Chronic long-term indwelling tunneled pleural catheters
Indwelling pleural catheters (IPCs) represent an alternative to pleurodesis for patients with malignant pleural effusion whose dyspnea has responded to thoracentesis. IPCs are relatively contraindicated in patients with a short life expectancy, pleural infections, multiloculated collections, and chylothorax. The insertion of chronic long-term indwelling tunneled pleural catheters is useful against recurrent and symptomatic malignant pleural effusions, including for patients with trapped lung. These tunneled pleural catheters allow up to 96% of patients to achieve symptom improvement, with spontaneous pleurodesis occurring in up to 44% of patients. Published results indicate significantly shorter hospital stays (1 day) for patients with IPCs versus the doxycycline pleurodesis group (6 days). In the IPC group, spontaneous pleurodesis was achieved in 42 of 91 patients. Both the IPC group and doxycycline pleurodesis group reported modest improvement in quality of life and dyspnea. A randomized controlled trial comparing IPC and talc pleurodesis showed similar reduction of dyspnea (24 mm of 100 mm) and similar quality of life. IPC use was associated with a shorter initial hospitalization and lower rates of re-treatment, with a spontaneous pleurodesis rate of 51%. However, there were also higher rates of adverse effects, such as infections and catheter blockage. The choice between IPC and pleurodesis should be based on patient preference and local resource availability.
Use of pleural sclerosing agents after chest tube drainage
Chemical sclerosants may be administered through a chest tube to create inflammation and subsequent fusion of the parietal and visceral pleura so that fluid cannot reaccumulate in this potential space. This kind of fusion is called pleurodesis. Numerous chemical agents can cause the irritation necessary to produce pleurodesis. The ideal agent would produce effective pleurodesis with minimal cost and minimal side effects. Agents that have been studied include chemotherapeutic agents (bleomycin, cisplatin, etoposide, doxorubicin, mitomycin-C, fluorouracil), antibiotics (doxycycline, minocycline, tetracycline), infectious agents (Corynebacterium parvum), biological agents (interferon beta, interleukin-2), bovine dermal collagen,[Level of evidence: II] and other agents (talc, methylprednisolone). Several uncontrolled trials and case series report the efficacy of pleurodesis,;[14,15][Level of evidence: II];[16,17] as do numerous randomized trials.[18,19,20,21,22,23,24][Level of evidence: I] A meta-analysis of pleurodesis studies that were reported between 1966 and 1992 indicates that about two-thirds of patients respond to pleurodesis and that tetracyclines (or tetracycline replacement agents, such as doxycycline and minocycline), bleomycin, and talc appear to be the most effective agents. A prospective, randomized study of video-assisted thoracoscopic pleurodesis with talc versus doxycycline in 33 patients with malignant pleural effusion suggests that talc provides superior short-term and long-term results.[Level of evidence: I] Talc appears to be the least expensive agent, at least when given as a slurry rather than by video-assisted thoracoscopic talc insufflation.[Level of evidence: I] Bleomycin, however, is the only agent approved by the U.S. Food and Drug Administration for the prevention of recurrent pleural effusions. An observational cohort study investigated the use of intrapleural urokinase in 48 patients with loculated pleural effusions or trapped lungs. Lung reexpansion and resolution of dyspnea occurred in approximately 60% of patients, suggesting that intrapleural urokinase may be useful in treating loculated pleural effusions or trapped lungs in medically inoperable cancer patients. Most responders successfully maintained pleurodesis when urokinase was followed by minocycline pleurodesis.[Level of evidence: II]