Indwelling Small Pleural Catheter Needle Thoracentesis in the Management of Large Pleural Effusions

Indwelling Small Pleural Catheter Needle Thoracentesis in the Management of Large Pleural Effusions* Charles]. Grodzin, MD; and Robert A Balk, MD, FCCP

Study objectives: To evaluate the clinical safety, efficacy, and cost of a small indwelling pleural catheter (7F, Turkel Safety Thoracentesis System [Sherwood, Davis, and Geck; St. Louis]) vs repeated needle thoracentesis or closed tube thoracostomy as a means to drain a large-volume pleural effusion. Setting: Inpatients in a tertiary care university teaching hospital in urban Chicago. Design: Prospective, consecutive patient comparative study using historical controls. Patients: Fifty-seven therapeutic aspirations in 23 patients with large pleural effusions as defined hy opacification of at least one third of the hemithorax on chest radiography. Patients were excluded if they had a history of thoracic surgery, documented loculations, structural chest abnormalities, severe coagulopathy, or refused to give informed consent. Measurements: Volume of each pleural aspiration, total fluid removed, pleural fluid lactate dehydrogenase, protein, glucose, cytologic analysis, microbiologic stains, and cultures based on clinical indications. Results: We found that initial thoracentesis and repeated pleural drainage using the indwelling catheter system is a safe, efficacious, and cost-effective procedure that may aid the evacuation and management of a large-volume pleural effusion. There were fewer adverse effects and complications such as pneumothorax, splenic laceration, hemopneumothorax, local pain, dry tap, and hematomas, as compared with previous reports. The overall complication rate was 12% (7/57). There were two pneumothoraces detected (3.5%), one of which required closed tube thoracostomy for treatment (1.75%). A further benefit comes in the form of a significant cost savings at our institution ($80 vs $240) when this needle-catheter system is used in place of closed tube thoracostomy in the drainage of a large-volume pleural effusion. Conclusion: An indwelling pleural catheter with the Turkel safety needle-catheter (as described in the study) can be used to successfully drain the pleural space with reduced morbidity and a significant cost saving in comparison to repeated needle thoracenteses or closed tube (CHEST 1997; 111:981-88) thoracostomy. Key words: needle drainage; pleural effusion; pleural fluid; thoracentesis; tube thoracostomy Abbreviations: PA = poste roanterior

is an important procedure in the Thoracentesis evaluation and management of pleural effusions . In many cases, biochemical ancl!or cytologic analysis can yield or strongly support a d efinitive diagnosis. Furthermore, drainage of large pleural effusions can *From th e Sections of Pulmonary and Critical Care Medicine, Department of Internal M edicine, Rush Presbyterian-S t. Lukes Medical Center and Rush Medical College, Chicago. At no time did either of the investigators act as an agent of Sherwood, Davis, and Geck or b enefit in any way professionally or monetarily (fees, gifts, or financial support ) throughout th e t study o r us bsequently o ract as a representative of duration of his the company. Manuscri pt r eceived March 1 , 1996; revision accepted Septe mber 10.

improve subjective dyspnea, gas exchange, pulmonary mechanics and, in some cases of significantly elevated i ntrapleural pressure, can provide immediate hemodynamic stabilization. The traditional method of thoracentesis entails the inse rtion of a sterile needle into the pleural sp ace. While usually considered a very safe and effective procedure, needle thoracentesis is associated with a small but significant incidence of morbidity. The usual approach to a l arge-volume pleural effu sion is with needle thoracentesis. Hown to effect eve r, when p e rsisten t or if there is a eed complete drainage, closed tube thoracostomy may be required. CHEST I 111 I 4 I APRIL, 1997

981

Pneumothorax is one of the primary complications of thoracenteses. Despars et al 1 studied 90 cases of iatrogenic pneumothorax. The most common causes were transthoracic needle aspiration (39% ), thoracentesis (33% ), subclavian venipuncture (25 %), and positive pressure ventilation (0.07%). Furthermore, 72% required therapeutic closed tube thoracostomy. Two patients died; one was associated with a staphylococcal empyema that was believed to be related to the chest tube. COPD is an important risk factor for iatrogenic 2 pneumothorax. In a study by Brandstetter et al, patients with COPD had a 41.7% rate of pneumothorax after thoracentesis compared to 18.5% in those without COPD. Collins and Sahn 3 found a 12% rate of pneumothorax in a s eries of 74 patients , three of whom required closed tube thoracostomy. Seneff et al4 evaluated 125 patients and found an overall complication rate of 46% with pneumothorax seen in 11% of procedures. Grogan et al5 evaluated thoracentesis done in several manners (needle aspiration, needle-catheter system, and with ultrasound guidance ). Overall, complications were seen in 46% and pneumothorax occurred in between 20% and 39% using these three methods. We believe that repeated thoracenteses will lead to increased costs and risk of complications. Doyle et al6 reported that the risk of pneumothorax was related to the number of passes made with the thoracentesis needle. Our obj ective was to perform thoracentesis in patients with large-volume pleural effusions using a new safety catheter-needle system and to compare complication rates and cost to that of repetitive needle thoracenteses and closed tube thoracostomy. The needle-catheter system was designed to perform thoracentesis in a safer manner compared to traditional needle thoracentesis. Specific safety features of this needle-catheter system include a colored flag, an audible clicking mechanism designed to signal entry into the pleural space, and a spring-loaded blunt tip that extends as the needle passes through the parietal pleura, thus protecting the lung from the sharp needle tip . We hypothesized that this indwelling needle-catheter system could be placed with less morbidity and decrease the cost of draining a large pleural effusion as compared with historical control. In addition, we believed that the small catheter used for drainage would be more comfortable for the patient and would have a higher degree of successful complete drainage of the pleural space in comparison with repeated needle thoracenteses. 982

MATERIALS AND METHODS Subjects

The protocol used in this study was approved by th e Human Investigations Committee and th e Institutional Revi ew Board of Rush Presbyterian-St. Lukes Medical Center. Patients were recruited from the inpatient population of Ru sh Presbyte1ian-St. Lukes Medical Center, a tertia1y care university hospital on Chicago's near west side. Patients with a large pleural e ffusion who fulfilled the inclusion and exclusion criteria for study participation were enrolled between July 1, 1994 and Jun e 30, 1995. The inclusion criteria included adu lt patients (age > 18 years ) who had a large freeflowing pleural effu sion. A large e ffusion was defin ed b y greater than one third opacification of the hemithorax on posteroante1ior (PA) and lateral chest radiographs. Patients were excluded from entry if they had documented loculations, structural chest abnormalities, seve re un controlled coagulopathy, or refused to give informed consent. Thoracentesis

The thoracentesis was performed in an identical mann er b ythe same individual (C.J.G. ) using a thoracentesis tray (T urkel Safety Thoracentesis Tray; Sherwood, Davis, and Geck; St. Louis [Fig 1]). Prior to th e procedure, PA and lateral chest radiographs were performed to establish the presence of a freely flowin g pleural effusion. The patients were placed in the sitting position and allowed to drape their arms on a bedside table. In two patients, the procedure was pe rform ed in th e la teral decubitus position because of physical limitations. Physical examination was used to determin e th e site for needle insertion. The skin was prepared with povidone-iodine (Betadine) solution and draped in a sterile fashion. Local anesthesia was accomplished with 1% lidocaine (1 to 5 mL) to th e skin, subcutaneous tissue, bony periosteum, and parietal pleura. After satisfactory local anesthesia was confirmed, the safety needle-catheter system was assembled: th e protective sheath was removed and the needle-cath eter system was connected via a three-way stopcock to drainage tubing and the collection bag to assure a closed sys tem. A small "cross"-shaped stab incision was made in the skin with the point of a No. 11 scalpel blade. With the stopcock in th e "off'

FIGURE l. Turkel Safety Thoracentesis System. Clinical Investigations

position with regard to the patient, the blunt tip of the safety needle was th en placed through th e stab wound and care fully advanced. The initial goal was contact of the needle tip with the superior m argin of the lower rib . The needle-catheter system was then aimed slightly cephalad, just supe rior to the upper edge of the inferior rib and advan ced until entry into the p leural space. Penetration ofthe parietal pleura and entry into th e pleural space was indicated b y a c han ge of the "flag" color fro m "red" to "green" and the "popping" sound of the s p ring-loaded valve system. One to 3 mL of fluid was aspi rated t oconfirm t hat the tip of the needle was in the pleural fluid. The catheter was advanced slowly ove r the ne edle as th e needle was carefully withdrawn. The catheter was advanced until th e hub was flu sh with the c hest wall. The syringe was then r emoved from the needle and placed on the o pen p01i of the stopcock. The stopcock was then opened and fluid was allowed to drain into the tubing/collection bag to a n arbitrarily set maximum o f 1,000 mUd. If drainage was slow, fluid could be drained manually using the attached syringe. If persistent fluid was present after the drainage procedure, th e catheter was secured in place and a dressing applied for continued intermittent drai nage. Subsequent drainage of th e persistent pleural fluid was accomplished u sing t he indwelling cathete r syste m. If an additional liter of fluid was collected , drainage was stopped and continu ed evacuation was addressed the next m orning. If < l L was collected, a c hest r adiograph was d one to assess the presence of residual pleural fluid . If th e p leural space was dty , the cathete r was subsequently removed. Postprocedure ches t r adiographs were performed t oassess drainage and to identify the presence of complications s uch a spneumothorax. Flu id Analysis

Pleural fluid was sent for routine c hemistry analysis (lactate dehydrogenase and protein) to de termine if it was a tr ansudate o r an exudate according to the criteria o f Light 7 Additional studies were performed as clinically indicated (eg, p H, cytology, Gram and acid-fast stai n and culture ). Parameters Follou;ed

A record was kept of complications (pneumothorax, bleeding, infection, pain, hematom a development, splenic laceration, cardiac arrhythmia, and need f or closed tube thoracostomy), the number ofaspirati ons foreach p atient and total for the group, th e total volume o ffluid removed in each p atient, the nu mber of days the catheter remained in the p leural space, patient complaints, and the a bility to perform com plete drainage of th e pleural space.

R ESULTS

A total o f23 patients were studied with a mean age of 57.7 years (range, 40 to 96 years). Comorbidities included the following: renal failure (two); congestive heart failure (five); respiratory failure (two ); hypertension (three); end-stage liver disease (two); diabetes m ellitus (three); sepsis (two, bacte1ial, fungal); cancer (six, lung, colon, breast, Kaposi's sarcoma, renal cell, and non-Hodgkins lymphoma); inflammatory processes (postpericardiotomy syndrome, pancreatitis ); AIDS ; Budd-Chiari syndrome; chest traum a; and anemia. Of the 23 patients, 8 had transudative effusions and 15 patients had an xeuda-

tive effusion. Table 1 summarizes the study population and the thoracentesis results. The average number of aspirations required to drain the pleural space was 2.5 (a total of 57 aspiration procedures). The catheter was left in place for a mean of 3.0 days with removal of an average of 1. 70 L per p taient. One would expect that if the average number of days the catheter was present was 2.5, with the goal to remove 1 Ud, the total average of fluid removed should be close to 2.6 L. This discrepancy r esults from the presence of < 1 L of fluid in the pleural space at the time of the fin al aspiration or because fluid continued to accumulate while a final chest radiograph was obtained but prior to catheter r emoval. In the latter group , aspiration of even this small residual fluid was deemed advantageous to the patient. Of the 23 subjects , 17 reported resolution of d yspnea during or soon after complete drainage of the pleural space; additionally, one patient reported increased ambulatory capacity. The overall complication rate was 7 of 57 (12%). The incidence of major complications was 3.5% and reflects two patients who developed a pneumothorax. One of these patients (1. 75%) required closed tube thoracostomy placement for management, whereas the other was treated by air aspiration using the indwelling pleural catheter. The re was no detected empyema, hemothorax, splenic laceration, shearing of the catheter tip, cardiac arrhythmias, need for thoracotomy, or death related t o the drainage thoracentesis procedure. Minor complications occurred in 5 of 57 (8.7%) and were a s follows. One (1.75%) patient complained of local pleuritic c hest p ain for the time the drainage catheter was in place . Two patients (3.5%) noted mild discomfort on placement of the pleural catheter. One (1.75%) patient complained of pain on instillation of lidocaine; a dry tap occurred on one (1.75%) occasion. A second procedure was necessitated in four patients owing to subsequent discovery of a loculated pleural effu sion (t\vo patients ), clotting of the catheter (one patient), and a d1y tap (one patient). There were no oc currences of subcutaneous hematoma or seroma, persistent cough, or inadequate fluid yield. A summary of the overall, minor, and major complications and a comparison with historical r eports of complications encountered with both diagnostic and therapeutic thoracentesis are presented in Figures 2 to 4. At our institution, the cost of this catheter and insertion kit is approximately $80. The cost of a single-use thoracentesis kit is also $80 while the cost associated with the insertion of a closed tube thoracostomy is$284. The cost of a d aily c hest r adiograph is an additional charge. Although use of a simple needle and syringe would be much cheaper, probCHEST I 111 I 4 I APRIL, 1997

983

Table 1-Summary of Patients* Patient No.

Days

Serial Aspirated Volumes, L

Total Volume Aspirated, L

Complications

Transudate/ Exudate

Comorbidities

1

4

1/1/.2

2.2

None

Exudate

2

3

1/0.8

1.8

None

Transudate

3

5

0.8/0.5/0.25/0.165/0.21

1.925

Local erythema

Exudate'

4 5

2 3

0.9 0 ..5/0.3

0.9 0.8

Transudate Exudate

6

3

1/02

1.02

7 8 9

3 5 3

l/0.2 110.5/0.4/0.425/0.5 0.5/0.15/0.05

1.2 2.825 0.7

None Slight discomfort when lying on catheter Catheter kinked, would not draw necessitating removal Pleuritic pain None None

Exudate 1 Transudate Exudate

10 12 13

2 2 5 2

1/0 1/0 0.99/0.25/0/0.27/0.3 1.0

1.0 1.0 1.81 1.0

None Difficulty lying on the back None None

Exudate Transudate Transudate Exudate

14 15

2 4

0.750/0.25 1/0.1 1

1.0 l.l

Exudate Transudate

16 17§

3 2

1.2/l.l/1.2 l.l/0.65

3.5 1.75

Transudate Exudate

ESLD CHF, arthritis

18

3

1.2/1.3/1.35

3.85

Exudate

19

2

0.85/l.l

1.9.5

Hepatic hydrothorax, Budd-Chiari S)mdrome RCC metastatic to pleura/lung

20

3

1.0/.275/.250

1.52.5

21

3

1.0/1.1/.125

2.225

22

3

1.05/1.15

2.22

1.2/0.4/0.075

1.675

None Pneumothorax treated by air aspiration via same catheter None Slight pain on insertion of tube, loculation precluded full drainage , pneumothorax required chest tube Pain on instillation of lidocaine, very histrionic at the time Pain on instillation of lidocaine; tube malfunction, needed to be replaced to adequately drain on day no. 2 Slight pain on insertion; removed for impending cardioversion procedure Tube clot after first night, then removed and replaced for days 2 and 3 Flow stopped spontaneously at end of second aspiration Dry tap on first attempt \\~th mild discomfort, second attempt successful \vithout complication

CHF, renal insufficiency, anemia, OM, MVR, PUD, RVD, AF Lung cancer, HTN CHF, colon cancer Postpericardiotomy syndrome, CAD CHF, CAD, dyspnea Cirrhosis None Hypoalbuminemia, pancreatitis, duodenal hematoma, fungemia, fungal elements in ascites fluid Lung cancer I--IIV+, KS

2.91 2.47 aspirations per patient

1.70

11

23~

Average

Exudate

Exudate

Renal failure , quad1iplegia, respiratmy htilure, staghorn renal calculi, urosepsis , hypothermia CAD and CABG, AF, CHF, NIDDM, HTN, cholecystectomy Colon cancer with liver metastases IBD, CAD, mtluitis, CHF Non-Hodgkin's lymphoma

Transudate

CHF, MVR, AF, breast cancer, bradycardia

Exudate

DM, CHF, diabetic retinopathy, LE occlusive disease Status post chest trauma with rib fracture , bronchitis OM, anemia, VF/AICD with pocket infection, DVT, HTN, AF,CVA

Exudate Exudate

*CAD=coronary artery disease; CABG=coronary artery bypass graft; CHF=congestive heart failure; IBD=inflammatory bowel disease; AF=atrial fibrillation; DM=diabetes mellitus; NIDDM=noninsulin-dependent diabetes mellitus; HTN=hypertension; MVR=mitral valve replacement; PUD=peptic ulcer disease; RVD=right ventricular dysfunction; HIV + =HIV infection; KS= Kaposi's sarcoma; ESLD=end-stage liver disease; RCC=renal cell carcinoma; LE= Iower extremity; VF/AICD=ventricular fibrillation/automatic implantable cardioverter defibrillator; DVT=deep venous thrombosis; CVA =cerebrovascular accident. 1 Malignant effusion. I Pneumothorax treated \vith aspiration of 180 mL of air \~a pleural catheter with full reexpansion of the lung. The catheter remained in place for an additional 3 days to ensure that the lung remained reinflated and then it was removed without further complication. §It was discovered that there was a large loculated effusion not drained after removal of l. 75 L of fluid. Loculated effusion, upon retapping, caused iatrogenic pneumothorax requiring tube thoracostomy. i1Tube clotted overnight; required removal and replacement of a new catheter \vith subsequent full evacuation of the effusion; tube removal and replacement accomplished without morbidity.

984

Clinical Investigations

70 60

50 40

% 30 20 :1.0 0 Seneff'

Grogan

( n =:125)

(n • 52)

G:rodzi:n. ( n =5'7) • M: in..or ConJ.plica:t i o:n. s

OM ajo::r Con"'.plica"t.io:n. e

FIGURE 2. Overall compli cation rate of thoracentesis in the current study population co mpared with series by Seneff et al 4 and Grogan et al. ->

40 35 30 25

%

20 :1..5 :J..O

5 0

Seneff

Grogan. (n.eedleca.'th.e t.er

Grogan. (needle s ystem)

Grod..zin.

system)

•:nrytap

• ~e:D'1a"t<>D'1a

3. Minor complication rate in th e current study population compared with Seneff et al 4 and Grogan et aJ.5

F I GURE

lems, including the presence of the needle in the pleural space, need for continued separation of the syringe from the needle for drainage, difficulty assuring full evacuation of the pleural space, and lack of built-in drainage tubing can lead to clinical risk and cost th at outweigh the cost and safety benefits of the needle-catheter system.

If the same number of thoracenteses had been carried out using a single-use thoracentesis kit for each aspiration, patients would have undergone 57 procedures as opposed to 27 using the Turkel Safety needle-catheter system. This would increase the chances for complications and translate into a cost savings of $2400 (30 procedures X $80). If a closedCHEST I 11 1 I 4 I APRIL, 1997

985

40

as 30

/o

0

25 20 15 10 5 0

Sen..ef:f

Grogan.
Grogan.
Grodzi:n.

• Pn..e"U:J:n.otho:ra::x OTube Tho:racosto:J:n.y R.eq"Ui:red • Sp1e:n.i.c Laceration. • ~e:J:n.op:n.e"U:J:n.otho:ra::x

FIGURE

4. Major complication rate of the current study compared with Seneff et al4 and Grogan et al. 5

tube thoracostomy had been used for the same number of days as there were individual aspirations, the total cost would be approximately $284 (plus the cost of a daily portable chest radiograph ) as compared with $80 for the Turkel Safety needle-catheter system (plus one to two chest radiographs per patient). In addition, asignificant investment of time is required on the part of the medical and nursing staff for care of the apparatus. Although not specifically tested as part of this trial, the use of this needle-catheter system could have allowed for multiple aspiration procedures throughout the day to effect more rapid clearance of the effusion while still protecting the patient from developing reexpansion pulmonary edema. In addition, the needle-catheter system could be used in outpatient management to effect even greater cost savings in comparison with inpatient care. DISCUSSIO

The goal of this study was to assess the efficacy of complete drainage of a large pleural effusion, the complication rate as compared with histmical data, and the cost savings of allowing a small catheter to remain in place for serial taps until the pleural space is dry. We found that initial thoracentesis and repeated pleural drainage using an indwelling catheter system is a safe and cost-effective procedure that may aid the evacuation and management of a large pleural effusion. 986

Seneff et al4 evaluated 125 thorace ntesis procedures in 91 patients with pleural effusion. The overall complication rate was 58 of 125 (46%) . Major complications included pneumothorax in 14 of 125 (11 %) of which 3 of 125 (2.4%) required tube thoracostomy for management. One patient died precipitously. Splenic laceration occurred in 1 of 125 (0.8%), shearing of the catheter tip (requiring thoracotomy for removal) occurred in 1 of 125 (0.8%), and delayed discovery of a hemopneumothorax occurred in 1 of 125 (0.8%) . Minor complications included pain in 28 of 125 (22% ), cough in 14 of 125 (11 %), dry tap in 16 of 125 (13%), development of a subcutaneous he matoma in 3 of 125 (2.4%), and seroma in 1 of 125 (0.8%) . Grogan et al5 evaluated thoracentesis performed with a needle-catheter system (14-gauge needle through a 16-gauge catheter) in comparison with the traditional needle (20-gauge) procedure . Patients qualified for the study if a pleural effusion was demonstrated on PA chest radiograph that obliterated more than half of the hemidiaphragm and was freely flowing on a lateral decubitus radiograph. In 52 patients, 46% of the procedures were associated with at least one complication. Using their needlecatheter system pneumothorax occurred in 7 of 18 (39%) patients. Two of these patients required closed tube thoracostomy for management of uncomplicated large pneumothoraces. Minor complications occurred in 11 of 18 (61 %) patients and included pain in 7 of 18 (38%), d1y taps in 2 of 18 Clinical Investigations

(11%), and subcutaneous hematoma in 1 of 18 (5.5%). In the group that underwent needle aspiration, 3 of 15 (20%) developed pneumothorax without need for tube thoracostomy. In the series of Grogan et al, 5 minor complications occurred in 4 of 15 (27%) and included pain in 2 of 15 (13.5%), and a dry tap in 2 of 15 (13.5%). Patient movement due to pain, cough, or reexpansion of the lung increases the risk of pneumothorax. Uncooperative patients and sudden patient movement may also increase the risk of a pneumothorax with or without an accompanying puncture or laceration of the lung. In addition, as the fluid is removed, it becomes increasingly difficult to completely drain the pleural space and may necessitate performance of tube thoracostomy to successfully complete the drainage. In this study, thoracentesis was done in the same manner by the same individual (C.J.G.). Past studies have yielded conflicting data concerning the impact of the operator on the development of complications. In two studies, 6 ·8 the pneumothorax rate was the same whether the thoracentesis was performed by a pulmonary specialist or by a nonpulmonary specialist. Even though the needle-catheter system is specifically designed for maximal safety, the level of acquired expertise was undoubtedly instrumental in our low complication rate. The most important feature of the safety needle is the ability to identify passage through the parietal pleura and into the pleural fluid collection without contacting the visceral pleura. At that point, one begins removal of the needle and insertion of the soft catheter. This ensures that the needle is never more than a few millimeters into the pleural space and is unlikely to puncture the visceral pleura. Since a one-way valve is built into the catheter, air entry from the atmosphere is obviated. Both of these features minimize the risk of pneumothorax. With proper instructions to the patient and nursing staff, patients were able to tolerate the presence of the catheter with minimal discomfort. The result was a low incidence of pneumothorax (3.5%) that is less than previous reports. 2· 6 .8 - 10 The reported incidence of pneumothorax ranges from 5.2 to 19.2%. These reports included both diagnostic and therapeutic thoracenteses. It would be anticipated that there would be a greater risk for inadvertent lung puncture or air entry during procedures directed at completely draining the pleural space as opposed to a single diagnostic procedure. Further study \vith a concurrent control group would be necessary to evaluate this potential for improved safety using this needlecatheter system. vVhether the intent is to use this catheter as an indwelling pleural drain or perform simple aspira-

tion, the safety features of the needle-catheter system reduce the rate of complications. Situations in which single use may be attractive are the acute relief of dyspnea or chest pain, diagnostic thoracentesis in an undiagnosed pleural effusion (in the hospital or in the outpatient setting), serial aspirations for the purpose of microbiologic or cytologic study, and complete drainage of a small pleural effusion. Situations in which the catheter may be left indwelling include large pleural effusion (> 1 L), persistent accumulation of pleural fluid (eg, hepatic hydrothorax, pancreatitis, nephrotic syndrome), or to facilitate pleurodesis. This catheter may be useful in either the inpatient or outpatient setting. In the hospital, the catheter has important potential use in both the ICU and on the general medical floor. In the ICU, this catheter offers an additional option in the approach to pleural effusion for patients receiving mechanical ventilation. Positioning may be difficult in these patients and risk of pneumothorax carries the necessity for placement of a closed-tube thoracostomy. In our experience, aspiration of fluid with this apparatus was carried out without complication. Another potential use for this needle-catheter system is in the treatment of pneumothorax via air aspiration. This procedure was successfully performed in patient 15. Another use of the needle-catheter drainage technique also has potential advantage in the outpatient setting, thus providing an even greater cost savings. Potential outpatient uses of this catheter include drainage of a malignant pleural effusion prior to pleurodesis, treatment of a persistent pleural effusion from cirrhosis, congestive heart failure , pancreatitis, or nephrotic syndrome, serial sampling of pleural fluid for cytologic analysis or culture in the appropriate clinical settings, and outpatient management of large pleural effusions. Use of an indwelling catheter placed via the needle-catheter system (Turkel Safety) is an effective strategy for draining the pleural space with reduced morbidity and offers the potential for a significant cost savings over more traditional methods. The needle-catheter design offers safety features that minimize the potential for pneumothorax in comparison with single-needle thoracentesis. A large prospective trial that compares this needle-catheter system to standard needle thoracentesis is required to confirm our pilot observations. As the practice of medicine becomes more outpatient based, this method of pleural fluid management offers a potential for reduced cost and increased patient comfort compared to repeated thoracentesis procedures or closed tube thoracostomy. Direct comparisons of these two strategies is not possible from these data. A questionnaire concerning patient tolerance of the CHEST 1111 I 4 I APRIL, 1997

987

indwelling pleural catheter was not included in this study. However, patients were not rendered immobile, had fewer complaints of pain, did not have long-lasting discomfort or a scar, and had minimal pleural irritation. We believe that the procedure described in this study has potential advantages over serial needle thoracentesis procedures and closed tube thoracostomy and is likely to have reduced morbidity, increased patient comfort, and reduced cost.

REFERENCES 1 Despars JA, Sassoon CS, Light RW. Significance of iatrogenic pneumothoraces. Chest 1994; 105:1147-50 2 Brandstetter RD, Karetzky M, Rastogi R, et al. Pneumothorax after thoracentesis in chronic obstructive pulmonary disease. Heatt Lung 1994; 23:67-70

988

3 Collins TR, Sahn SA. Thoracentesis: complications, patient experience and diagnostic value [abstract]. Am Rev Respir Dis 1983; 127:A114 4 Seneff MG, Corwin RW, Gold LH, et al. Complications associated with thoracentesis. Chest 1986; 90:97-100 5 Grogan DR, Irwin RS, Channick R, et a!. Complications associated with thoracentesis: a prospective, randomized study comparing three different methods. Arch Intern Med 1990; 150:873-77 6 Doyle JD, Hnatiuk OW, Torrington KG, et al. Necessity of routine chest roentgenography after thoracentesis. Ann Intern Med 1996; 124:816-20 7 Light RW. Pleural disease. 2nd ed. Philadelphia: Lea & Febiger, 1990; 42 8 Swinburne AJ, Bixby K, Fedullo AJ, eta!. Pneumothorax after thoracentesis . Arch Intern Med 1991; 151:2095 9 Kohan JM, Pie RH, Israel RH, et a!. Value of chest ultrasonography versus decubitus roentgenography for thoracentesis. Am Rev Respir Dis 1986; 133:1124-26 10 Shepard JW. Thoracentesis: a safer method. Am Rev Respir Dis 1980; 121(suppl):188-89

Clinical Investigations