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MANAGEMENT OF MALIGNANT PLEURAL EFFUSIONS AND PNEUMOTHORAX
INTERVENTIONAL CHEST RADIOLOGY
0033-8389/00 $15.00
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MANAGEMENT OF MALIGNANT PLEURAL EFFUSIONS AND PNEUMOTHORAX Jeremy J. Erasmus, MD, Philip C. Goodman, MD, and Edward F. Patz, Jr, MD
Pleural abnormalities result from a wide range of diseases including inflammatory, neoplastic, and infectious processes, and iatrogenic causes. This article focuses on the management of two common pleural abnormalities: malignant pleural effusion and pneumothorax. PLEURAL ANATOMY AND PHYSIOLOGY
The pleural surface is formed by a continuous, single layer of mesothelial cells that line the lung (visceral pleura); chest wall; diaphragm; and mediastinum (parietal pleura). Approximately 10 to 20 mL of fluid is normally present in the pleural space, acting as a lubricant during respiration. This predominantly low-protein fluid is generated from the parietal surface, which is supplied by the high-pressure systemic circulation (i.e., intercostal vessels), and is reabsorbed into capillaries within the visceral surface supplied by pulmonary vessels. The pressure gradient between the two surfaces accounts for the flow of as much as 10 L of fluid through the pleural space in a 24-hour period.', 9, 17, 29- Disruption of any part of the pleural fluid dynamics (i.e., hydrostatic pressure, colloid osmotic pressure, capillary permeability, or lymphatic
drainage) can result in the formation of an abnormal pleural fluid colle~tion.~, 41, 52 PLEURAL FLUID CHARACTERISTICS
Pleural effusions are classified as transudates or exudates, depending on fluid characteristics. This distinction is important in suggesting the appropriate differential diagnosis and subsequently in determining treatment options. Transudates are rarely a cause of malignant effusion, whereas malignancy is the most common cause of an exudate in adults 43, 78, 82 Criteria used to over 60 years of age.42, diagnose an exudate include'3,43 pleural fluid-serum protein ratio >0.5 pleural fluid lactate dehydrogenase (LDH) > 200 units pleural fluid-serum LDH ratio >0.6 protein >3 g/dL pH >7.3 specific gravity >1.016 MALIGNANT PLEURAL EFFUSIONS
Malignant pleural effusions are a common problem in cancer patients with advanced disease. Approximately 50% of patients with breast carcinoma, 25% of patients with lung
From the Department of Radiology, Duke University Medical Center, Durham, North Carolina
RADIOLOGIC CLINICS OF NORTH AMERICA VOLUME 38 * NUMBER 2 * MARCH 2000
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carcinoma, and 35% of patients with lymphoma develop a malignant effusion during the course of their disease. These three tumors and ovarian carcinoma account for over 75% of all malignant effusion^.^, 11, 25, 35, 74 Patients with malignant pleural effusions typically present with progressive dyspnea, although occasionally they have a persistent cough or chest pain.81Chest radiographs confirm the size and location of the pleural collection and aid in management. For initial diagnosis and treatment, a thoracentesis usually is performed. Symptomatic relief is frequently attained by removing a large amount of fluid. Not all pleural effusions in patients with a known primary neoplasm are malignant; malignant cells are only detected in approximately 50% of proved malignant effus i o n ~ ,68,~75~ but , exudative collections should be considered metastatic until proved otherwise. Treatment depends on a number of variables including the patient's symptoms, performance status, extent of disease, effectiveness of systemic therapy, and prognosis. For example, pleural effusions caused by lymphoma, small-cell lung cancer, or germ cell neoplasm may be controlled by systemic chemotherapy. Pleural effusions that are not controlled by systemic treatment often require local palliative therapy to improve symptoms, reduce unnecessary hospitalizations, and minimize expense and complications. Most commonly, tube thoracostomy and drainage followed by sclerotherapy are the modalities of choice. This has traditionally been performed with large-bore thoracostomy tubes (greater than 24F catheter).29, 76 The disadvantages to this approach are that hospitalization is required, mobility is limited, and patients often are uncomfortable. More recently, smallbore catheters placed using radiologic guidance have produced response rates equal to those seen using larger tubes.26,29, 56, 59, 63, 76 Imaging not only localizes the pleural collection but at times reveals unexpected findings (e.g., CT demonstration of pleural metastases instead of fluid), which prevents an unnecessary procedure. The primary goal of drainage and sclerotherapy is to effect a prolonged reexpansion of lung and improve oxygenation. Patients with a central mass obstructing the ipsilateral bronchus or patients with a thick pleural peel do not benefit from tube thoracostomy because the lung cannot be fully reexpanded.
Technical Considerations Small-bore catheters typically are placed in the midaxillary line at the sixth or seventh intercostal space, although image guidance is helpful in selecting the optimal route and site. Patients should be prepared and draped in sterile fashion, and well anesthetized down to the pleural surface using 1%lidocaine. A skin incision large enough to accommodate a 14F catheter is made and blunt dissection with a needle driver or Kelly clamp is performed along the anticipated chest tube tract. An 18-gauge trocar needle is then placed into the pleural space; the positioning is confirmed by observing fluid flowing from the proximal end of the needle after the stylet is removed or by aspirating a small amount of fluid from the pleural space using a small syringe. A 0.038-in floppy-tipped wire is advanced well into the fluid collection (this helps to break down adhesions mechanically). Sequential dilators (usually 8F, lOF, 12F, and 14F catheter) are then used to prepare the tube tract. A 14F catheter pigtail chest drainage tube is advanced over the wire into the pleural fluid. The pigtail catheter is curled and locked, and up to 1 L of fluid may be aspirated depending on patient comfort and symptoms. If the patient begins to cough before 1 L has been removed, aspiration is discontinued. Tubes may be secured to the skin using an adhesive disk arrangement and are not generally sutured in place. This permits easy tube manipulation if necessary. A postprocedure chest radiograph is obtained to ensure proper catheter placement and evaluate the degree of remaining fluid. Up to 30% of patients may have a pneumothorax demonstrated on this chest film. The pneumothorax does not require therapy and is thought to occur for the following reasons: the lung is relatively stiff and incapable of immediate re-expansion; and the musculoskeletal hemithorax is fixed in position and does not collapse inward, yet something must fill in the pleural space previously occupied by fluid.16 The source of air for this "ex vacuo" phenomenon is unknown but it is not thought to be caused by visceral pleural violation, and resolves once the lung re-expands (Fig. 1). The tube can then be connected by a threeway stopcock to an underwater drainage system, such as a Pleur-evac with continuous wall suction at 20 to 30 cm H20.The catheters should be flushed with 10 mL of normal sa-
MANAGEMENT OF MALIGNANT PLEURAL EFFUSIONS AND PNEUMOTHORAX
Figure 1. A 48-year-old woman with breast cancer presents with increasing cough and shortness of breath. A, Posteroanteriorchest radiograph demonstrates a complex right pleural effusion. B, Portable chest film immediately following chest tube placement demonstrates a decrease in the effusion and a right basilar pneumothorax (arrows). The right chest tube is in satisfactory position. C,One day later, a posteroanterior chest film demonstrates a decrease in the right pleural effusion, without evidence of a pneumothorax. 0,A posteroanterior chest radiograph following tube removal demonstrates re-expansion of the lung and a small residual pleural effusion. The patient had significant improvement in her shortness of breath.
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line every 8 to 12 hours. Patients are seen daily to ensure proper tube functioning and to record the drainage amounts. Daily chest radiographs are not essential when drainage continues without difficulty and there are no unexpected patient complaints. When drainage decreases to 200 mL in a 24-hour period, a chest radiograph is performed to exclude loculated fluid and confirm complete lung reexpansion. Patients with decreased drainage but radiographically evident fluid should have their catheters flushed to determine patency. Sometimes heparin or streptokinase, or occasionally insertion of a guidewire, is required to open a clotted catheter. If fluid loculation occurs, instillation of streptokinase (250,000 units in 100 mL of normal saline for 1 to 3 days) may break down adhesions and improve drainage.l0,57 If the tube is severely kinked it may need to be replaced. It is important that the pleural fluid is drained before instilling the sclerosing agent, because successful pleurodesis requires close contact between the visceral and parietal pleural surfaces. Once the pleural space has been completely drained (usually 2 to 5 days), a sclerosant is selected. Different substances, such as talc, biologic substances, antibiotics, antineoplastics, and radioisotopes, have been used for this purpose.+ Although different mechanisms of action have been proposed for the various classes of drug, no single agent has a proven advantage. Ongoing trials have continually evaluated the efficacy and cost benefit of these agents. In one recent study, a 5-g talc slurry instilled through a small-bore tube produced as effective a response rate as other agents placed through larger tubes and cost less, with fewer complications than other combination^.^^ After the sclerosing agent is introduced, the tube is closed and the patient is instructed to change position (roll from side to side) every 15 minutes for 2 hours in an effort to distribute the sclerosant uniformly throughout the pleural space. The tube is then reopened to suction for 24 hours, at which time, if the drainage remains less than 200 mL, the tube is removed. A second dose of sclerosant usually is administered if drainage amounts exceed 200 mL. Complications are unusual and include *References 8, 12, 14, 18, 20, 21, 23, 24, 26, 28, 30, 31, 34, 36, 37, 45, 46, 48, 49, 51, 54, 55, 60-62, 65, 71-73, 76, 77, 83, 84, 86, 87.
tube malfunction ( e g , clotting or kinking); tube malposition; infection; hemorrhage; loculation of fluid; and pneumothorax. Ambulatory Sclerotherapy
One significant advantage of sclerotherapy with small-bore catheters is the potential for outpatient treatment. Patients with symptomatic, unilateral malignant pleural effusions with a reasonable performance status should be considered for ambulatory therapy. As with inpatient procedures, all patients should have a predrainage baseline chest radiograph. Using the same techniques described previously, a small-bore (10.3F to 14F catheter) all-purpose drainage catheter is placed using image guidance (generally ultrasound or CT). The tube is secured to the skin using a Molnar disk. This allows easy accessibility for repositioning of the catheter if necessary. Similar to other pleural drainage procedures, about 1 L of fluid is aspirated, less if the patient begins to cough. The catheter is then connected to a Tru-Close 600-mL bag (UreSil, L.P. Skokie, IL) for gravity drainage. This bag is designed to be emptied by the patient without danger of backflow of air into the pleural space. A postprocedure chest radiograph is taken to assess catheter position. Patients are provided with home care instructions and told that when drainage falls below 200 mL per day, to return to the hospital or outpatient clinic for sclerotherapy. A repeat chest radiograph is obtained at this time to confirm complete fluid drainage, absence of loculations, and complete lung reexpansion. Any remaining fluid is aspirated before instillation of the sclerosing agent. After the sclerosant is introduced and the tube clamped, patients are instructed to change positions for 2 hours, after which time the tube is reopened to gravity drainage. The patient is then sent home and returns the following day for chest tube removal. In one pilot study of ambulatory sclerotherapy, 19 patients required chest tubes for 2 to 11 days (mean, 5.1 days), while draining between 950 and 3925 mL of pleural fluid (mean, 1647 mL). At 30 days, 10 patients (53%) had a complete radiographic response and 5 (26%)had a partial response. Four patients (21%) had progressive disease. Of the four treatment failures, three had a good initial response, but had failed at 30 days. There was no significant difference in either tube
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duration or total drainage between the three response groups. No patient required hospitalization during the course of therapy, and all patients had significant symptomatic improvement in their respiratory These data suggest outpatient management of malignant pleural effusion is a viable alternative to traditional inpatient tube thoracostomy and sclerotherapy. Such treatment offers an important potential benefit to the patient, including a better quality of life and reduction in health care costs.
hours following tube in~ertion.'~, 19, 38*40, Lack of response usually is caused by technical factors (catheter malposition and occlusion) or a very large air leak.19,38, 67,69 Common indications for pneumothorax drainage include38,39, 70 chest pain accompanied by shortness of breath and decreased oxygenation, particularly if the pneumothorax is estimated to be greater than 20% to 25% of the volume of a hemithorax; and progressive enlargement of a pneumothorax or findings of tension pneumothorax.
Summary
Contraindications
Malignant pleural effusions are a common problem for cancer patients. The fluid collections may be a result of contiguous spread of tumor or metastases from distant disease. Patients usually present with shortness of breath, which significantly impacts on their quality of life. Therapy is palliative only and is designed to minimize discomfort, cost, and morbidity. Rapid symptomatic relief is the goal. Some patients require an immediate, temporizing thoracentesis, whereas others with asymptomatic intervals may benefit from repeat thoracenteses. The majority of patients, however, require tube drainage and sclerotherapy. Small-bore catheters are well tolerated and effective for this purpose and permit outpatient care.
There are no absolute contraindications to percutaneous drainage of pneumothorax using small-bore catheters. Because patients on mechanical ventilation can have large air leaks, a standard thoracostomy tube may be required. If there is a coexisting complex pleural fluid collection, a small catheter may become occluded, and a standard thoracos8o tomy tube may be a better
PERCUTANEOUS TUBE PLACEMENT FOR PNEUMOTHORAX
Clinically significant pneumothorax with collapse caused by increased pleural pressure usually results from disruption of the visceral pleura. This may occur spontaneously in patients without previously known pulmonary abnormalities, as a result of long-standing lung disease (e.g., eosinophilic granuloma, emphysema); trauma; or as a complication of a diagnostic or therapeutic p r o c e d ~ r e The .~ incidence of pneumothorax is 5% to 20% following thoracentesis and pleural biopsy5,22, 27, 79 less than 1% to 3% after transbronchial biopsy5,58 and 10% to 50% after transthoracic needle lung biopsy.57, 38, 85 The treatment for most iatrogenic pneumothoraces is small-bore tube placement (7F to 10F catheter). Success rates are reported to be 87% to 97%, with the vast majority of pneumothoraces resolving within 24 to 72
Techniques
Tube placement usually is performed with fluoroscopic guidance. Occasionally, CT is helpful because it can prevent intraparenchyma1 catheter placement in patients with pulmonary fibrosis and pleural adhesions. The entry site depends on the location and size of the pneumothorax. We generally place the tubes in the fifth or sixth intercostal space at the midaxillary line, although initial reports suggested the second or third anterior intercostal space at the midclavicular line might produce optimal positioning of the catheter in the apex of the pleural space.38,8o The site is cleaned with an antiseptic solution and anesthetized with 1% lidocaine. A small skin incision slightly larger than the catheter diameter is then made to ensure no resistance when the tube is inserted. The choice of drainage tube depends on physician preference. Many use a trocar-stiffened 8F to 10F straight catheter placed with a single puncture. Pigtail catheters inserted over a guidewire using Seldinger technique can also be used, and are probably preferable in patients with fluid in the pleural space. The catheter-trocar system is angled in a cranial direction above the rib to avoid intercostal neurovascular bundle injury and ad-
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Figure 2. See legend on opposite page
vanced into the pleural space. A gush of air should be apparent when the catheter tip transverses the parietal pleura. The trocar is then held in position, and the catheter advanced. Once the tip is in satisfactory position, the trocar is removed, and the catheter secured with skin sutures. At our institution, the tube usually is connected to a one-way Heimlich valve, although patients with a large air leak and a nonexpanding lung may have the tube connected to an underwater drainage system, such as a Pleur-evac with continuous suction (-20 cm H,O). Management
Upright posteroanterior and lateral chest radiographs are obtained after the procedure
to determine the size of any residual pneumothorax and to confirm the position of the drainage catheter. A repeat radiograph is performed after 18 to 24 hours of drainage. If the pneumothorax has resolved, the catheter is clamped for approximately 4 hours, after which a repeat chest film is obtained. If the lung remains completely expanded the catheter is removed (Fig. 2). Occlusion or malposition of the catheter can result in a persistent neumothorax. This is suspected clinically if t ere is no symptomatic improvement, or if there is no pressure variation in the water-seal chamber of the Pleur-evac with breathing.38 Residual pneumothoraces may also be seen after catheter placement if the air leak is large, wherein insertion of a second catheter or large thora-
R
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Figure 2. A 67-year-old man presented for percutaneous biopsy of a large right hilar mass. A, The patient developed an increasing right hydropneurnothorax following the biopsy, with progressive shortness of breath. B, An 8F pigtail catheter was inserted into the pleural space, with a significant decrease in the right pneurnothorax. C, Posteroanterior chest radiograph 2 days later demonstrates no significant pneumothorax following removal of the chest tube.
costomy tube may be required for successful treatment. Patients with a persistent pneumothorax may also benefit from chemical pleurodesis using sclerosing agents, such doxycycline, talc, or bleomycin.2,33, 53, 66 Complications
Complications of percutaneous placement of small-bore drainage catheters for the treatment of pneumothorax are rare. They include the following19,38r47, 67, 80: 1. Laceration of an intercostal artery resulting in a chest wall hematoma or hemothorax 2. Laceration of the visceral pIeura and lung by the trocar or catheter, or intraparenchymal placement of the catheter resulting in a persistent air leak and bronchopleural fistula 3. Tension pneumothorax if the Heimlich tube is occluded or connected backward 4. Re-expansion pulmonary edema after rapid evacuation of a large, subacute pneumothorax 5. Empyema following nonsterile catheter placement
Summary
Pneumothorax may occur spontaneously or result from underlying lung disease or as a complication of interventional thoracic procedures. Percutaneous catheter placement enables safe and effective drainage of pneumothoraces with rapid relief of symptoms and restoration of vital capacity and oxygenation.
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Address reprint requests to Jeremy J. Erasmus, MD Department of Radiology Box 3808 Duke University Medical Center Durham, NC 27710 e:mail: [email protected]
0033-8389/00 $15.00
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MANAGEMENT OF MALIGNANT PLEURAL EFFUSIONS AND PNEUMOTHORAX Jeremy J. Erasmus, MD, Philip C. Goodman, MD, and Edward F. Patz, Jr, MD
Pleural abnormalities result from a wide range of diseases including inflammatory, neoplastic, and infectious processes, and iatrogenic causes. This article focuses on the management of two common pleural abnormalities: malignant pleural effusion and pneumothorax. PLEURAL ANATOMY AND PHYSIOLOGY
The pleural surface is formed by a continuous, single layer of mesothelial cells that line the lung (visceral pleura); chest wall; diaphragm; and mediastinum (parietal pleura). Approximately 10 to 20 mL of fluid is normally present in the pleural space, acting as a lubricant during respiration. This predominantly low-protein fluid is generated from the parietal surface, which is supplied by the high-pressure systemic circulation (i.e., intercostal vessels), and is reabsorbed into capillaries within the visceral surface supplied by pulmonary vessels. The pressure gradient between the two surfaces accounts for the flow of as much as 10 L of fluid through the pleural space in a 24-hour period.', 9, 17, 29- Disruption of any part of the pleural fluid dynamics (i.e., hydrostatic pressure, colloid osmotic pressure, capillary permeability, or lymphatic
drainage) can result in the formation of an abnormal pleural fluid colle~tion.~, 41, 52 PLEURAL FLUID CHARACTERISTICS
Pleural effusions are classified as transudates or exudates, depending on fluid characteristics. This distinction is important in suggesting the appropriate differential diagnosis and subsequently in determining treatment options. Transudates are rarely a cause of malignant effusion, whereas malignancy is the most common cause of an exudate in adults 43, 78, 82 Criteria used to over 60 years of age.42, diagnose an exudate include'3,43 pleural fluid-serum protein ratio >0.5 pleural fluid lactate dehydrogenase (LDH) > 200 units pleural fluid-serum LDH ratio >0.6 protein >3 g/dL pH >7.3 specific gravity >1.016 MALIGNANT PLEURAL EFFUSIONS
Malignant pleural effusions are a common problem in cancer patients with advanced disease. Approximately 50% of patients with breast carcinoma, 25% of patients with lung
From the Department of Radiology, Duke University Medical Center, Durham, North Carolina
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carcinoma, and 35% of patients with lymphoma develop a malignant effusion during the course of their disease. These three tumors and ovarian carcinoma account for over 75% of all malignant effusion^.^, 11, 25, 35, 74 Patients with malignant pleural effusions typically present with progressive dyspnea, although occasionally they have a persistent cough or chest pain.81Chest radiographs confirm the size and location of the pleural collection and aid in management. For initial diagnosis and treatment, a thoracentesis usually is performed. Symptomatic relief is frequently attained by removing a large amount of fluid. Not all pleural effusions in patients with a known primary neoplasm are malignant; malignant cells are only detected in approximately 50% of proved malignant effus i o n ~ ,68,~75~ but , exudative collections should be considered metastatic until proved otherwise. Treatment depends on a number of variables including the patient's symptoms, performance status, extent of disease, effectiveness of systemic therapy, and prognosis. For example, pleural effusions caused by lymphoma, small-cell lung cancer, or germ cell neoplasm may be controlled by systemic chemotherapy. Pleural effusions that are not controlled by systemic treatment often require local palliative therapy to improve symptoms, reduce unnecessary hospitalizations, and minimize expense and complications. Most commonly, tube thoracostomy and drainage followed by sclerotherapy are the modalities of choice. This has traditionally been performed with large-bore thoracostomy tubes (greater than 24F catheter).29, 76 The disadvantages to this approach are that hospitalization is required, mobility is limited, and patients often are uncomfortable. More recently, smallbore catheters placed using radiologic guidance have produced response rates equal to those seen using larger tubes.26,29, 56, 59, 63, 76 Imaging not only localizes the pleural collection but at times reveals unexpected findings (e.g., CT demonstration of pleural metastases instead of fluid), which prevents an unnecessary procedure. The primary goal of drainage and sclerotherapy is to effect a prolonged reexpansion of lung and improve oxygenation. Patients with a central mass obstructing the ipsilateral bronchus or patients with a thick pleural peel do not benefit from tube thoracostomy because the lung cannot be fully reexpanded.
Technical Considerations Small-bore catheters typically are placed in the midaxillary line at the sixth or seventh intercostal space, although image guidance is helpful in selecting the optimal route and site. Patients should be prepared and draped in sterile fashion, and well anesthetized down to the pleural surface using 1%lidocaine. A skin incision large enough to accommodate a 14F catheter is made and blunt dissection with a needle driver or Kelly clamp is performed along the anticipated chest tube tract. An 18-gauge trocar needle is then placed into the pleural space; the positioning is confirmed by observing fluid flowing from the proximal end of the needle after the stylet is removed or by aspirating a small amount of fluid from the pleural space using a small syringe. A 0.038-in floppy-tipped wire is advanced well into the fluid collection (this helps to break down adhesions mechanically). Sequential dilators (usually 8F, lOF, 12F, and 14F catheter) are then used to prepare the tube tract. A 14F catheter pigtail chest drainage tube is advanced over the wire into the pleural fluid. The pigtail catheter is curled and locked, and up to 1 L of fluid may be aspirated depending on patient comfort and symptoms. If the patient begins to cough before 1 L has been removed, aspiration is discontinued. Tubes may be secured to the skin using an adhesive disk arrangement and are not generally sutured in place. This permits easy tube manipulation if necessary. A postprocedure chest radiograph is obtained to ensure proper catheter placement and evaluate the degree of remaining fluid. Up to 30% of patients may have a pneumothorax demonstrated on this chest film. The pneumothorax does not require therapy and is thought to occur for the following reasons: the lung is relatively stiff and incapable of immediate re-expansion; and the musculoskeletal hemithorax is fixed in position and does not collapse inward, yet something must fill in the pleural space previously occupied by fluid.16 The source of air for this "ex vacuo" phenomenon is unknown but it is not thought to be caused by visceral pleural violation, and resolves once the lung re-expands (Fig. 1). The tube can then be connected by a threeway stopcock to an underwater drainage system, such as a Pleur-evac with continuous wall suction at 20 to 30 cm H20.The catheters should be flushed with 10 mL of normal sa-
MANAGEMENT OF MALIGNANT PLEURAL EFFUSIONS AND PNEUMOTHORAX
Figure 1. A 48-year-old woman with breast cancer presents with increasing cough and shortness of breath. A, Posteroanteriorchest radiograph demonstrates a complex right pleural effusion. B, Portable chest film immediately following chest tube placement demonstrates a decrease in the effusion and a right basilar pneumothorax (arrows). The right chest tube is in satisfactory position. C,One day later, a posteroanterior chest film demonstrates a decrease in the right pleural effusion, without evidence of a pneumothorax. 0,A posteroanterior chest radiograph following tube removal demonstrates re-expansion of the lung and a small residual pleural effusion. The patient had significant improvement in her shortness of breath.
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line every 8 to 12 hours. Patients are seen daily to ensure proper tube functioning and to record the drainage amounts. Daily chest radiographs are not essential when drainage continues without difficulty and there are no unexpected patient complaints. When drainage decreases to 200 mL in a 24-hour period, a chest radiograph is performed to exclude loculated fluid and confirm complete lung reexpansion. Patients with decreased drainage but radiographically evident fluid should have their catheters flushed to determine patency. Sometimes heparin or streptokinase, or occasionally insertion of a guidewire, is required to open a clotted catheter. If fluid loculation occurs, instillation of streptokinase (250,000 units in 100 mL of normal saline for 1 to 3 days) may break down adhesions and improve drainage.l0,57 If the tube is severely kinked it may need to be replaced. It is important that the pleural fluid is drained before instilling the sclerosing agent, because successful pleurodesis requires close contact between the visceral and parietal pleural surfaces. Once the pleural space has been completely drained (usually 2 to 5 days), a sclerosant is selected. Different substances, such as talc, biologic substances, antibiotics, antineoplastics, and radioisotopes, have been used for this purpose.+ Although different mechanisms of action have been proposed for the various classes of drug, no single agent has a proven advantage. Ongoing trials have continually evaluated the efficacy and cost benefit of these agents. In one recent study, a 5-g talc slurry instilled through a small-bore tube produced as effective a response rate as other agents placed through larger tubes and cost less, with fewer complications than other combination^.^^ After the sclerosing agent is introduced, the tube is closed and the patient is instructed to change position (roll from side to side) every 15 minutes for 2 hours in an effort to distribute the sclerosant uniformly throughout the pleural space. The tube is then reopened to suction for 24 hours, at which time, if the drainage remains less than 200 mL, the tube is removed. A second dose of sclerosant usually is administered if drainage amounts exceed 200 mL. Complications are unusual and include *References 8, 12, 14, 18, 20, 21, 23, 24, 26, 28, 30, 31, 34, 36, 37, 45, 46, 48, 49, 51, 54, 55, 60-62, 65, 71-73, 76, 77, 83, 84, 86, 87.
tube malfunction ( e g , clotting or kinking); tube malposition; infection; hemorrhage; loculation of fluid; and pneumothorax. Ambulatory Sclerotherapy
One significant advantage of sclerotherapy with small-bore catheters is the potential for outpatient treatment. Patients with symptomatic, unilateral malignant pleural effusions with a reasonable performance status should be considered for ambulatory therapy. As with inpatient procedures, all patients should have a predrainage baseline chest radiograph. Using the same techniques described previously, a small-bore (10.3F to 14F catheter) all-purpose drainage catheter is placed using image guidance (generally ultrasound or CT). The tube is secured to the skin using a Molnar disk. This allows easy accessibility for repositioning of the catheter if necessary. Similar to other pleural drainage procedures, about 1 L of fluid is aspirated, less if the patient begins to cough. The catheter is then connected to a Tru-Close 600-mL bag (UreSil, L.P. Skokie, IL) for gravity drainage. This bag is designed to be emptied by the patient without danger of backflow of air into the pleural space. A postprocedure chest radiograph is taken to assess catheter position. Patients are provided with home care instructions and told that when drainage falls below 200 mL per day, to return to the hospital or outpatient clinic for sclerotherapy. A repeat chest radiograph is obtained at this time to confirm complete fluid drainage, absence of loculations, and complete lung reexpansion. Any remaining fluid is aspirated before instillation of the sclerosing agent. After the sclerosant is introduced and the tube clamped, patients are instructed to change positions for 2 hours, after which time the tube is reopened to gravity drainage. The patient is then sent home and returns the following day for chest tube removal. In one pilot study of ambulatory sclerotherapy, 19 patients required chest tubes for 2 to 11 days (mean, 5.1 days), while draining between 950 and 3925 mL of pleural fluid (mean, 1647 mL). At 30 days, 10 patients (53%) had a complete radiographic response and 5 (26%)had a partial response. Four patients (21%) had progressive disease. Of the four treatment failures, three had a good initial response, but had failed at 30 days. There was no significant difference in either tube
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duration or total drainage between the three response groups. No patient required hospitalization during the course of therapy, and all patients had significant symptomatic improvement in their respiratory These data suggest outpatient management of malignant pleural effusion is a viable alternative to traditional inpatient tube thoracostomy and sclerotherapy. Such treatment offers an important potential benefit to the patient, including a better quality of life and reduction in health care costs.
hours following tube in~ertion.'~, 19, 38*40, Lack of response usually is caused by technical factors (catheter malposition and occlusion) or a very large air leak.19,38, 67,69 Common indications for pneumothorax drainage include38,39, 70 chest pain accompanied by shortness of breath and decreased oxygenation, particularly if the pneumothorax is estimated to be greater than 20% to 25% of the volume of a hemithorax; and progressive enlargement of a pneumothorax or findings of tension pneumothorax.
Summary
Contraindications
Malignant pleural effusions are a common problem for cancer patients. The fluid collections may be a result of contiguous spread of tumor or metastases from distant disease. Patients usually present with shortness of breath, which significantly impacts on their quality of life. Therapy is palliative only and is designed to minimize discomfort, cost, and morbidity. Rapid symptomatic relief is the goal. Some patients require an immediate, temporizing thoracentesis, whereas others with asymptomatic intervals may benefit from repeat thoracenteses. The majority of patients, however, require tube drainage and sclerotherapy. Small-bore catheters are well tolerated and effective for this purpose and permit outpatient care.
There are no absolute contraindications to percutaneous drainage of pneumothorax using small-bore catheters. Because patients on mechanical ventilation can have large air leaks, a standard thoracostomy tube may be required. If there is a coexisting complex pleural fluid collection, a small catheter may become occluded, and a standard thoracos8o tomy tube may be a better
PERCUTANEOUS TUBE PLACEMENT FOR PNEUMOTHORAX
Clinically significant pneumothorax with collapse caused by increased pleural pressure usually results from disruption of the visceral pleura. This may occur spontaneously in patients without previously known pulmonary abnormalities, as a result of long-standing lung disease (e.g., eosinophilic granuloma, emphysema); trauma; or as a complication of a diagnostic or therapeutic p r o c e d ~ r e The .~ incidence of pneumothorax is 5% to 20% following thoracentesis and pleural biopsy5,22, 27, 79 less than 1% to 3% after transbronchial biopsy5,58 and 10% to 50% after transthoracic needle lung biopsy.57, 38, 85 The treatment for most iatrogenic pneumothoraces is small-bore tube placement (7F to 10F catheter). Success rates are reported to be 87% to 97%, with the vast majority of pneumothoraces resolving within 24 to 72
Techniques
Tube placement usually is performed with fluoroscopic guidance. Occasionally, CT is helpful because it can prevent intraparenchyma1 catheter placement in patients with pulmonary fibrosis and pleural adhesions. The entry site depends on the location and size of the pneumothorax. We generally place the tubes in the fifth or sixth intercostal space at the midaxillary line, although initial reports suggested the second or third anterior intercostal space at the midclavicular line might produce optimal positioning of the catheter in the apex of the pleural space.38,8o The site is cleaned with an antiseptic solution and anesthetized with 1% lidocaine. A small skin incision slightly larger than the catheter diameter is then made to ensure no resistance when the tube is inserted. The choice of drainage tube depends on physician preference. Many use a trocar-stiffened 8F to 10F straight catheter placed with a single puncture. Pigtail catheters inserted over a guidewire using Seldinger technique can also be used, and are probably preferable in patients with fluid in the pleural space. The catheter-trocar system is angled in a cranial direction above the rib to avoid intercostal neurovascular bundle injury and ad-
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Figure 2. See legend on opposite page
vanced into the pleural space. A gush of air should be apparent when the catheter tip transverses the parietal pleura. The trocar is then held in position, and the catheter advanced. Once the tip is in satisfactory position, the trocar is removed, and the catheter secured with skin sutures. At our institution, the tube usually is connected to a one-way Heimlich valve, although patients with a large air leak and a nonexpanding lung may have the tube connected to an underwater drainage system, such as a Pleur-evac with continuous suction (-20 cm H,O). Management
Upright posteroanterior and lateral chest radiographs are obtained after the procedure
to determine the size of any residual pneumothorax and to confirm the position of the drainage catheter. A repeat radiograph is performed after 18 to 24 hours of drainage. If the pneumothorax has resolved, the catheter is clamped for approximately 4 hours, after which a repeat chest film is obtained. If the lung remains completely expanded the catheter is removed (Fig. 2). Occlusion or malposition of the catheter can result in a persistent neumothorax. This is suspected clinically if t ere is no symptomatic improvement, or if there is no pressure variation in the water-seal chamber of the Pleur-evac with breathing.38 Residual pneumothoraces may also be seen after catheter placement if the air leak is large, wherein insertion of a second catheter or large thora-
R
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Figure 2. A 67-year-old man presented for percutaneous biopsy of a large right hilar mass. A, The patient developed an increasing right hydropneurnothorax following the biopsy, with progressive shortness of breath. B, An 8F pigtail catheter was inserted into the pleural space, with a significant decrease in the right pneurnothorax. C, Posteroanterior chest radiograph 2 days later demonstrates no significant pneumothorax following removal of the chest tube.
costomy tube may be required for successful treatment. Patients with a persistent pneumothorax may also benefit from chemical pleurodesis using sclerosing agents, such doxycycline, talc, or bleomycin.2,33, 53, 66 Complications
Complications of percutaneous placement of small-bore drainage catheters for the treatment of pneumothorax are rare. They include the following19,38r47, 67, 80: 1. Laceration of an intercostal artery resulting in a chest wall hematoma or hemothorax 2. Laceration of the visceral pIeura and lung by the trocar or catheter, or intraparenchymal placement of the catheter resulting in a persistent air leak and bronchopleural fistula 3. Tension pneumothorax if the Heimlich tube is occluded or connected backward 4. Re-expansion pulmonary edema after rapid evacuation of a large, subacute pneumothorax 5. Empyema following nonsterile catheter placement
Summary
Pneumothorax may occur spontaneously or result from underlying lung disease or as a complication of interventional thoracic procedures. Percutaneous catheter placement enables safe and effective drainage of pneumothoraces with rapid relief of symptoms and restoration of vital capacity and oxygenation.
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Address reprint requests to Jeremy J. Erasmus, MD Department of Radiology Box 3808 Duke University Medical Center Durham, NC 27710 e:mail: [email protected]