Despite recent advances in the management of pleural effusions, such as the introduction of indwelling tunneled pleural catheters (IPCs) and medical pleuroscopy, the treatment of hemothoraces has not changed in decades. The general consensus is that hemothorax should be treated with tube thoracostomy, regardless of its cause.1–3 Often, a large-bore chest tube placement is recommended.1,2 To our knowledge, a hemothorax has never been treated with the placement of an IPC. We describe 2 patients with hemothorax and malignancy who were successfully treated with an IPC alone. Our experience suggests that in selected patients, this approach may be safe, effective, and provide the most comfortable treatment option.
A 65-year-old man with metastatic colon cancer presented to the hospital complaining of significant dyspnea during the previous 24 hours. His medical history included a malignant right pleural effusion found several months before and a deep venous thrombosis and pulmonary embolism, which were felt to be secondary to his malignancy. The right pleural effusion was drained once at initial diagnosis and had not recurred. The patient also had hypertension and coronary artery disease and was on warfarin, spironolactone, and losartan. Upon hospital arrival, blood pressure was 85/54 mm Hg, respiratory rate was 18 rpm, and heart rate was 88 bpm. He was in no distress, although he had significantly diminished breath sounds to auscultation in the lower left hemithorax and dullness to percussion at the same area. Physical examination was otherwise unremarkable. Chest x-ray (CXR) demonstrated a moderate-to-large left pleural effusion (Fig. 1). Hemoglobin was 11.4 g/dL and international normalized ratio (INR) was 3.88. Warfarin was discontinued, and the patient was given intravenous fluids and fresh frozen plasma (FFP) before a left thoracentesis. The blood pressure rapidly improved with fluid resuscitation. Pleural drainage was limited to approximately 1800 mL of bloody fluid, due to concerns of reexpansion pulmonary edema. The pleural/serum hematocrit ratio was >0.5, confirming a hemothorax. The fluid also demonstrated malignant cells consistent with metastatic colon cancer. The next day, his INR was 2.09, and a CXR demonstrated residual left pleural fluid, but not increased from the postthoracentesis CXR. Additional FFP was given and a second thoracentesis was performed with additional 1700 mL of bloody fluid drained. Two days later, with the INR down to 1.65, a CXR demonstrated a tiny left pleural effusion. Dyspnea was much improved, an inferior vena caval filter was placed, and he was discharged home without warfarin. His left hemothorax was felt to be secondary to a combination of anticoagulation and malignancy. He was seen as an outpatient 2 weeks later with worsening dyspnea, and a CXR demonstrated recurrent moderate-to-large pleural effusion. His hemoglobin had dropped from 10.8 to 8.9 gm/dL. Given the patient's overall clinical status and poor prognosis, a left IPC (Pleurx; Denver Biomedical; Golden, CO) was placed and the fluid drained was also noted to be consistent with a hemothorax. Approximately 3000 mL of fluid was drained immediately in the first 3 hours after catheter placement. He was advised to drain his left chest every other day, and during the first week after the catheter placement, approximately 1500 mL of bloody fluid was drained each time. Five days after the catheter placement, his hemoglobin was noted to be 7.8 gm/dL without any other obvious source of bleeding, and 2 units of packed red blood cells were transfused. Posttransfusion hemoglobin was 10 gm/dL. Thereafter, the amount of drainage from the catheter rapidly decreased and his hemoglobin remained stable throughout the following weeks. Pleural fluid drainage ceased 4 weeks after the catheter placement. He then had an embolic stroke and full anticoagulation was resumed. CXR performed approximately 1 week later, while on full anticoagulation failed to demonstrate any significant left pleural effusion (Fig. 2). He was scheduled to have his IPC removed, but had another massive stroke and died before this could be performed.
A 34-year-old African American woman with metastatic infiltrating ductal carcinoma of the left breast presented with progressively increasing dyspnea over a week. Three months before the index presentation, she had been diagnosed with pulmonary embolism, which was managed with warfarin. Her cancer was initially treated with neoadjuvant chemotherapy and modified radical left mastectomy, followed by radiation. Unfortunately, she had disease progression and metastases to the supraclavicular lymph nodes, bone, and liver, so she came to our institution for a second opinion.
Upon arrival to the emergency center, her vital signs were as follows: blood pressure 120/74 mm Hg, temperature 37.2 degrees Celsius, heart rate 127 bpm, respiratory rate 20 rpm, and SpO2 98% on room air. Physical examination revealed absent breath sounds and dullness to percussion in the left hemithorax. CXR demonstrated complete opacification of left hemithorax with contralateral mediastinal shift (Fig. 3). Laboratory data showed hemoglobin of 8.7 g/dL, hematocrit 26.3%, and INR 5.44. The patient was given FFP and Vitamin K, and the warfarin was discontinued. Ultrasound-guided left thoracentesis was performed, and 2100 mL of bloody fluid was drained. Drainage was stopped due to chest pain, and postprocedure ultrasound demonstrated residual pleural fluid. Pleural fluid analysis showed an exudate with malignant cells and a pleural fluid/serum hematocrit ratio was >0.5, thus confirming hemothorax. Postprocedure CXR demonstrated continued opacification of the left hemithorax, but without mediastinal shift. The hemothorax was postulated to be secondary to a combination of her anticoagulation and malignancy. The next day, her INR was still elevated at 2.62 and she continued to be dyspneic. Additional FFP was administered, and a left IPC (Pleurx; Denver Biomedical; Golden, CO) was placed. Approximately 1000 mL of fluid was drained, and the catheter was connected to a pleurovac for continuous drainage for total of 3 days. Postprocedure, the patient received additional FFP to correct the coagulopathy, and a blood transfusion (2 units of packed red blood cells) was also given. Radiographic and symptomatic improvement was noted, and as coagulopathy normalized, the pleural fluid changed to a clear serosanguineous color. An inferior vena cava filter was then placed, and the patient was discharged home with close follow-up and daily drainage. Five weeks after catheter placement, the CXR showed more than 80% pleural apposition on the left side without significant additional drainage, and the IPC was removed. Follow-up CXR 2 months after removal showed no reaccumulation of pleural effusion (Fig. 4).
We believe that these hemothoraces were likely secondary to a combination of malignancy and anticoagulation. As the fluid reaccumulated while off warfarin, and once adequately treated, did not reaccumulate even after full anticoagulation was resumed in case 1, it is possible this patient's pleural effusion was mainly related to his malignancy; however, the second case was more clearly exacerbated by the anticoagulation.
The rationale for treating hemothoraces with large-bore chest tubes has included the concerns that small-bore chest tube would not have sufficient flow capacity to decompress a brisk intrathoracic bleed and also that clotting blood would clog smaller bore chest tubes. Although this may be appropriate concern in a trauma patient with rupture of large intrathoracic vessels, in the nontrauma patient with cancer with malignant involvement of the pleura, bleeding is much more likely from smaller, ectatic vessels infiltrating the pleura.
The placement of IPCs has been shown to be safe and effective in the treatment of malignant pleural effusion.4–6 Spontaneous pleurodesis has been reported to occur in up to 58% of patients.4 The use of IPCs has also been demonstrated to be useful for the treatment of trapped lung syndrome associated with malignant pleural effusions,7 chylothorax in individuals with cancer,8 and in chronic pleural infections.9 Yet, the use of this catheter in hemothoraces has not been studied.
In our experience, patients with cancer who present with findings suggestive of hemothorax are most often treated with large-bore chest tubes in a manner similar to trauma patients. Tremblay and Michaud5 have suggested that the pleural apposition achieved with IPCs along with local inflammatory changes induced by pleural effusion malignant cells or the IPC itself can achieve pleurodesis without the administration of a sclerosing agent. Probably in both our cases and perhaps in malignant hemothoraces in general, we believe that the presence of fresh blood with its innumerous inflammatory mediators might actually contribute to the pleurodesis as well.
These 2 cases raise the question whether the classical approach to hemothorax with the placement of a large-bore chest tube applies to patients with malignancy presenting with hemothorax in the absence of trauma. We hypothesize that the placement of an IPC can be a safe, effective, and comfortable method of treatment for patients with malignancy-associated hemothoraces, perhaps with decreased hospital stay and lower morbidity.
1. Light RW, Lee YC, et al.Mason RJ, Murray JF, Broaddus VC Pneumothorax, chylothorax, hemothorax, and fibrothorax Murray and Nadel's Textbook of Respiratory Medicine.. 20054th ed Philadelphia, PA Elsevier Saunders:1978–1980
2. Eckstein M, Henderson S, et al.Marx JA, Hockberger RS, Walls RM Thoracic trauma Rosen's Emergency Medicine: Concepts and Clinical Practice.. 20066th ed St. Louis, MO Elsevier:464–465
3. Kosowsky JMMarx JA, Hockberger RS, Walls RM. Pleural disease Rosen's Emergency Medicine: Concepts and Clinical Practice. 20066th ed St. Louis, MO Elsevier:1152
4. Musani AI, Haas AR, Seijo L, et al. Outpatient management of malignant pleural effusions with small-bore, tunneled pleural catheters Respiration.. 2004;71:559–566
5. Tremblay A, Michaud G. Single-center experience with 250 tunnelled pleural catheter insertions for malignant pleural effusion Chest.. 2006;129:362–368
6. Warren WH, Kalimi R, Khodadadian LM, et al. Management of malignant pleural effusions using the Pleur(x) catheter Ann Thorac Surg.. 2008;85:1049–1055
7. Pien GW, Gant MJ, Washam CL, et al. Use of an implantable pleural catheter for trapped lung syndrome in patients with malignant pleural effusion Chest.. 2001;119:1641–1646
8. Jimenez CA, Mhatre AD, Martinez CH, et al. Use of an indwelling pleural catheter for the management of recurrent chylothorax in patients with cancer Chest.. 2007;132::1584–1590
9. Davies HE, Rahman NM, Parker RJ, et al. Use of indwelling pleural catheters for chronic pleural infection Chest.. 2008;133:546–549