- Email: [email protected]
Use of Indwelling Pleural Catheters for Chronic Pleural Infection
CHEST
Selected Reports
Use of Indwelling Pleural Catheters for Chronic Pleural Infection* Helen E. Davies, MBBS; Najib M. Rahman, BMBCh, MA (Oxon); Robert J. Parker, MSc; and Robert J. O. Davies, DM
Recurrent, chronic pleural infection creates difficult management issues. Surgical drainage is currently recommended for patients who have failed initial “medical treatment” (ie, tube thoracostomy and antibiotic therapy), but the options for patients not fit for surgery are limited. Prolonged closed tube drainage may be an option in this group, although concerns exist regarding the efficacy and risk of catheter blockage. Long-term indwelling pleural catheters are increasingly used for the treatment of recurrent malignant pleural effusion. Pleural infection is recognized as a complication and is cited as a contraindication to insertion of an indwelling pleural drain within the product literature. We report two patients with empyema in a fixed pleural space in whom the insertion of an ambulatory catheter produced successful drainage. Longterm indwelling pleural catheters may have a role in maintaining the drainage of a chronically infected pleural space that is not readily treated in other ways. (CHEST 2008; 133:546 –549) Key words: chronic empyema; indwelling pleural catheter; pleural effusion; pleural infection
Case 1 A 54-year-old man with seropositive erosive rheumatoid arthritis, controlled with long-term therapy with methotrexate and steroids, and a chronic right bronchopleural fistula presented with a right-sided empyema. Chest radiography showed a right hydropneumothorax (Fig 1) and purulent pleural aspirate cultured coliforms.
Figure 1. Chest radiographs showing a large right pyopneumothorax.
*From the Oxford Pleural Unit, Oxford Centre for Respiratory Medicine, University of Oxford and Oxford Radcliffe NHS Trust, Oxford, UK. The authors have reported to the ACCP that no significant conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article. Manuscript received July 13, 2007; revision accepted August 6, 2007. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal. org/misc/reprints.shtml). Correspondence to: Helen E. Davies, MBBS, Oxford Pleural Unit, Oxford Centre for Respiratory Medicine, Churchill Hospital, Oxford Radcliffe NHS Trust, Oxford, OX3 7LJ, UK; e-mail: [email protected] DOI: 10.1378/chest.07-1742
Initial treatment was with tube drainage (12F Portex chest drain; SIMS Portex Ltd; Hythe, Kent, UK) and broad-spectrum antibiotic therapy. Surgery was considered, but the residual lung was severely damaged and fibrotically contracted, and it was thought that lung expansion could not be achieved. The pyopneumothorax recurred on removal of the chest tube. A 15.5F indwelling pleural catheter (Pleurx; Denver Biomedicals; Golden, CO) was inserted to maintain a dry pleural space, and alternate-day drainage was commenced, with up to 400 mL of fluid obtained on each occasion. Clinical and radiographic improvement subsequently occurred with significant lung reexpansion (Fig 2) and closure of the bronchopleural fistula. Pleural fluid production correspondingly reduced, and the pleural catheter was removed 21 months after insertion.
546
Selected Reports
Figure 2. Series of radiographs showing gradual resolution of the right pyopneumothorax and resultant development of pleural thickening. Top left: following insertion of indwelling pleural catheter. Top right: at 3 months. Bottom left: at 6 months. Bottom right: at 21 months prior to drain removal.
Case 2 A 31-year-old Indian man was referred for management of his pleural empyema. He had a 6-month history of productive cough, weight loss, and night sweats. His chest radiograph showed a large left pleural effusion (Fig 3, top left). Thoracentesis yielded lymphocytic exudative fluid, and closed pleural biopsies showed necrotizing granulomatous inflammation and were culture positive for acid-fast bacilli. He started quadruple antituberculous chemotherapy with rifampicin, isoniazid, pyrazinamide, and ethambutol. After initial complete chest tube drainage (12F Seldinger chest drain; Rocket Medical PLC; Washington, Tyne & Wear, UK), the effusion recurred and when resampled was turbid with a pleural fluid pH of 6.97, a glucose concentration of 1.0 mmol/L, and a lactate dehydrogenase concentration of 5,476 IU/L. The patient remained febrile. Thoracic ultrasound demonstrated a multiloculated, echogenic collection (Fig 3, top right), and CT scanning showed a residual left pleural effusion with right upper lobe nodularity and necrotic mediastinal lymphadenopathy consistent with active tuberculosis. Mediastinal air was also visible, and oral contrast administration confirmed esophageal perforation due to necrotizing tuberculous lymphadenopathy (Fig 3, bottom left). Tuberculous pleurisy with superadded bacterial empyema was diagnosed, and treatment with broad-spectrum antibiotics was added to the antituberculous therapy. www.chestjournal.org
Upper GI endoscopy demonstrated the presence of a 1.5-cm opening in the distal esophagus due to erosion by tuberculous lymph nodes; laparotomy, omental biopsy (which showed multiple epithelioid granulomata with caseous necrosis), and insertion of a feeding jejunostomy tube was subsequently performed. Despite these measures, his fever persisted, and the pleural collection reaccumulated. An ambulatory long-term tunneled pleural catheter (15.5F Pleurx catheter; Denver Biomedicals) was inserted. This was initially drained three times per week by the patient, with aspiration of up to a total of 1,250 mL each week. He was discharged to home on day 52 and steadily recovered, requiring less frequent pleural drainage. The drain was removed when no pleural fluid had been obtained for 6 weeks. At 8 months, his chest radiograph findings were nearly normal (Fig 3, bottom right).
Discussion Long-term indwelling pleural catheters are increasingly used for the treatment of recurrent pleural effusion. Pleural infection is recognized as a complication1–3 and is cited as a contraindication to insertion of an indwelling pleural drain. The use of ambulatory indwelling pleural catheters in our two cases illustrates a novel strategy for the treatment of a persistently infected pleural space, in CHEST / 133 / 2 / FEBRUARY, 2008
547
Figure 3. Top left: chest radiograph on presentation. Top right: thoracic ultrasound image demonstrating multiple septations (arrows) within pleural collection. Bottom left: CT image showing pockets of mediastinal air and extraluminal leak of oral contrast (arrow). Bottom right: chest radiograph at 8 months.
one case with a bronchopleural fistula, and in the other with an esophagopleural fistula. Previously, the standard care for these patients has been rib resection and longterm open drainage, which is unpleasant for the patient, substantially reducing quality of life.4 Rib excision with associated large-bore chest tube insertion into the residual infected cavity often takes ⬎ 6 months to heal and, in patients already debilitated by chronic pleural infection, may be poorly tolerated. The use of a more permanent “open” drainage system, introduced initially by Eloesser in 19355,6 and subsequently modified by Symbas et al7 and Thourani et al,8 provides an alternative approach; however, it is only an option in a select cohort of this patient population (ie, those fit for operative intervention) and still leaves the patient with an unpleasant open draining fistula. Our cases suggest that outcomes as successful as those seen with open drainage can be achieved with small-bore indwelling catheters that allow the patient a better quality of life during sustained pleural drainage. Thus, just as short-term fine-bore pigtail catheter drainage can be useful during the acute phase of care,9 long-term drainage can be effective for chronic pleural infection, without the problems of catheter blockage or 548
tract infection. This strategy warrants exploration in larger patient samples and randomized trials.
References 1 Pien GW, Gant MJ, Washam CL, et al. Use of an implantable pleural catheter for trapped lung syndrome in patients with malignant pleural effusion. Chest 2001; 119:1641–1646 2 Putnam JB Jr, Light RW, Rodriguez RM, et al. A randomized comparison of indwelling pleural catheter and doxycycline pleurodesis in the management of malignant pleural effusions. Cancer 1999; 86:1992–1999 3 van den Toorn LM, Schaap E, Surmont VF, et al. Management of recurrent malignant pleural effusions with a chronic indwelling pleural catheter. Lung Cancer 2005; 50:123–127 4 Davies CW, Gleeson FV, Davies RJ. BTS guidelines for the management of pleural infection. Thorax 2003; 58(suppl): ii18 –ii28 5 Eloesser L. An operation for tuberculous empyema. Surg Gynecol Obstet 1935; 60:1096 –1097 6 Eloesser L. Of an operation for tuberculous empyema. Ann Thorac Surg 1969; 8:355–357 7 Symbas PN, Nugent JT, Abbott OA, et al. Nontuberculous Selected Reports
pleural empyema in adults: the role of a modified Eloesser procedure in its management. Ann Thorac Surg 1971; 12:69 –78 8 Thourani VH, Lancaster RT, Mansour KA, et al. Twenty-six years of experience with the modified Eloesser flap. Ann Thorac Surg 2003; 76:401– 405 9 Crouch JD, Keagy BA, Delany DJ. “Pigtail” catheter drainage in thoracic surgery. Am Rev Respir Dis 1987; 136:174 –175
A Hitherto Unreported Pulmonary Complication in an IV Heroin User* Ayman Bishay, MD; Alexey Amchentsev, MD; Anthony Saleh, MD, FCCP; Neelam Patel, MD; William Travis, MD, FCCP; and Suhail Raoof, MD, FCCP
IV heroin use is associated with several welldescribed complications, including noncardiogenic pulmonary edema, aspiration pneumonitis, ARDS, pneumonia, lung abscess, septic pulmonary emboli, and atelectasis. Foreign-body granulomatosis may develop when drug users inject solutions containing crushed oral tablets in which talc is used as filler and can be complicated by pulmonary fibrosis. The effects are distinct from pulmonary edema, which may occur acutely with heroin injection. We describe the case of a young female patient who was an IV heroin user who also smoked cigarettes, and presented with progressive dyspnea, hypoxia, and bilateral lung infiltrates. The final pathologic diagnosis in this case was one that had not been previously reported in IV heroin users. (CHEST 2008; 133:549 –551) Key words: drug abuse; interstitial lung disease; lung pathology Abbreviations: BOOP ⫽ bronchiolitis obliterans organizing pneumonia; OP ⫽ organizing pneumonia
a case of an IV heroin user with progresW esivedescribe dyspnea, hypoxia, and bilateral lung infiltrates.
Figure 1. Diffuse bilateral reticular infiltrates.
one that has not been previously reported in IV heroin users.1,2
Case Report A 24-year-old female patient presented with nonproductive cough and progressive shortness of breath for 5 months with significant worsening in the last 2 weeks. She also had night sweats, nausea, and headache. The patient had been an active IV heroin user for the last 7 years and has a smoking history of 8 pack-years. Her medical history was significant for depression and cardiac arrest in 2001 secondary to an illicit drug overdose. Her medications included fluoxetine, 80 mg daily, trazodone, 100 mg daily, and methadone, 30 mg daily. A physical examination demonstrated a cachectic young white female in moderate respiratory distress who was normotensive and afebrile. Her arterial oxygen saturation at rest while breathing room air was 88%. She had a few scattered crackles, which were prominent at the lung bases. Laboratory results were significant for a total bilirubin concentration of 2.8 mg/dL, an aspartate aminotransferase concentration of 171 IU/L, an alanine aminotransferase concentration of 155 IU/L, and an alkaline
Surprisingly, the final pathologic diagnosis in this case was
*From the Department of Internal Medicine (Drs. Bishay, Amchentsev, Saleh, Patel, and Raoof), Division of Pulmonary and Critical Care Medicine, New York Methodist Hospital, New York, NY; and the Department of Pathology (Dr. Travis), Memorial Sloan Kettering Cancer Center, New York, NY. The authors have reported to the ACCP that no significant conflict of interests exist with any companies/organizations whose products or services may be discussed in this article. Manuscript received March 30, 2007; revision accepted July 16, 2007. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal. org/misc/reprints.shtml). Correspondence to: Ayman Bishay, MD, New York Methodist Hospital, Internal Medicine/Division of Pulmonary and Critical Care, 506 6th St, Brooklyn, NY 11215; e-mail: aymanbishay@ yahoo.com DOI: 10.1378/chest.07-0805 www.chestjournal.org
Figure 2. Diffuse infiltrates with areas of ground-glass opacities. CHEST / 133 / 2 / FEBRUARY, 2008
549
Selected Reports
Use of Indwelling Pleural Catheters for Chronic Pleural Infection* Helen E. Davies, MBBS; Najib M. Rahman, BMBCh, MA (Oxon); Robert J. Parker, MSc; and Robert J. O. Davies, DM
Recurrent, chronic pleural infection creates difficult management issues. Surgical drainage is currently recommended for patients who have failed initial “medical treatment” (ie, tube thoracostomy and antibiotic therapy), but the options for patients not fit for surgery are limited. Prolonged closed tube drainage may be an option in this group, although concerns exist regarding the efficacy and risk of catheter blockage. Long-term indwelling pleural catheters are increasingly used for the treatment of recurrent malignant pleural effusion. Pleural infection is recognized as a complication and is cited as a contraindication to insertion of an indwelling pleural drain within the product literature. We report two patients with empyema in a fixed pleural space in whom the insertion of an ambulatory catheter produced successful drainage. Longterm indwelling pleural catheters may have a role in maintaining the drainage of a chronically infected pleural space that is not readily treated in other ways. (CHEST 2008; 133:546 –549) Key words: chronic empyema; indwelling pleural catheter; pleural effusion; pleural infection
Case 1 A 54-year-old man with seropositive erosive rheumatoid arthritis, controlled with long-term therapy with methotrexate and steroids, and a chronic right bronchopleural fistula presented with a right-sided empyema. Chest radiography showed a right hydropneumothorax (Fig 1) and purulent pleural aspirate cultured coliforms.
Figure 1. Chest radiographs showing a large right pyopneumothorax.
*From the Oxford Pleural Unit, Oxford Centre for Respiratory Medicine, University of Oxford and Oxford Radcliffe NHS Trust, Oxford, UK. The authors have reported to the ACCP that no significant conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article. Manuscript received July 13, 2007; revision accepted August 6, 2007. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal. org/misc/reprints.shtml). Correspondence to: Helen E. Davies, MBBS, Oxford Pleural Unit, Oxford Centre for Respiratory Medicine, Churchill Hospital, Oxford Radcliffe NHS Trust, Oxford, OX3 7LJ, UK; e-mail: [email protected] DOI: 10.1378/chest.07-1742
Initial treatment was with tube drainage (12F Portex chest drain; SIMS Portex Ltd; Hythe, Kent, UK) and broad-spectrum antibiotic therapy. Surgery was considered, but the residual lung was severely damaged and fibrotically contracted, and it was thought that lung expansion could not be achieved. The pyopneumothorax recurred on removal of the chest tube. A 15.5F indwelling pleural catheter (Pleurx; Denver Biomedicals; Golden, CO) was inserted to maintain a dry pleural space, and alternate-day drainage was commenced, with up to 400 mL of fluid obtained on each occasion. Clinical and radiographic improvement subsequently occurred with significant lung reexpansion (Fig 2) and closure of the bronchopleural fistula. Pleural fluid production correspondingly reduced, and the pleural catheter was removed 21 months after insertion.
546
Selected Reports
Figure 2. Series of radiographs showing gradual resolution of the right pyopneumothorax and resultant development of pleural thickening. Top left: following insertion of indwelling pleural catheter. Top right: at 3 months. Bottom left: at 6 months. Bottom right: at 21 months prior to drain removal.
Case 2 A 31-year-old Indian man was referred for management of his pleural empyema. He had a 6-month history of productive cough, weight loss, and night sweats. His chest radiograph showed a large left pleural effusion (Fig 3, top left). Thoracentesis yielded lymphocytic exudative fluid, and closed pleural biopsies showed necrotizing granulomatous inflammation and were culture positive for acid-fast bacilli. He started quadruple antituberculous chemotherapy with rifampicin, isoniazid, pyrazinamide, and ethambutol. After initial complete chest tube drainage (12F Seldinger chest drain; Rocket Medical PLC; Washington, Tyne & Wear, UK), the effusion recurred and when resampled was turbid with a pleural fluid pH of 6.97, a glucose concentration of 1.0 mmol/L, and a lactate dehydrogenase concentration of 5,476 IU/L. The patient remained febrile. Thoracic ultrasound demonstrated a multiloculated, echogenic collection (Fig 3, top right), and CT scanning showed a residual left pleural effusion with right upper lobe nodularity and necrotic mediastinal lymphadenopathy consistent with active tuberculosis. Mediastinal air was also visible, and oral contrast administration confirmed esophageal perforation due to necrotizing tuberculous lymphadenopathy (Fig 3, bottom left). Tuberculous pleurisy with superadded bacterial empyema was diagnosed, and treatment with broad-spectrum antibiotics was added to the antituberculous therapy. www.chestjournal.org
Upper GI endoscopy demonstrated the presence of a 1.5-cm opening in the distal esophagus due to erosion by tuberculous lymph nodes; laparotomy, omental biopsy (which showed multiple epithelioid granulomata with caseous necrosis), and insertion of a feeding jejunostomy tube was subsequently performed. Despite these measures, his fever persisted, and the pleural collection reaccumulated. An ambulatory long-term tunneled pleural catheter (15.5F Pleurx catheter; Denver Biomedicals) was inserted. This was initially drained three times per week by the patient, with aspiration of up to a total of 1,250 mL each week. He was discharged to home on day 52 and steadily recovered, requiring less frequent pleural drainage. The drain was removed when no pleural fluid had been obtained for 6 weeks. At 8 months, his chest radiograph findings were nearly normal (Fig 3, bottom right).
Discussion Long-term indwelling pleural catheters are increasingly used for the treatment of recurrent pleural effusion. Pleural infection is recognized as a complication1–3 and is cited as a contraindication to insertion of an indwelling pleural drain. The use of ambulatory indwelling pleural catheters in our two cases illustrates a novel strategy for the treatment of a persistently infected pleural space, in CHEST / 133 / 2 / FEBRUARY, 2008
547
Figure 3. Top left: chest radiograph on presentation. Top right: thoracic ultrasound image demonstrating multiple septations (arrows) within pleural collection. Bottom left: CT image showing pockets of mediastinal air and extraluminal leak of oral contrast (arrow). Bottom right: chest radiograph at 8 months.
one case with a bronchopleural fistula, and in the other with an esophagopleural fistula. Previously, the standard care for these patients has been rib resection and longterm open drainage, which is unpleasant for the patient, substantially reducing quality of life.4 Rib excision with associated large-bore chest tube insertion into the residual infected cavity often takes ⬎ 6 months to heal and, in patients already debilitated by chronic pleural infection, may be poorly tolerated. The use of a more permanent “open” drainage system, introduced initially by Eloesser in 19355,6 and subsequently modified by Symbas et al7 and Thourani et al,8 provides an alternative approach; however, it is only an option in a select cohort of this patient population (ie, those fit for operative intervention) and still leaves the patient with an unpleasant open draining fistula. Our cases suggest that outcomes as successful as those seen with open drainage can be achieved with small-bore indwelling catheters that allow the patient a better quality of life during sustained pleural drainage. Thus, just as short-term fine-bore pigtail catheter drainage can be useful during the acute phase of care,9 long-term drainage can be effective for chronic pleural infection, without the problems of catheter blockage or 548
tract infection. This strategy warrants exploration in larger patient samples and randomized trials.
References 1 Pien GW, Gant MJ, Washam CL, et al. Use of an implantable pleural catheter for trapped lung syndrome in patients with malignant pleural effusion. Chest 2001; 119:1641–1646 2 Putnam JB Jr, Light RW, Rodriguez RM, et al. A randomized comparison of indwelling pleural catheter and doxycycline pleurodesis in the management of malignant pleural effusions. Cancer 1999; 86:1992–1999 3 van den Toorn LM, Schaap E, Surmont VF, et al. Management of recurrent malignant pleural effusions with a chronic indwelling pleural catheter. Lung Cancer 2005; 50:123–127 4 Davies CW, Gleeson FV, Davies RJ. BTS guidelines for the management of pleural infection. Thorax 2003; 58(suppl): ii18 –ii28 5 Eloesser L. An operation for tuberculous empyema. Surg Gynecol Obstet 1935; 60:1096 –1097 6 Eloesser L. Of an operation for tuberculous empyema. Ann Thorac Surg 1969; 8:355–357 7 Symbas PN, Nugent JT, Abbott OA, et al. Nontuberculous Selected Reports
pleural empyema in adults: the role of a modified Eloesser procedure in its management. Ann Thorac Surg 1971; 12:69 –78 8 Thourani VH, Lancaster RT, Mansour KA, et al. Twenty-six years of experience with the modified Eloesser flap. Ann Thorac Surg 2003; 76:401– 405 9 Crouch JD, Keagy BA, Delany DJ. “Pigtail” catheter drainage in thoracic surgery. Am Rev Respir Dis 1987; 136:174 –175
A Hitherto Unreported Pulmonary Complication in an IV Heroin User* Ayman Bishay, MD; Alexey Amchentsev, MD; Anthony Saleh, MD, FCCP; Neelam Patel, MD; William Travis, MD, FCCP; and Suhail Raoof, MD, FCCP
IV heroin use is associated with several welldescribed complications, including noncardiogenic pulmonary edema, aspiration pneumonitis, ARDS, pneumonia, lung abscess, septic pulmonary emboli, and atelectasis. Foreign-body granulomatosis may develop when drug users inject solutions containing crushed oral tablets in which talc is used as filler and can be complicated by pulmonary fibrosis. The effects are distinct from pulmonary edema, which may occur acutely with heroin injection. We describe the case of a young female patient who was an IV heroin user who also smoked cigarettes, and presented with progressive dyspnea, hypoxia, and bilateral lung infiltrates. The final pathologic diagnosis in this case was one that had not been previously reported in IV heroin users. (CHEST 2008; 133:549 –551) Key words: drug abuse; interstitial lung disease; lung pathology Abbreviations: BOOP ⫽ bronchiolitis obliterans organizing pneumonia; OP ⫽ organizing pneumonia
a case of an IV heroin user with progresW esivedescribe dyspnea, hypoxia, and bilateral lung infiltrates.
Figure 1. Diffuse bilateral reticular infiltrates.
one that has not been previously reported in IV heroin users.1,2
Case Report A 24-year-old female patient presented with nonproductive cough and progressive shortness of breath for 5 months with significant worsening in the last 2 weeks. She also had night sweats, nausea, and headache. The patient had been an active IV heroin user for the last 7 years and has a smoking history of 8 pack-years. Her medical history was significant for depression and cardiac arrest in 2001 secondary to an illicit drug overdose. Her medications included fluoxetine, 80 mg daily, trazodone, 100 mg daily, and methadone, 30 mg daily. A physical examination demonstrated a cachectic young white female in moderate respiratory distress who was normotensive and afebrile. Her arterial oxygen saturation at rest while breathing room air was 88%. She had a few scattered crackles, which were prominent at the lung bases. Laboratory results were significant for a total bilirubin concentration of 2.8 mg/dL, an aspartate aminotransferase concentration of 171 IU/L, an alanine aminotransferase concentration of 155 IU/L, and an alkaline
Surprisingly, the final pathologic diagnosis in this case was
*From the Department of Internal Medicine (Drs. Bishay, Amchentsev, Saleh, Patel, and Raoof), Division of Pulmonary and Critical Care Medicine, New York Methodist Hospital, New York, NY; and the Department of Pathology (Dr. Travis), Memorial Sloan Kettering Cancer Center, New York, NY. The authors have reported to the ACCP that no significant conflict of interests exist with any companies/organizations whose products or services may be discussed in this article. Manuscript received March 30, 2007; revision accepted July 16, 2007. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal. org/misc/reprints.shtml). Correspondence to: Ayman Bishay, MD, New York Methodist Hospital, Internal Medicine/Division of Pulmonary and Critical Care, 506 6th St, Brooklyn, NY 11215; e-mail: aymanbishay@ yahoo.com DOI: 10.1378/chest.07-0805 www.chestjournal.org
Figure 2. Diffuse infiltrates with areas of ground-glass opacities. CHEST / 133 / 2 / FEBRUARY, 2008
549