Insertion of a Right-Sided PleurX Catheter for Palliation of a Malignant Pleural Effusion

CHAPTER 1

I am Hugh Auchincloss. I'm a thoracic surgeon at Massachusetts General Hospital. And today, we're doing the insertion of a right-sided PleurX catheter for palliation of a malignant pleural effusion in an elderly woman who has a large inoperable right-sided lung cancer associated with a symptomatic pleural effusion, for which she's already had several image-guided thoracenteses. And PleurX catheter is generally considered a better palliative option as it doesn't require multiple trips to the hospital and multiple procedures. It's something that patient can manage at home and do drainage by themselves and hopefully improve her quality of life. Typically, we often do this procedure in the office or at the bedside. I'm doing it in the operating room today, because I had the time available. And originally, we had thought we might do a thoracoscopy concurrent with this. These tubes can certainly be placed under direct thoracoscopic guidance. That ends up not being necessary for her, but we'll use the operating room time for optimal conditions. The key to the procedure is the key to any bedside procedure is achieving good local anesthesia, finding a good spot for the tube to exit her body, such that she can manage it without too much assistance at home. And an entry spot in her chest that's hopefully dependent and maximizes our fluid drainage. The kit contains everything that we would need for insertion of this. It has basic drapes, skin prep, local anesthetic, and then a series of needles, insertion sheaths, and guidewires, and the tube itself. So, it's basically a self-contained setup. All told, the procedure should take about 20 minutes. It's comfortably done with just local anesthesia, but since she's in the operating room, we'll add some sedation as well. So, the steps of the procedure, after we have her in a suitable position, in this case it's lateral decubitus. You can also do it with the patient sitting at the edge of a bed and leaning over a working table. But appropriately positioned, we'll clean the skin, drape, and then select entry and exit sites for the tube, inject some local anesthesia in both these sites, and then once that has set some time to settle, we'll make two skin incisions here, create a tunnel where our PleurX catheter will tunnel between the anterior skin entry site and the posterior pleural space entry site. Set that aside. And then, access the pleural space in the posterior site first with a small sheath through which we'll insert a guidewire. And over the guidewire in serial fashion, we'll place first a dilator and then a breakaway sheath. And through the breakaway sheath, we'll insert the PleurX catheter. Once the sheath is removed and the PleurX is in place, we will close the skin at the posterior site, dress that separately, and then evacuate the pleural space to the degree that we think is appropriate, usually a liter or a liter and a half at any one drainage to prevent re-expansion pulmonary edema, which is quite significant when it does happen, although it's a rare event. And we'll secure the tube to her skin with just a dressing. And then, she should be good to go to the recovery room.

CHAPTER 2

You're just gonna feel me washing you with a little bit of cold soap.

CHAPTER 3

All right, so our first concern when we're placing a PleurX catheter is to find an acceptable site for the tube to exit her skin. And we want that to be in a location that she's gonna be able to access. And then, we want the tube to actually enter the pleural space a little bit more posteriorly, and that creates enough of a tunnel to serve as a barrier for infection. Can I see a marking pen, please? So, usually right here at about the costal margin is where you want your tube to exit. So, we'll mark a spot right here. And then, she has very small rib spaces, but I think we would find an acceptable site for the tube to enter about back here. So, we'll mark these two spots.

CHAPTER 4

And the next most important part here is, and this is true for any bedside procedure, any procedure where we're gonna be having a patient who's awake, is that we wanna give our local anesthesia upfront and we wanna give it before, with enough time that it can really sink in before we start doing anything. So, why don't you do skin wheals at both of these sites? A little pinch and burn here, okay? Just a couple of seconds. Make it nice and numb for you. So, we'll raise a nice skin wheal where we anticipate the tube exiting the skin, and another skin wheal where we anticipate the tube actually entering the pleural space. And then, at this posterior site, we'll now switch for the longer needle, please. We wanna go in and make sure that we can actually aspirate pleural fluid here at this site. So we're gonna go down and hit the rib, and then go just up above it into the pleural space while aspirating, and make sure that we can really aspirate some pleural fluid. Which, it looks like we are not getting any pleural fluid. Hmm. So maybe we'll choose a different site here. So small. Let me see that for a second. I'm on rib there. I'm walking up over the rib. And aspirating. And we're not getting anything. Hmm. Let me try one more thing here. Go up a little bit higher. So, we're getting fluid there. That is a little bit more posterior than maybe you'd like your tube to be. What I'm gonna do is just inject some local on the way out there. I'm trying to get that whole track anesthetized, and then we'll use a little bit more and raise another skin wheal up right here. And I think what we'll do now is just move the skin exit site a little bit more anterior, so the tunnel is not so long. All right, needle back.

CHAPTER 5

So, while we're waiting for that to kind of set in, we'll just go over the elements of the PleurX kit here. So, this is the tube itself, which comes with a tunneler that we loaded on. We're gonna use this to create the tunnel between the skin entry site and where it enters the pleural space. The tube has a small cuff on it that it's designed to keep it in place without needing to be secured by a suture. It takes a few weeks for the scar tissue to set in around that cuff. There's obviously a scalpel for making our skin incisions. And this is gonna be our insertion sheath through which we'll place first a guidewire, then a dilator, and then a breakaway sheath. And through the breakaway sheath, we're gonna put our PleurX catheter. Knife.

CHAPTER 6

So make a nice 11 blade skin nick here. That should be good. And then, we'll do another one here at the entrance site for the tube.

CHAPTER 7

And next, we'll take the tube itself with the tunneler. And then use that to create a tunnel between the skin entrance site and the insertion site. And even though we didn't anesthetize this tract, as long as we stay away from the skin and the deeper chest wall, it's surprisingly insensitive, so you really don't need to locally anesthetize the tract. Okay, so our tunneler pops out here. I'll pull the tube all the way through, and then try to get the cuff just deep to the skin incision. That makes these tubes much easier to remove in the office. If the cuff is buried very close to the entry site in the chest, then you really have to dig around for it if you're trying to remove it in the office. So, I'll give that to you to control for a second.

CHAPTER 8

Pass the tunneler back. And then, next, we're gonna take the insertion sheath and the guidewire, please. So, going alongside the tube now. And following that same track on which we got fluid before. You can see we're aspirating a good deal of pleural fluid here. And I just sort of Seldinger the sheath into the chest. And then, I might just check again to make sure that I'm still aspirating pleural fluid, which I am.

CHAPTER 9

As much as I can, I try to occlude the syringe. This may make you cough a little bit. The wire tends to irritate the plural space, but it really should go very smoothly. This goes back.

CHAPTER 10

Next, we'll pass the dilator. And after this, we'll take a breakaway sheath. The dilator only needs to go in a very superficial amount just to get beyond the ribs.

CHAPTER 11

And finally, we take the breakaway sheath. Lots of pressure.

CHAPTER 12

Once that's in place, you can remove the wire. We remove the inner part of the breakaway sheath, and again, occlude with your finger.

CHAPTER 13

And we'll place the catheter through it. And begin the process of breaking away the sheath, while we feed the tube in more. And then, we should be able to dunk it the rest of the way manually.

CHAPTER 14

All right, so that should now be in the pleural space. If we wanna confirm that, we're gonna take that adapter setup that I have there. So, this piece interfaces with the cap on the PleurX, and this is the adapter that one would use to connect a PleurX to a chest tube. You have the sputum trap and the suction tubing. All right, so our suction's on, so we open the tube up to suction and we'll collect some pleural fluid. We're gonna do this a few times. Send this for some... So let's, yeah, we can... So we can switch off, if you wanna just give me the... And just dump that into the... Okay, that should be enough. And then we'll just drain the rest of this effusion. And probably wise to limit drainage to about a liter, a liter and a half. How much did we take out for the sample there? We took out at least - about 120. Okay. Actually about 200. Yeah, and usually, coughing is a sign that it's time to stop draining. So then, we'll just disconnect that apparatus. Can I have that cap that comes with the PleurX, please? So, we'll cap the PleurX.

CHAPTER 15

We'll close the deep layer here associated with the insertion site. Do you have the - there's a Vicryl that comes in the kit. Just kind of one deep layer here. And then, we'll cover the insertion site with some glue. I'll take an Adson, please. You're doing great. Almost done. Slow deep breaths. Can she have the Dermabond? And the scissors, please? Or a knife. Knife's fine. And a little bit of glue to dress the insertion site separately. And then, I try not to secure the tubes to the skin with any suture, because it tends to not get removed in a timely fashion. I'll take the foam dressing that comes with it and the big Tegy. So instead, we kind of tape it up in a way that it's difficult to accidentally pull it out. Okay. We can take the drapes down. Okay.