and gynecologic malignancies were more likely to have the catheter removed. A higher likelihood of catheter removal and complete lung re-expansion following catheter implantation were associated with positive cytological results from the pleural fluid. In addition, compared to patients who had chest wall irradiation, people without a history of it were more likely to have their catheter removed.[8]

Fysh et al. examined protein and albumin depletion in those with IPCs for MPE.[26] When comparing patients having IPCs to those who underwent conventional talc pleurodesis, they were unable to show either substantial reductions or between-group differences after a 3-month follow-up. In a short series examining chylothoraces requiring recurrent drainage, Jimenez et al. did notice a statistically significant drop in albumin levels, but they also noted that patients did not need any nutritional supplementation.[11] Following the removal of the IPC or the end of routine thoracenteses, albumin levels reverted to normal. Some pleural processes can result in the accumulation of inflammatory debris in an effusion. When fluid drainage stops, this could potentially result in blockage, which should always be suspected. Although a recent study claimed up to a fifth of IPCs were affected,[7] larger series have shown that occluded drains may be predicted in 4% of cases.[27],[28] While saline flushes are frequently effective to eliminate any line obstruction in treating instances, difficult occlusions can also be treated by administering fibrinolytic treatment.[29] However, this method may be very expensive and does not ensure that the drain will not need to be repositioned or replaced.[30]

The local tissues may be affected by tract metastases if an IPC has been implanted because of cancer. This can occur in different cancers[31] but usually results from mesothelioma.[32] Although there are few reported cases in the literature, the incidence of metastasis seems to be just below 1%.[27] A clinical diagnosis or an ultrasound-guided biopsy can be used to make the diagnosis,[33] and radiation is typically administered after IPC implantation. Nothing in the literature suggests that radiation harms the IPC[32] and treatment is generally effective, avoiding the need to remove the drain.[31] Trials are still being conducted, however it is unclear whether prophylactic radiation has a purpose in mesothelioma patients having IPC insertion.

Pleural infection rates were reported to be 4.7% and 2.8%, respectively, with the typical time to infection being around 2 months after IPC insertion in the two largest collections of IPC data currently available, one an abstract detailing the experience of infection at ten centers[34] and the other a systematic review of 19 studies.[27] Although one group reported that asymptomatic colonization with other species, such as coagulase-negative staphylococci, may also occur, the most prevalent organism cultivated from pleural effusion in these conditions appears to be S. aureus.[35] When pleural infection does occur, patients hardly ever require thoracic surgery or drain removal. However, the majority will need to be admitted to the hospital for continuous drainage and intravenous antibiotics. According to Rosenstengel et al.,[34] 94% had their infection successfully treated and 26% needed intrapleural fibrinolytic therapy as a supplemental treatment. The whole group had a 0.3% mortality rate, all of which were due to pleural infections. Localized infection may also appear near the insertion site, possibly happening in about 3% of cases.[27] This normally resolves with straightforward oral antibiotic therapy, but it should serve as a reminder to use the proper drain management strategies.

Olden and Holloway[36] examined the cost-effectiveness of IPCs for the first time in 2010, contrasting the PleurX drain with chest drains and talc slurry. They reached to the conclusion that both arms had identical total costs and cost-effectiveness (measured in quality-adjusted life-years), but that IPCs were more beneficial when patients had a life expectancy of 6 weeks or fewer, based on a schedule of three drainage treatments per week. The use of peritoneal dialysis patients to inform utility data, the unique assumption that 10% of patients would fail an IPC and proceed to get talc slurry, as well as the exclusion of alternate means of treatment such as thoracoscopy,[36] were all weaknesses of this analysis.

Puri et al.[37] looked at talc slurry and IPCs once more while also taking VATS pleurodesis and recurring thoracenteses into consideration. IPCs were once again found to be the better option in the short run, this time after 3 months of therapy, in their model, which conservatively estimates an IPC success rate of 40%; once-weekly drainage; and drainage by family in 50% of cases. Bedside pleurodesis seemed to be the most economically advantageous treatment option for patients who survived for a full year. IPCs were also recommended for short-term use in the lone trial that included medical thoracoscopy as a separate treatment and was published as an abstract.[38]
  Conclusions Top

Since their inception more than 15 years ago, IPCs have established themselves as a staple of treatment for RPEs. They enable patients to take control of both the management of their disease and the decisions regarding their treatment because they are extremely simple to insert, manage, and remove.

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Conflicts of interest

There are no conflicts of interest.

  References Top

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Putnam JB Jr., Walsh GL, Swisher SG, Roth JA, Suell DM, Vaporciyan AA, et al. Outpatient management of malignant pleural effusion by a chronic indwelling pleural catheter. Ann Thorac Surg 2000;69:369-75.  Back to cited text no. 5
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Jimenez CA, Mhatre AD, Martinez CH, Eapen GA, Onn A, Morice RC. Use of an indwelling pleural catheter for the management of recurrent chylothorax in patients with cancer. Chest 2007;132:1584-90.  Back to cited text no. 11
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Thornton RH, Miller Z, Covey AM, Brody L, Sofocleous CT, Solomon SB, et al. Tunneled pleural catheters for treatment of recurrent malignant pleural effusion following failed pleurodesis. J Vasc Interv Radiol 2010;21:696-700.  Back to cited text no. 13
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Almeida FA, Bruno DS, Faiz S, Hinrichs B, Eapen GA, Bashoura L. Hemothorax treated with indwelling tunneled pleural catheter: Are all hemothoraces the same? J Bronchology Interv Pulmonol 2011;18:261-4.  Back to cited text no. 15
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