Introduction
Indwelling pleural catheters are used in the treatment of recurrent malignant pleural effusions. Recurrent pleural effusions recur despite treatment and typically require repeated thoracentesis (a procedure to remove the fluid from the pleural cavity). Indwelling pleural catheters have emerged to be an effective method to relieve dyspnea (shortness of breath) in patients with malignant effusions, improving their quality of life. Indwelling pleural catheters have also proven effective in nonmalignant pleural effusions.
What Are Indwelling Pleural Catheters?
An indwelling pleural catheter is a soft, flexible silicone tube that is small. This catheter is inserted into the chest to remove pleural fluid from the lungs. The intrapleural catheters are inserted into the pleural cavity or the pleural space between the lungs and the thoracic cavity wall. These catheters drain the excess pleural fluid and improve the breathing of the patient. These catheters have emerged as an effective management strategy for treating and controlling recurrent pleural effusions. Usually, thoracentesis is performed to treat pleural effusions. The healthcare provider recommends the placement of an intrapleural catheter if pleural effusion and shortness of breath recur.
What Are the Complications Associated With Indwelling Pleural Catheters and Their Management Strategies?
An indwelling intrapleural catheter insertion may be associated with the following complications:
Procedure-Related Complications:
In most cases, procedure-related complications are acute and similar to those observed during any pleural interventional procedure. This includes bleeding, skin infections, pneumothorax (air leak into the space between the lungs and the chest wall resulting in lung collapse), and subcutaneous emphysema (a condition in which air infiltrates under the skin’s dermal layers). Pneumothorax is common in cases of trapped lungs. Procedure-related complications are usually treated similarly to complications during other pleural interventional procedures.
Catheter-Related Complications:
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Pleural Infection:
Pleural infections due to catheter placement are usually mild and can be managed with antibiotic therapy alone without having to remove the catheter. Catheter-related pleural infections are diagnosed when the patients develop signs of infection with purulent drainage of fluid. Catheter-related pleural infections can be categorized into cellulitis, empyema, and tunnel infections. Cellulitis is a serious bacterial infection of the skin and is usually treated with oral antibiotic therapy. Empyema refers to the collection of pus in a cavity that is present in the body. In pleural infections, empyema is seen in the pleural cavity. It is usually managed with continuous drainage through the catheter along with antibiotic therapy. Tunnel infections refer to tenderness, erythema (redness), and induration in the overlying tract, which extends more than 0.78 inches from the exit site of the catheter. Tunnel infections are managed with antibiotic therapy in most cases.
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Catheter Tract Metastases or Seeding:
Catheter tract metastases are not typical and are seen in less than five percent of cases. More than half of the cases reported are associated with mesothelioma (a tumor of the tissue lining the stomach, lungs, heart, and other organs). Catheter tract metastasis can be managed with intra-pleural chemotherapy subsequent to clearance of the effusion. In addition, metastasis or seeding of the cancer cells can be avoided by removing the pleural fluid through a procedure called thoracentesis prior to indwelling catheter insertion.
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Loculations:
Loculations are due to the accumulation of fibrinous materials that result in the formation of septations, leading to multiple loculations. The formation of septations and loculations impair fluid removal causing fluid accumulation. This fluid accumulation results in dyspnea (shortness of breath) and discomfort. The patients with loculations showed improvement in fluid drainage after treatment with fibrinolytic agents like Streptokinase or Urokinase.
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Chest Pain:
Patients usually experience mild chest pain after indwelling catheter placement. The chest pain usually resolves within three days after insertion of the catheter. The chest pain is usually mild and can be managed with analgesics (pain relievers). In addition, negative pressure that develops during fluid drainage through the catheter can cause chest pain. Chest pain is severe if an indwelling catheter is placed in a trapped lung. This type of pain is usually intense and refractory to medications.
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Immunosuppression and Malnutrition From Chronic Drainage:
Long-term drainage of fluid can cause significant nutritional and cellular losses. Studies have shown that 0.264 us liquid gallons of exudative pleural fluid contains 1.058 ounces of proteins. Patients with malignant pleural effusions may be immunocompromised and malnourished and may be unable to compensate for the nutritional loss due to chronic pleural fluid drainage. However, the benefits offered by indwelling catheters often outweigh the risk of immunosuppression and malnutrition.
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Dislodgement:
The rate of dislodgement after the catheter placement varies by person. It has been reported that indwelling catheter dislodgement is common in patients with malignant pleural effusions or in patients under chemotherapy. Dislodgement can be prevented by placing the anchoring suture at the site of entry of the catheter.
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Blockage:
Blockage of the catheter is uncommon and is seen in less than five percent of cases. Partial blockage is more common compared to complete blockage. Blockage in these catheters can be due to the accumulation of fibrinous exudates in and around the catheter lumen. Blockage can be managed by flushing the indwelling catheter with a saline solution. A fibrinolytic agent called Alteplase helps relieve the obstruction in the blocked catheters. Failure to properly flush to restore the patency can be followed by the use of a fibrinolytic agent to restore the fluid drainage.
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Catheter Fracture During Removal:
An indwelling catheter may fracture while removing the catheter. Catheter removal is indicated in cases of spontaneous pleurodesis and in cases of complications like empyema or intractable pain. Breakage usually occurs while attempting to release the cuff.
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Other Specifications:
The risk of infection is increased in long-term indwelling catheters in patients with hematologic malignancies. It is also increased in patients with a solid organ transplant on immunosuppressive therapy.
Conclusion
The use of indwelling catheters is significant in patients with recurrent pleural effusions and malignant pleural effusions. They are simple to place, and they improve the quality of life by relieving the patient from dyspnea. The long-term presence of an indwelling catheter can increase the risk of various complications. However, most of these complications can be managed conservatively. Some complications might require the removal of the catheter, and some cases may require aggressive surgical interventions. Despite the potential complications, an indwelling catheter remains the best treatment of choice for the management of recurrent malignant and nonmalignant pleural effusions. In addition, an indwelling catheter is an effective therapeutic modality with a low complication rate and can be inserted on an outpatient basis.
