Pleural space infection is a highly prevalent condition that is associated with substantial morbidity, mortality, and increased hospital costs.1–3 Surgical management with decortication and/or pleural obliteration procedures (thoracoplasty and muscle flap transposition) is often required in patients with chronic pleural infection and nonexpandable lung.3–6 These are highly invasive procedures requiring patients to tolerate prolonged surgical time and single lung ventilation.5 These procedures are also associated with increased hospital stay,6 significant mortality (3.4%) and morbidity, including air leaks (2.6%), hemorrhage (3.0%), wound infection (2.6%), and need for reintervention or further drainage (6.8%).7 Hence, patients with chronic pleural infection and a nonexpandable lung, who are considered unfit for a major surgical procedure, have limited treatment options, such as open window thoracostomy (ie, Clagett window or Eloesser flap).8,9 Unfortunately, these procedures are associated with significant morbidity (reported between 5% and 18%), decreased quality of life, chest-wall deformity, and chronic pain.8,10–12
“Empyema tubes” (cutting the tube near the skin and securing the end with a sterile clip to allow for open pleural drainage) have been proposed as an alternative to chronically drain the pleural space in this population in a recent case series of 8 patients.13 Despite limited evidence, tunneled pleural catheters (TPCs) may represent an alternative, since it offers better patient quality of life (tube not attached continuously to a drainage system) and higher patient safety (as TPCs are unlikely to dislodge).14 Hence, these devices could represent a feasible alternative for long-term pleural drainage for this patient population.15,16
We report our experience using TPCs as an alternative to drain (and obliterate) residual pleural space in patients with pleural infection and nonexpandable lung.
A retrospective study was conducted at Beth Israel Deaconess Medical Center (IRB 2015P000008) with a waiver of consent. Consecutive patients with a history of pleural infection and a nonexpandable lung treated with TPC placement were included in this study. A total of 1054 cases were identified by searching hospital billing records for CPT codes related to TPC insertion (32550) between January 2010 and March 2018. Following the revision of records, 11 patients were identified of having TPC placed due to pleural infection with ICD codes: ICD-10: J86.9 and J86.0/ICD-9: 510.9 and 510.0. Records were reviewed for patient demographics, comorbidities, microorganism isolated from pleural fluid, TPC insertion technique, number of days between TPC insertion and discharge, number of days between TPC insertion and removal, and number of days until latest medical follow-up. Complications were also recorded.
All patients with proven pleural infection had been treated per protocol with antibiotics, tube thoracostomy and intrapleural fibrinolytic therapy (tissue plasminogen activator and deoxyribonuclease) as described previously17 and as per protocol followed at our center. Patients were considered for TPC if they had (1) clinical evidence of a persistent pleural infection, (2) radiologic evidence of a nonexpandable lung on chest imaging, and (3) poor candidacy for major surgery (decortication) as determined by our thoracic surgery team or declined surgery.
Eight patients had the TPC placed at bedside under sonographic guidance using a modified Seldinger technique.
Three patients had the TPC placed under thoracoscopy (medical, n=2 and video assisted, n=1) as they required mechanical debridement of pleural space since they did not adequately respond to intrapleural fibrinolytic therapy. None of these patients were candidates for decortication: either due to limited life expectancy (patient 8) or because they declined more invasive surgery beside mechanical debridement (patients 5 and 11). During these procedures, interventions were limited to pleural adhesiolysis and pleural space washout with further tunneling and insertion of TPC. Following TPC placement, patients were instructed to drain the TPC daily and were scheduled for outpatient follow-up in 2 to 3 weeks. Antibiotic therapy was continued in the ambulatory setting for 4 to 6 weeks based on individual antibiogram susceptibility results. The TPC was removed in the interventional pulmonary outpatient clinic after clinical improvement, the catheter drainage was <50 mL per day for 3 consecutive days and chest imaging (chest ultrasound and/or computed tomography) showed <200 mL of residual pleural fluid. The fluid volume on ultrasound was calculated by measuring the interpleural distance at maximum inspiration. The measurement is made above the diaphragm’s superior margin with a distance of <15-mm extension corresponds to an average volume of ≤200 mL.18 The pleural effusion volume was quantified using the OsiriX digital analysis program (OsiriX Imaging Software, v3.6.1; OsiriX Foundation, Geneva, Switzerland) reconstructed from patients’ chest computed tomographic scanning images as described previously by our group.17 Descriptive statistics were used to describe patient demographics and outcomes.
Eleven patients (7 men and 4 women) were included with median age 70 years. The baseline demographic, clinical, medical comorbidities and microbiological characteristics of the patients are shown in (Table 1).
The median time between TPC insertion and hospital discharge was 5 days. Seven patients had the TPC removed within a median of 36 days. Three patients passed away with the TPC due to their terminal illness without TPC-related complications. One patient was seen for 45 days following TPC placement and then was lost to follow-up (Table 2).
Three patients had residual loculated pleural effusions after TPC placement which resolved with intrapleural fibrinolytic therapy. One patient had soft tissue infection at the site of catheter insertion along with worsening pleural space infection. Unfortunately, this patient was noncompliant with TPC management (daily drainage, proper hygiene on catheter insertion site, and close outpatient follow-up). The combination of these factors was deemed as the cause for soft tissue infection and further TPC failure. This patient underwent open window thoracostomy (Table 2).
TPCs are being increasingly used in clinical practice as a minimally invasive method to drain recurrent malignant pleural effusions. Pleural space infection is regarded as an indication to remove TPC if such an infection is not adequately controlled with drainage and antibiotics. However, a small case series reported that such drainage catheters were used to successfully drain complicated pleural space infections in patients with a nonexpandable lung.15,16 We expand on this evidence, by reporting our experience using TPCs as an alternative to chronically drain an infected pleural space in a selected patient population (Fig. 1). This modality is comparable with empyema tubes. However, the advantages of TPC approach is that (1) it is more securely attached to the patient via the cuff without fear of chest tube dislodgement, (2) more convenient to apply intermittent suction to it via the evacuated drainage bottles, and (3) more comfortable to the patient than a traditional tube. Such treatment may favor earlier hospital discharge and eventual infection resolution with ambulatory management and close outpatient follow-up. This may be particularly valuable in the setting of terminally ill patients, as it may allow this population to spend their last days away from a hospital despite the existence of pleural space infection as well as in patients not considered fit for a decortication or decline an open window thoracostomy.
Appropriate patient education with regard to TPC, outpatient clinical follow-up, and patient’s ability to properly care for the catheter is fundamental to achieve adequate treatment goals with this technique. If these circumstances cannot be secured, more definitive treatment alternative, such as an open window thoracostomy should be pursued as demonstrated by one patient in our cohort who was noncompliant.
This study has limitations. This was a retrospective case series with a small sample size that needs to be validated in a large multicenter study.
TPCs are a minimally invasive alternative that may effectively drain chronic pleural space infections in a selected group of patients with a nonexpandable lung in whom invasive treatment options that include surgical decortication are not feasible or not desired.
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