What is the management and care of a dwelling pleural catheter (DPC) for patients with recurrent malignant pleural effusions?

Management of Dwelling Pleural Catheters for Recurrent Malignant Pleural Effusions

Chronic indwelling pleural catheters are effective in controlling recurrent and symptomatic malignant pleural effusions in selected patients, providing significant symptom relief while requiring minimal hospitalization. 1

Indications and Patient Selection

• Indwelling pleural catheters (IPCs) are indicated for:

  • Recurrent malignant pleural effusions requiring symptomatic relief
  • Patients with trapped lung where pleurodesis would likely fail
  • Patients with limited life expectancy where minimizing hospitalization is a priority
  • Cases where outpatient management is preferred or necessary 1, 2

• IPCs are particularly valuable when:

  • Length of hospitalization needs to be kept to a minimum
  • Expertise and facilities exist for outpatient management 1

Insertion Procedure

• Insertion is typically performed as an outpatient procedure
• The catheter is tunneled under the skin to reduce infection risk
• The procedure requires minimal sedation and local anesthesia
• Ultrasound guidance is recommended to reduce pneumothorax risk 2

Drainage Protocol

• Initial drainage schedule:

  • Every other day or as needed for symptom relief 3
  • Daily drainage if catheter removal is a priority (increases spontaneous pleurodesis rates) 2
  • Symptom-based drainage is equally effective for controlling breathlessness and requires fewer supplies 2

• Typical fluid removal:

  • Average 360ml (range 150-1000ml) per drainage in the first weeks 4
  • Limit drainage to <1.5L at once to prevent re-expansion pulmonary edema 2

Monitoring and Follow-up

• Regular outpatient follow-up to assess:
  • Symptom control and quality of life
  • Catheter function and complications
  • Signs of spontaneous pleurodesis (decreasing fluid output)
  • Need for catheter removal 2

Complications and Management

• Overall complication rate: 14-17% 1, 5

• Major complications:

  • Infection/empyema (2.3%)
  • Catheter blockage/malfunction (1.1%)
  • Catheter dislodgement (1.3%)
  • Loculation (2.0%)
  • Pneumothorax (1.2%) 5

• Minor complications:

  • Local cellulitis (most common, 2.7%)
  • Leakage around insertion site (1.3%)
  • Subcutaneous emphysema (1.1%) 1, 5

• Management of complications:

  • Cellulitis: Oral antibiotics
  • Empyema: Systemic antibiotics, consider catheter removal
  • Blockage: Attempt flushing with sterile saline, replace if unsuccessful
  • Dislodgement: Replace catheter if needed 2

Expected Outcomes

• Symptomatic improvement:

  • Significant reduction in dyspnea, especially in lung cancer patients 6
  • Improved quality of life scores at 30 and 60 days post-placement 6

• Spontaneous pleurodesis:

  • Occurs in approximately 46% of patients at a median of 26.5 days 3
  • Higher rates with daily drainage (51.3%) 5
  • Lower late recurrence rate (13%) compared to chemical pleurodesis (21%) 1, 3

• Hospitalization:

  • Median hospitalization time of 1 day for IPC vs. 6.5 days for chemical pleurodesis 3

Catheter Removal

• Indications for removal:

  • Achievement of spontaneous pleurodesis (minimal drainage for 2-3 consecutive attempts)
  • Resolution of underlying condition
  • Persistent infection not responding to antibiotics
  • Catheter malfunction that cannot be corrected 2, 7

• Removal procedure:

  • Simple outpatient procedure
  • Local anesthesia
  • Suture closure of the site

Special Considerations

• Trapped lung:

  • IPCs are particularly valuable in trapped lung where pleurodesis would fail 1
  • Consider pleuroperitoneal shunting as an alternative for trapped lung with large effusions refractory to drainage 1

• Malignancy type:

  • Consider response to systemic therapy for lymphomatous effusions
  • More aggressive local control may be needed for mesothelioma 2

Pitfalls and Caveats

• Do not place IPCs in patients with:

  • Active pleural infection
  • Multiple pleural loculations that would prevent effective drainage
  • Bleeding disorders without correction
  • Poor compliance with home care instructions 1, 2

• Avoid drainage of >1.5L at once to prevent re-expansion pulmonary edema 2

• Patient and caregiver education is crucial for successful management and early identification of complications

• IPCs should be managed by healthcare providers with experience in pleural procedures and with systems in place for outpatient follow-up