Bilateral Indwelling Pleural Catheter Placement for Advanced Non-small Cell Lung Cancer with Recurrent Pleural Effusion

Pleural effusions are frequently observed in a variety of conditions. Reasons for intervention include obtaining an underlying diagnosis as to the cause and providing symptom relief. One of the most frequent causes of a recurrent pleural effusion is malignancy, which will typically continue to accumulate for as long as the cancer is progressing. When patients have a rapidly recurring effusion, requiring frequent intervention by way of thoracentesis or chest tube, other options for management are considered. An indwelling pleural catheter (IPC) can be offered to a patient to help drain the effusion on a regular basis, without requiring repeat thoracentesis. The goal of the drain placement is to provide symptom relief, and it is often in place for as long as the patient has an appreciable effusion that can be drained intermittently by vacuum canisters.

Indwelling catheter; recurrent pleural effusion; malignancy; malignant effusion; pleural drain.

Malignant pleural effusions are very common in the cancer patient population. They have been appreciated in many various forms of malignancy but are most commonly associated with lung and breast cancer.¹ Not all patients are symptomatic, but when they do develop symptoms, intervention is necessary. While thoracentesis is an effective modality for removing excess pleural fluid, depending on the course of the patient’s cancer, the fluid can sometimes rapidly accumulate, which could mean that a patient may require a repeat procedure performed as frequently as every week. To prevent the patient from having to undergo repeat procedures on a regular basis, which can be a taxing process and puts the patient at risk for infection, pneumothorax, and bleeding, the concept of an indwelling drain was developed so that the fluid can be drained as needed. This will help prevent the patient from having to seek medical attention on a regular basis for dyspnea from a known pleural effusion, and they can manage their effusion at home with a simple vacuum canister and avoid going to the hospital. They have become extremely popular for these reasons so that the patient can self-manage and control their symptoms. The frequency by which a person may drain their chest tube depends but can be as frequent as every other day.²

Indwelling pleural catheters (IPCs) are appropriate for malignant effusions as they are exudative in nature and are less capable of becoming infected. Malignant pleural effusions are the second most common cause of exudative effusions in patients.³ Transudative effusions have low protein content, and studies have shown they are more susceptible to infection. The rate of catheter infection is overall very low and is typically not life threatening. Common offending bacteria are Staphylococcus aureus and species of Streptococcus.

Pleurodesis has been considered for the management of recurrent effusions as well; however currently, IPC are often considered first-line therapy. The catheters are well tolerated and are considered to have less adverse events associated with them. Pleurodesis is also not guaranteed to work, so an IPC catheter may need to be considered anyway.³

For IPC placement, primary concerns for the patient are the underlying cause of the malignancy and life expectancy. It is generally thought that if a patient’s life expectancy is at least 3 months, they could benefit from an IPC if they are already experiencing recurrent effusions requiring frequent thoracentesis. Typically, if a patient is requiring a thoracentesis about once every 4–6 weeks, it is reasonable to consider offering an IPC if the cause of the effusion is likely to persist (for example malignancy). Other considerations would be anticoagulation and antiplatelet use. These medications should be held prior to drain placement for the appropriate amount of time to prevent chest wall complications and hemothorax. 

This patient had advanced non-small cell lung cancer with recurrent bilateral pleural effusions for which he had already had repeated thoracenteses on each side. Each time he had a thoracentesis he had symptomatic relief, thus justifying the placement of bilateral IPCs.

Physical exam findings should include typical preoperative assessment including vitals and evaluation of the chest wall. Ideal placement of the drain will depend on their chest wall anatomy, specifically if there are any infections on the skin, obvious metastases, or any other process that may prevent chest tube placement. Typically, chest tubes are placed laterally and to a degree anteriorly to make it easier for the patient to access the chest tube themselves. If it is placed too posteriorly, then it can make it hard for the patient to be able to sleep comfortably.

To evaluate the patient for the drain placement, chest radiograph and ultrasound imaging would be appropriate to start the work up. First, it is necessary to check that the effusion is indeed recurrent and large enough to benefit from IPC placement. Next, it is essential as above, to make sure that there are no metastases that the drain would potentially be going through prior to advancing into the pleural space. If there are any concerns about the chest wall and pleural space, CT chest would be beneficial for further detailed review. It is important to not place the catheter through not only bony or soft tissue metastasis, but also pleural plaques or pleural-based metastases too.

As mentioned above, location of the IPC may be affected by any metastasis or other chest wall abnormalities. If a metastasis is in the lateral location that would have been considered initially, a more posterior approach may need to be considered. Also, antiplatelet and anticoagulant use prior to the procedure need to be assessed to minimize risk of bleeding. Also to note, the fluid must appear simple in nature to be effectively removed by the drainage catheter. If it is not simple or is too loculated, then an IPC will not be effective.

The procedure begins with placing the patient in an ideal position for catheter placement. This can be either with the patient lying on their side so that the side with the effusion is up and away from the table. Another option is for the patient to be sitting in a reclined position with the arm on the affected side elevated and behind their head to avoid the sterile field. Here the patient is lying on his side. 

After the patient has been positioned and the patient is comfortable, the pocket of pleural fluid is identified by ultrasound. The skin is marked for the best entry site laterally and for the site at which the catheter will come out of the skin anteriorly, which is where the catheter will be accessed to drain the fluid. A track is going to be formed between these two sites. The area is prepped in a sterile manner with chlorhexidine and draped. The fluid pocket is reassessed under sterile conditions. The skin is then numbed with lidocaine and then a track with lidocaine to the pleural space is made until the pleural space is reached. When there is fluid return, it is evident you are in the pleural space. Lidocaine should not be placed while removing the needle to prevent seeding of a malignancy.

Next, the track is made in the subcutaneous tissue between the two sites that were identified on the skin from the lateral to the anterior mark. To make sure that the entire track is numb, the track should have lidocaine injected from both directions. The track will be about 6–8 cm long. 

Attention is brought back to the posterior lateral mark. A hollow needle is inserted into this site and advanced until pleural fluid is able to be withdrawn. Once in the pleural space, a guidewire is advanced into the pocket of pleural fluid. The guidewire is advanced in 30 cm (three dashes on the wire) to ensure that the wire is securely in the pleural space. The needle can come out with the wire remaining. Confirmation of the guidewire in the pleural space is confirmed with ultrasound prior to any other interventions being done.

A small cut is made on top of the wire about a centimeter deep. Then another cut is made at the anterior site so that a track can be made. The catheter is attached to a metal rod and starting from the anterior cut, the metal rod is advanced towards the lateral posterior cut that has the wire. This is done while holding the skin tight to make a straight path. Once the metal rod has made it to the other cut site with the wire, the metal rod is pulled out and the catheter is now going under the skin. The plastic catheter should be advanced until the cuff on the catheter is sitting approximately in the middle of the subcutaneous tissue making up the track. Some with personal preference may leave the cuff closer to the anterior cut site. As it can be challenging to advance the catheter, it may be necessary to squeeze the catheter as you are pulling it through the tissue. The rod is removed from the catheter now, and the catheter is temporarily secured while the next step is performed.

Over the guidewire, a dilator is now placed that dilates through all of the subcutaneous tissue into the pleural space. After the first dilator, another one is used that has an extra layer. The inner portion of the dilator and the guidewire are now removed and pleural fluid then starts to leak from the site. Cover the site temporarily with your finger until the end of the catheter can be obtained. Then take the catheter end with the hole and feed it into the dilated site until it is flush to the skin. Then the sheath can be broken and removed from the skin, while pushing the catheter into the tissue as much as possible. This portion of the catheter should be completely hidden from view. Also check to make sure that the catheter is not kinked. The catheter is now ready to be tested, and the adapters are added to open the channel and attach it to the suction canister. A small volume is removed from the space to make sure that the catheter is working. A suture is then placed over the posterior insertion site to close the hole. The site is closed with multiple surgical knots. The anterior site also has a stitch placed to maintain the IPC and keep it in place. Additional fluid can be removed as appropriate to help with the patient’s symptoms. 

After the site is cleaned, Dermabond is placed over the posterior lateral site to help seal it. The tubing is then disconnected, and a sterile cap is placed on the end of the tube. The tubing is then wrapped on itself and covered in a sterile dressing. This consists of a foam pad closest to the skin, followed by the coiled tube, then a few 4x4 gauze squares and finally a large clear adhesive dressing. 

As this patient had bilateral recurrent effusions, this procedure was repeated for a second time on the other side as well. 

As described in the video, an IPC is the device that is being placed into the patient. This will be attached to a metal rod to guide its placement under the skin. Additional equipment that will be required include: sterile fields, bedside ultrasound with a sterile probe cover, scalpel, lidocaine with syringe, guidewire, introducer needle, suture, dilators, sterile dressing supplies, and a suction canister. If performing the procedure bilaterally, you will need two sets of everything to complete the task.

Nothing to disclose.

The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.