My case study is based on a 74 year old man who came into the hospital for elective admission for the insertion of a pleurex chest drain after several recurrent episodes of malignant pleural effusions. The patient was admitted in a respiratory ward by a nurse with increased shortness of breath and was found to have right pleural effusion after a chest X-ray. A pleurex chest drain was inserted and 2000mls of pleural fluid was drained. Although a number of treatment modalities are available, pleurex chest drainage was the modality being used to manage this specific patient, as such it is necessary to determine whether it is the best management option for malignant pleural effusion. This paper will therefore focus on the issue of the use of pleurex chest drainage in the management of malignant pleural effusions and specifically on the use of pleurex chest catheters. In this regard, issues to do with the background, scientific evidence, the merits and demerits of pleural catheters and those relating to the cost and reimbursements, medical and nursing care, support in the community and self management of patients with pleurex chest catheters in-situ will be explored.
Malignant pleural effusion (MPE), defined as the presence of malignant cells in the pleural space comprise an important complication as well as source of morbidity for patients with intrathoracic and/or extrathoracic malignancies. The median survival following the diagnosis of MPE is 3 to 12 months. MPE can present as the first manifestation of an underlying malignancy or as a complication in late cancer disease. Nearly all the tumor types can cause MPE but lymphomas, carcinomas and mesotheliomas of the lungs, breasts, ovaries and GIT are the most common causes of MPEs. Almost all patients with MPEs present with chronic shortness of breath. Other debilitating symptoms include cough and pain. The aforementioned symptoms impact negatively on the quality of life in the final phase of cancer. A number of cytologic, histologic techniques as well as imaging modalities like X –rays and CT-scans are used in the evaluation of patients suspected to have MPEs (Muduly et al., 2011; Heffner and Klein, 2008).
The goals of management for MPE patients are focused on the relief or total elimination of dyspnea, reestablishment of normal function and activity, reduction or elimination of hospitalization and finally, the efficient use of medical resources. The management of MPE particularly in regard to dyspnea remains palliative and entails the removal of the fluid from the pleural space through the least invasive procedure possible and which in addition must have minimal associated morbidity (Muduly et al., 2011). Thoracentesis, tube thoracostomy or video-assisted thoracoscopic surgery and pleuroperitioneal shunting are the methods used to remove fluid from the pleural space. Thoracentesis entails the installation of pleural tap to drain accumulated pleural fluid. It provides rapid immediate but transient relief of symptoms. It can be performed on an outpatient basis. However, it has a high recurrence rate and is thus recommended for patients with limited expected survival and poor functional status since it avoids the need for hospitalization. VATS and tube-thoracostomy can be followed by pleurodesis, the process of obliterating the pleural space via chemically or mechanically induced inflammation. Pleurodesis is meant to achieve definitive long-term pleural apposition with fibrosis. The aggressiveness of management depends on the functional status of the patient and the severity of MPE symptoms (Muduly et al., 2011; Heffner and Klein, 2008).
As mentioned previously, pleurex/ambulatory chest drainage is also amongst the modalities used to remove fluid accumulated in the pleural space. Large bore (24-36F) and small (7-16F) bore tubes and catheters have been used to drain fluid. Accumulating evidence from a number of studies however supports the use of small bore tubes or catheters because they have been shown to reduce the number of hospitalization days and to reduce the incidence of recurrence. In one such study by Putnam et al. (2000 as cited in Heffner and Klein, 2008) the number of hospitalization days for patients and rate of recurrence for patients on pleurex catheter was 1.5 days and 13% respectively as opposed to 6.5 days and 21% for patients on a standard chest tube. Both large and small bore tubes and catheters have been shown to have almost equal results in the relief of symptoms, enhancing the quality of life and reducing the incidence of complications. Findings from a myriad of studies in addition indicate that small bore tubes cause less discomfort to patients with MPE. As such, they do not limit the patients’ activities. Large bore tubes were used initially because they were thought to be less likely to be obstructed by clots, however there is no evidence from studies so far to support this presumption. As such, small bore tubes are recommended (Muduly et al., 2011; Heffner and Klein, 2008).
Regardless of the size, pleurex chest drainage catheters or tubes are normally inserted at the bedside in the triangle of safety, anterior to the mid-axillary line in the fifth intercostals space under local anaesthesia, with or without ultrasonographic guidance. These tubes or catheters allow the intermittent drainage of about 1000ml of pleural fluid two to three times a week for prolonged periods of time. Studies that have investigated the utility of ultrasonographic guidance during chest catheter insertion and subsequent pleurodosis have reported high success rates because ultrasonographic guidance ensures proper positioning as well as enables the confirmation of the absence of fluid in the pleural space before sclerosants can be instilled (Heffner and Klein, 2008).
Accumulating evidence from a number of studies shows that pleurex chest drainage provides immediate relief of shortness of breath in 94 to 100% of patients and persistent relief for about 30days in 90% of patients. In one such study by Qureshi et al. (2008), 94.2% of the 54 patients who participated in the study had symptomatic relief and a significant reduction in the MRC (Medical Research Council) dyspnea score (pConclusion
In conclusion therefore, MPE is a major cause of morbidity in patients with advanced cancer. It presents with amongst other symptoms shortness of breath. Pleuroperitoneal shunting, thoracentesis, pleurodesis and pleural chest catheters are amongst the various treatment modalities used in the management of the condition. Thoracentesis and pleural catheters are the modalities commonly employed to remove accumulated pleural fluid. Thoracentesis provides rapid and immediate relief of symptoms particularly shortness of breath. However, this benefit is shadowed by its high rates of recurrence and complications. Pleural chest catheters drain about 1000ml of pleural fluid in a week and hence achieve relief of dyspnea. In addition, they promote spontaneous pleurodesis. They can be easily managed at home although they require close follow-up by community nurses as well as by physicians. Therefore, pleural chest catheters provide a cost-effective measure for improving the quality of life for advanced cancer patients who normally have a limited life expectancy.
Patients and their relatives are normally educated on home care of the plural chest catheter by an oncology nurse educator before they are discharged. Pleural chest catheters are normally inserted under local anaesthesia with or without ultrasonographic guidance. Ultrasonographic guidance during insertion is however recommended because amongst other merits it ensures appropriate positioning. A specific kind of pleural catheter called the tunneled pleural catheter is highly recommended because for one, it allows for sclerosants to be instilled, two, it promotes spontaneous pleurodesis and three it is effective in managing MPE patients with trapped lung syndrome. Trapped lung syndrome is a condition which has been shown to be very complicated to manage.
If pleurodesis fails to occur spontaneously two weeks after insertion of the pleural chest catheter, sclerosants can be instilled to promote pleurodesis. The decision on whether to instill sclerosants is influenced by amongst other factors the functional status of the patient as well as the expected survival rate. For patients with a relatively short expected survival duration period of about 1 to 3 months, it is recommended that they be managed using pleural chest catheters. Sclerosants are recommended for patients with a longer expected survival period. Although there is no general consensus on the most appropriate sclerosant, a number of literature review based studies have concluded that talc is by far the most effective.
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