Use of an Implantable Pleural Catheter for Trapped Lung Syndrome in Patients With Malignant Pleural Effusion*

Grace W. Pien, MD; Mary Jones Gant, MSN, RN, RRT; Cathi L. Washam, RN, BSN; and Daniel H. Sterman, MD

Study objectives: We describe a series of patients with symptomatic, refractory malignant pleural effusion (MPE) and underlying trapped lung syndrome who underwent placement of a smallbore, flexible indwelling pleural catheter for home drainage of recurrent MPE. Design: The medical records of 11 consecutive patients who underwent pleural catheter placement for MPE with trapped lung syndrome were reviewed retrospectively. Setting: Patients were evaluated and followed up in the Pulmonary Outpatient Practice at the Hospital of the University of Pennsylvania. Patients: Nine men and two women with underlying malignancies including lung cancer, lymphoma, and mesothelioma underwent pleural catheter placement. Interventions: Thirteen pleural catheters were placed in 11 patients, all under local anesthesia. Patients received detailed instructions for drainage and catheter care. They were reevaluated weekly for the first 2 weeks, and then as clinically indicated. Patients typically performed pleural drainage at home up to 1,000 mL two or three times weekly. Measurements and results: All patients reported symptomatic benefit, defined as improved dyspnea and exercise tolerance, except for one patient. In 10 patients, the pleural catheters remained in place until death, for 15 to 234 days. The mean length of placement was 115 days. One patient required revision after catheter occlusion. Other complications included catheter infection, localized skin breakdown, and possible cellulitis. Conclusion: We have described a series of patients with MPE and trapped lung syndrome for whom placement of a permanent pleural catheter provided a convenient, effective alternative to the procedures currently in use. Our patients reported good symptomatic relief following catheter placement with few major complications. (CHEST 2001; 119:16411646)
Key words: indwelling catheter; malignant pleural effusion; trapped lung syndrome Abbreviation: MPE malignant pleural effusion

leural effusions are a common and frequently P troublesome complication of advanced malignancy. The most frequent etiology of malignant pleural effusion (MPE) is bronchogenic carcinoma, which causes over a third of all such cases. Breast cancer is next in incidence, followed by lymphoma. Other causes include mesothelioma, gastric or esophageal cancer, and ovarian carcinoma.13 The development of MPE, in general, portends poor prognosis, and the mean length of survival of patients with MPE has been estimated at 6 months.4 Fre*From the Pulmonary, Allergy and Critical Care Division, Hospital of the University of Pennsylvania, Philadelphia, PA. Manuscript received June 19, 2000; revision accepted December 12, 2000. Correspondence to: Daniel H. Sterman, MD, Pulmonary, Allergy and Critical Care Division, 3600 Spruce St, Hospital of the University of Pennsylvania, Philadelphia, PA 19104; e-mail: sterman@mail.med.upenn.edu

quently, therefore, the primary therapeutic goal in MPE is effective palliation of associated dyspnea and chest discomfort. Several different palliative modalities for MPE are available to the clinician. Thoracentesis, often the initial approach to MPE, is not reliably effective for long-term control, as pleural fluid may reaccumulate rapidly in a symptomatic fashion. In one study, for instance, symptomatic MPE was noted to recur within an average of 4.2 days after thoracentesis alone.5 In recent years, palliative therapy for MPE has largely focused on chemical sclerosis of the pleural space to achieve pleurodesis, using agents such as talc, doxycycline, and quinacrine.2,6 Although talc pleurodesis has been reported to be effective in producing pleural symphysis in 80 to 90% of cases in some series of carefully selected and aggressively treated patients, a significant subpopulation of paCHEST / 119 / 6 / JUNE, 2001

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tients fails to respond.6 8 Additional patients may not be offered this therapy because they are believed to be poor candidates for successful pleurodesis. The patients with MPE who are least likely to benefit from pleural drainage and chemical sclerosis are those with so-called trapped lung. These patients have a dense peel of malignant tissue encasing the visceral pleura, and they fail to exhibit complete lung reexpansion after drainage of the effusion.9 Because apposition of the pleural surfaces cannot be achieved, sclerosis attempts are rarely successful and management for these patients has proved challenging. Therapeutic options include repeated thoracenteses, long-term thoracostomy drainage, pleurectomy with decortication, and pleuroperitoneal shunting.3,8,10 Each of these techniques, however, carries with it specific risks and liabilities, and some may not be feasible for all patients. The adaptation of small-bore catheters for prolonged inpatient and outpatient drainage of pleural effusions has been explored in a number of case reports.1114 These reports contributed to the development of a pleural catheter that may be implanted in the pleural space for the long-term management of MPE. We report herein on a series of 11 patients with symptomatic MPE and underlying trapped lung who underwent placement of a small-bore, flexible indwelling pleural catheter (Pleurx; Denver Biomedical; Golden, CO) for periodic home drainage of refractory MPE.

Materials and Methods Patient Population The charts and other medical records of 11 consecutive patients who underwent pleural catheter placement between July 1998 and December 1999 for recurrent MPE with trapped lung were reviewed retrospectively. All patients who underwent evaluation and subsequent pleural catheter placement for the indication of trapped lung at the Penn Lung Center have been included. Procedures were performed under the direction of the Director of Interventional Pulmonology at our institution. The patients included nine men and two women, ranging in age from 50 to 83 years, with a mean age of 69.4 years. The underlying malignancy was mesothelioma in six patients, lymphoma in three patients, and metastatic adenocarcinoma and multiple myeloma in one patient each (Table 1). All of the patients had respiratory symptoms due to the pleural effusions, including dyspnea at rest or with exertion and, frequently, cough. Patients were selected for pleural catheter insertion on the basis of the following: (1) advanced, unresectable pleural malignancy; (2) predicted life expectancy of at least 3 months; (3) symptomatic relief of dyspnea or other symptoms after prior thoracentesis; (4) chest radiographic findings consistent with trapped lung; and (5) failure to achieve full lung reexpansion after previous diagnostic and palliative procedures. The last criterion was important because patients who fail

Table 1Summary of Patient Characteristics and Survival*

Patient Age, No. yr Sex 1 2 3 4 5 6 7 8 9 10 11 73 72 52 75 83 76 66 79 65 72 50 Diagnosis Indication Prior Treatment Serial thoracenteses Radiation therapy, gene therapy Serial thoracenteses Decortication Pleurodesis, thoracentesis Serial thoracenteses Serial thoracenteses Serial thoracenteses Serial thoracenteses Serial thoracenteses Serial thoracenteses Survival, d 202 221 63 185 74 234 15 103 218 32 32 None Skin breakdown, cellulitis None Skin breakdown, cellulitis None Catheter infection None Catheter occlusion Catheter infection None None Complications

M Mesothelioma F M M M M M M F M M

Right MPE, TLS, dyspnea, cough Mesothelioma Right MPE, TLS, dyspnea Mesothelioma Right MPE, TLS, dyspnea Mesothelioma Right MPE, TLS, dyspnea Mesothelioma Left MPE, TLS, dyspnea, cough Multiple myeloma Right MPE, TLS, dyspnea, cough Lymphoma Left MPE, TLS, dyspnea Mesothelioma Right MPE, TLS, cough Metastatic adenocarcinoma Left MPE, TLS, dyspnea Lymphoma Left MPE, TLS, dyspnea Lymphoma Bilateral MPE, TLS, dyspnea

*M male; F female; TLS trapped lung syndrome. Catheter replaced after 65 days. Bilateral pleural catheter placement. 1642
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to achieve full lung expansion after drainage are not candidates for pleurodesis. Prior therapies in patients selected for catheter placement included thoracenteses in eight patients, and radiation therapy, attempted talc pleurodesis, and decortication in one patient each. Catheter Placement The Pleurx pleural catheter is a 66-cm-long, 15.5F, silicone rubber catheter with fenestrations along the distal 24 cm. A valve at the proximal end of the catheter prevents fluid or air from traveling along the catheter until it has been accessed by the matched drainage line. A polyester cuff helps to prevent infection and to secure the catheter in place. After placement, pleural fluid may be drained periodically from the chest into vacuum bottles by connecting the drainage line access tip to the valve.15 In all cases, pleural catheter placement was performed under local anesthesia, with use of IV midazolam and/or fentanyl for conscious sedation as needed. BP, pulse oximetry, and heart rate and rhythm were monitored continuously throughout the procedure. All but two catheter placements were performed as outpatient procedures. In one case, the patient underwent pleural catheter placement during a hospitalization for intractable dyspnea due to large bilateral pleural effusions; another patient was admitted to the hospital after therapeutic thoracentesis to await pleural catheter implantation the next day. The catheters were placed using a modified Seldinger technique in the anterior axillary line, as described elsewhere, and tunneled under the skin along the chest wall.15 After catheter insertion, 1,000 to 1,500 mL of pleural fluid was drained immediately and a chest radiograph was obtained to evaluate catheter position. Prior to hospital discharge, patients and/or their caregivers received detailed written and oral instructions for drainage and care of the catheters at home. Pain medications were prescribed as needed. Use of oral narcotics for chest wall discomfort beyond 24 to 48 h after catheter insertion was uncommon. Visiting nurse services assisted initially with catheter care and drainage and provided additional teaching to patients. We arranged for these nurses to view an instructional videotape and receive a handbook on catheter maintenance provided by the manufacturer of the pleural catheter (Denver Biomedical). Patients were reevaluated in the Pulmonary Outpatient Practice at the University of Pennsylvania Medical Center weekly for the first 2 weeks, and then as clinically indicated. Patients were instructed to perform home pleural drainage of up to 1,000 mL per session on an as-needed basis. Some patients required drainage as

often as three to four times per week, while others required drainage only once every 1 to 2 weeks. Patients were evaluated in follow-up for improvement in respiratory symptoms and pleural effusion on chest radiographs, and for complications of the pleural catheter placement. The frequency of drainage was reduced if pleural fluid drainage decreased in conjunction with symptomatic improvement. These decisions were made in regular follow-up clinic visits with us or with the patients referring physician, and occasionally in telephone follow-up (eg, for a patient receiving hospice care). Results Details of the patients and their course and survival are summarized in Table 1. Thirteen pleural catheters were placed in 11 patients: 1 patient had large bilateral effusions and underwent bilateral pleural catheter placement; another patient required catheter revision, described below. All patients tolerated implantation of the pleural catheter uneventfully. Frequency and volume of pleural fluid drainage varied widely from patient to patient, and over time in individual patients. All patients except one received symptomatic benefit following regular drainage, including improvement in or cessation of cough and resting or exertional dyspnea, and increased exercise tolerance. As patients developed increasing lung encasement or invasion of mediastinal structures due to progression of underlying malignancy, diminishing symptomatic benefit from drainage via the pleural catheter was observed. The pleural catheters remained in place until death, except for in one patient, who required replacement after the catheter ceased functioning. Therefore, the pleural catheters remained in place for 15 to 234 days, with a mean length of placement of 115 days and mean survival of 125 days. As noted, in one patient with mesothelioma, the pleural catheter ceased to function after 58 days. This patient quickly developed symptomatic reaccumulation of effusion, and was additionally noted on chest radiograph to have developed loculations within the pleural space. He received symptomatic relief of dyspnea after thoracentesis was performed to drain fluid from within a large loculated area separate from the area drained by the pleural catheter. Therefore, a new pleural catheter was inserted into the largest area of loculation. The original pleural catheter, in place for a total of 65 days, was thought to have become occluded with cellular debris and was removed. However, this procedure was complicated by catheter rupture, and a portion of the catheter was left within the pleural space. Although the patient experienced persistent pleural
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fluid drainage from the previous catheter insertion site, he showed no signs of subsequent infection. The patient died 38 days after catheter revision, with the second, still-functioning pleural catheter in place. No other pleural catheter occlusions were noted. Other complications included possible empyema in two patients, and skin breakdown and possible cellulitis at the catheter insertion site in two patients. In the patients with possible empyema, one grew Gram-positive cocci from a culture of the pleural fluid, although the fluid itself was nonpurulent and a Grams stain of the fluid failed to reveal bacteria. We believed this result was consistent with colonization of the pleural catheter rather than overt infection of the pleural space. The patient improved without further intervention. The other patient died at an unaffiliated institution prior to determination of the nature of the pleural catheter infection. Patients with localized skin breakdown and possible cellulitis responded promptly to wound care and administration of oral antibiotics. Discussion The term trapped lung describes persistent atelectasis with failure of the lung to reexpand following evacuation of a chronic pleural effusion. It most commonly results from the development of a fibrous peel over the visceral pleura, in the setting of chronic pleural inflammation. An ongoing malignant process in the pleural space may also produce a thick visceral pleural peel. The peel restricts expansion of the underlying lung parenchyma, generating higher negative pleural pressures within the pleural space. The negative pleural pressure, in turn, leads to increased pleural fluid formation despite decreased pleural fluid absorption, and the development of a chronic pleural effusion.9,16 Dyspnea in the setting of trapped lung is likely multifactorial and due not only to restrictive ventilatory dysfunction caused by the malignant peel, but also to physiologic changes attributable to the MPE. These may include distention of the thoracic cavity, dysfunction of the affected hemidiaphragm, and decreased lung compliance and atelectasis.17,18 Ventilation-perfusion mismatch, in which the lung may be either poorly ventilated due to atelectasis19 or poorly perfused as a result of circulatory shunting,20 can occur in either the affected lung due to direct compression or in the other lung as a consequence of the contralateral shift in mediastinal structures that may be observed in patients with large unilateral pleural effusions.21 Patients with trapped lung fail to demonstrate full lung reexpansion despite complete drainage of the pleural effusion. However, they may exhibit symptomatic improvement because of partial lung reexpansion and improvement in these physiologic parameters.
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The pathognomonic radiographic sign of trapped lung is the pneumothorax ex vacuo, or suction pneumothorax, a small to moderate-sized air collection in the pleural space after evacuation of the effusion, often seen in association with a visibly thickened visceral pleural surface (Fig 1).22,23 For patients with trapped lung due to malignant pleural effusions, successful palliation with procedures such as repeated thoracenteses, extended tube thoracostomy placement, pleuroperitoneal shunting, and pleurectomy and decortication has proven difficult to achieve. In this report, we have described a series of patients with MPE and trapped lung for whom placement of a permanent pleural catheter for drainage of recurrent pleural fluid provided a convenient, effective alternative to the procedures currently in use. Our patients generally reported good symptomatic relief following catheter placement. Most experienced relatively minor, if any, problems with its use. Skin breakdown and insertion site infection should respond promptly to wound care and oral antibiotics, as in these cases. Catheter infection is a potentially serious complication for which patients should be vigilantly monitored. Only one of our patients experienced catheter occlusion, although as illustrated by his case, catheter removal may be complicated by persistent pleural fluid drainage or catheter rupture. We believed several features of pleural catheter implantation make it an excellent solution to the problem of refractory MPE in the setting of trapped lung. As a relatively noninvasive procedure, pleural catheter placement may be reasonably performed in patients in whom other invasive procedures are contraindicated due, for example, to somewhat limited life expectancy or metastatic abdominal disease. The pleural catheter is usually placed in the outpatient setting and may be largely maintained at home, minimizing time spent at office visits and in the hospital. Formal cost-effectiveness analysis has not been performed to compare pleural catheter placement to other therapies. However, at one center, a comparison of hospital charges incurred by patients with MPE who underwent pleural catheter placement with those who underwent inpatient thoracostomy tube placement and sclerosis demonstrated that outpatient placement of the pleural catheter was associated with significantly fewer charges.24 Patients can initiate drainage at their convenience and are able to control the frequency of pleural drainage for maximal symptom alleviation. We found that patients and their caregivers were able to perform satisfactory drainage after receiving instruction at the time of catheter placement, with additional teaching as necessary from visiting nurses and at return office visits with a physician or advanced practice nurse. Although patients may initially experience some
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discomfort associated with subcutaneous tunneling of the pleural catheter, the pleural catheter is more comfortable than a traditional thoracostomy tube because of its greater flexibility and smaller size. Catheter tunneling may reduce the possibility of pleural space infection and accidental catheter displacement. Nevertheless, as illustrated by our patients, over the course of months, empyema remains a possibility. After initial accession, there is no repetitive risk of traumatic pneumothorax and, because of the valve at the proximal end of the catheter, essentially no risk of tension pneumothorax. Since pleural fluid is drained externally and discarded, there is no risk of malignant peritoneal seeding or small-bowel obstruction, as would be posed by pleuroperitoneal shunting. Tumor growth along the catheter tract causing catheter occlusion may occur, and has been described.15 In our series, one patient developed catheter occlusion, which appeared to be due to accumulation of fibrinous material within the pleural space, possibly occluding the catheter ports. This case also illustrates the possibility of catheter rupture during removal, which we postulate may have been related to formation of adhesions within the pleural space. Minor complications such as local skin breakdown and cellulitis are not unexpected and in our series were responsive to routine outpatient treatment. We should note that although we selected patients who were believed by us and by their referring physicians to have a 3-month predicted life expectancy, five patients died within 3 months. Although the general prognostic significance of MPE in the setting of lymphoma appears to be uncertain,25,26 the three patients with lymphoma in this series had the most limited survivals. The use of long-term indwelling pleural catheters in patients with trapped lung and MPE has not been specifically reported previously. However, long-term pleural catheter implantation was recently compared to doxycycline pleurodesis in a trial of 144 patients with MPE without known trapped lung.15 In these patients, the pleural catheter was implanted for periods lasting days to months, during which patients or their caregivers performed pleural fluid drainage at home every other day. The only reported compli-

Figure 1. Top: Posteroanterior chest radiograph of a 52-year-old man with lymphoma and a large left-sided MPE causing severe

dyspnea. Prior thoracenteses resulted in rapid, symptomatic reaccumulation of pleural fluid. Bottom: Subsequent chest radiograph 9 days status postinsertion of an indwelling pleural catheter for drainage of the pleural space. The catheter has successfully drained the pleural effusion with symptomatic relief, but with incomplete expansion of the left lung, and demonstration of large central and pleurally based mass lesions (white arrows). A pneumothorax ex vacuo is visualized along the lateral aspect of the left pleural space (black arrows), pathognomonic of trapped lung.
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cations, similar to those in our series of patients, were tumor seeding of the catheter tract not requiring specific therapy, localized cellulitis, and pain during fluid drainage. These results support the feasibility of prolonged pleural catheter implantation. For patients with symptomatic malignant pleural effusion, definitive pleurodesis without placement of a long-term pleural catheter remains desirable. Although high elastance ( 19 cm H2O) or low pH ( 7.15 to 7.3) values have been examined for their predictive value in determining whether patients are likely to fail to achieve pleurodesis,27,28 it is difficult using such indicators to determine which patients will respond successfully.29 However, for patients with known trapped lung or failure to achieve pleurodesis, permanent implantation of the pleural catheter can be an attractive alternative. Patients for whom drainage using an indwelling pleural catheter will remain problematic include those with loculations in the pleural space, particularly those patients with prior tube thoracostomies, and those who are unlikely to attain complete evacuation of the effusion. Also, patients who are unable to adequately perform pleural drainage and those with clearly limited life expectancy may not be appropriate candidates. Obviously, pleural catheter implantation will not be useful for patients who have previously failed to receive symptomatic relief from pleural fluid drainage and those experiencing dyspnea from other mechanisms, such as chest wall restriction or infiltrative parenchymal disease. As evidenced by our series of patients, the principal complications of pleural catheter placement appear to be catheter occlusion and infections of the pleural space and around the catheter insertion site. Studies that directly compare permanent pleural catheter placement to other therapies for trapped lung and incorporate quantitative measures to assess functional outcome and symptomatic improvement will be useful in further detailing its acceptability and effectiveness in the treatment of this often frustrating problem. References
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