When excessive pleural uid drainage is not a consideration, the Heimlich valve can be used. It is a one-way valve used to treat pneumothorax that closes upon inspiration to prevent unwanted air entry into the pleural space and opens on expiration to allow for the escape of air. The Rocket® Pleural Vent™ is another pneumothorax device allowing for improved patient mobility during treatment. Both devices can be used while in the hospital or implemented upon discharge to minimize hospital length of stay in patients that do not require continuous pleural suction. These devices are then removed once a pneumothorax and alveolar-­pleural fstula have resolved.

The three-chamber drainage systems are commonly used for both pleural effusions and pneumothorax and consist of three basic parts: (1) a water-seal chamber that has a one-way valve allowing air or uid to exit the pleural space while inhibiting air entry into the pleural space,

(2) a collection chamber that collects and measures drainage from the pleural space, and (3) a wet or dry suction control chamber to regulate the amount of suction applied to the pleural space. The level of suction is controlled by the amount of sterile water in the system for wet-­ suction setups (typically −20 cmH2O), whereas there is a self-controlled dial that regulates the amount of suction applied in dry-suction systems. Not all patients require suction on the pleural drainage system so this is determined on an individual basis.

More advanced digital drainage systems have now been developed that function similarly to the three-chamber drainage system described above. They also have the capability to collect data about pleural uid volume, variations in pleural pressure, and severity of air leak in patients with alveolaror broncho-pleural fstulas while providing precise levels of suction. The commercially available digital drainage systems are the Thopaz™ (Medela, Switzerland) and Atmos® (Atmosmed, Allentown, PA, USA).

AIRFIX® was the frst digital chest tube air-ometry device used to quantify air leak after lung resection [21]. Measurements are made based on a “mass air ow sensor” that collects and transmits data to a specialized software sys-

tem. The AIRFIX® device is attached in-line to the chest tube and drainage system and displays air ow as mL per breath (mL/b) and mL/minute (mL/min). This device was frst validated in patients undergoing lung resection or lymph node dissection for non-small cell lung cancer. Air leak values obtained via intra-operative spirometry and leak tests were compared to the AIRFIX® values and were found to be very similar [21]. The DigiVent™ system was the frst commercially available digital pleural drainage system that allowed for measurements and recordings of air ow and pressure [22].

A 2019 systematic review and meta-analysis by Wang et al. compared the effcacy of digital drainage systems with traditional drainage systems after pulmonary resection [23]. Digital drainage systems were not only found to reduce the incidence of prolonged air leak but the ability to objectively review data trends also reduced intra-observer variability leading to shorter duration of chest drainage and hospital lengths of stay [23]. It has also been shown that there is a reduced need for chest tube re-insertion after removal when digital drainage systems are used [23].

History of and Introduction to Indwelling Pleural Catheters

As already discussed, there are multiple potential causes of pleural effusions that require intervention both for patient safety and palliation of symptoms. Pleural effusion is a common clinical problem estimated to affect 1.5 million people in the United States each year and an even larger portion of patients across the world [24]. Many pleural effusions are related to infection or non-­ malignant conditions, but malignant pleural effusions are also quite common. Many cancer patients will develop a pleural effusion at some point during their disease, either malignant or paramalignant. Approximately 50% of all cancer-­ related pleural effusions are due to lung cancer and up to 15% of these patients will have an MPE at diagnosis [25]. Almost any malignancy can be complicated by a MPE with breast cancer, lymphoma and leukemia being the next most com-

mon types [15]. Paramalignant effusions have negative pleural uid cytology but develop as a result of tumor effects on the pleural space, primarily bronchial obstruction, infltration of mediastinal lymph nodes and vascular structures, non-expandable lung or pulmonary embolus from hypercoagulability of malignancy. Regardless of the underlying etiology, pleural effusions may cause signifcant dyspnea, cough, and chest discomfort, resulting in a poor quality of life for patients. After identifcation of a pleural effusion, particularly in symptomatic patients, a thoracentesis is performed to analyze pleuraluid and assess improvement in patient symptoms to guide further management. The majority of MPEs will recur within 90 days of initial drainage [26] and additional interventions are often required.

Defnitive management is recommended for most patients with a recurrent, symptomatic MPE [15–17] and the primary goals of treatment are palliation of symptoms while minimizing complications. Historically, chemical pleurodesis, either thoracoscopic or via chest tube, was the treatment of choice in these patients, but these procedures require hospitalization and potentially general anesthesia. IPCs are being placed with increasing frequency since their introduction over 30 years ago, [27] largely because of the ease of outpatient placement and lack of need for general anesthesia and hospitalization. Repeat thoracentesis procedures may be the best management in patients with limited life expectancy. A thorough discussion about treatment options, patient preferences and goals should occur prior to any intervention to determine the best treatment approach. This chapter will focus on summarizing the latest, high-quality evidence, and recommendations for IPC use in patients with recurrent, symptomatic pleural effusions.

Indications and Contraindications for IPC Placement

IPCs are traditionally placed in patients with a recurrent, symptomatic MPE, but as discussed in more detail in this chapter, they may also be uti-

lized for the management of non-malignant pleural effusions that are refractory to optimal medical management. IPCs are typically placed in patients with a poor performance status but may also be utilized in those with a good performance status that wish to minimize hospitalization as compared to thoracoscopy and pleurodesis.

Contraindications for IPC placement are similar to any chest tube or other invasive procedure and are already described in this chapter. Regarding pleural catheters, it is important to determine if a patient has symptomatic improvement after initial pleural uid drainage. If the patient does not experience symptomatic improvement, then IPC placement would expose the patient to unnecessary risks with minimal beneft and should not be pursued. Active pleural infection, multiple pleural loculations, inadequate pleural space for safe implantation and lack of an area for IPC tunneling are additional contraindications to IPC placement. IPCs require maintenance to minimize complications. If a patient is incapable of caring for the catheter themselves or if an adequate support system is unavailable, then alternatives for the treatment of a recurrent, symptomatic pleural effusion should be investigated.

IPC Procedural Technique

and Necessary Equipment

Several IPC options are available and the decision to use one catheter over another depends on local availability and provider preference. Each catheter has slight differences, but all are made of soft silicone material and have multiple fenestrations to allow for drainage of pleural uid. The Merit Medical Aspira® drainage system is designed to drain with low pressure via gravity, [28] whereas the PleurX® and Rocket® systems drain uid via vacuum bottle [29, 30]. IPC procedural technique may vary slightly between providers and depending on which IPC is placed but are generally quite similar.

The procedure should be performed in an area capable of continuous telemetry and pulse oximetry monitoring. A peripheral IV should be placed

in the event intravenous uids or emergency medications need to be administered. A procedure nurse and a technician are typically required, in addition to the proceduralist placing the IPC. A time out procedure should be performed prior to IPC insertion. The patient’s name, medical record

number and date of birth should be read aloud while all procedural participants are present. This allows for confrmation of the correct patient, procedure, and intended IPC insertion site. One approach to IPC placement is listed here (Figs. 31.7, 31.8, 31.9, 31.10, 31.11 and 31.12).

Fig. 31.7  PleurX® catheter insertion kit contents: (a) insertion kit just after opening, (b) syringes with lidocaine and needle, (c) guidewire introducer needle and j-tipped wire, (d) dilator and peel away catheter insertion sheath,

(e) silicone catheter with multiple fenestrations and attached metal tunneler, (f) suture for anchoring catheter and dressing contents

Fig. 31.8  Patient positioning (lateral decubitus or supine), ultrasound of the pleural space and marking of appropriate IPC insertion sites

\1.\ Place the patient in a semi-recumbent position. Other positions are acceptable, such as lateral decubitus, depending on patient tolerance, and expected insertion site.

\2.\ Secure the patient’s ipsilateral arm above the head or across the chest to fully expose the potential pleural entry site.

\3.\ Identify the optimal site for IPC insertion and exit with the use of an ultrasound and mark these sites. Ideally, the largest collection­

of uid is chosen as the insertion site. When possible, avoid areas of skin with evidence of active infection or malignant skin infltration.

\4.\ Clean the pleural entry and exit sites as well as the surrounding chest wall. An alcohol-­ based solution such as chlorhexidine is most used.

\5.\ Don sterile personal protective equipment and prepare the IPC insertion kit.

\6.\ Cover the chest with a sterile drape, leaving only the intended catheter insertion site exposed. Additional cleaning of the skin is typically performed.

\7.\ Use the flter straw to prepare syringes with 1% lidocaine and then anesthetize the skin, subcutaneous tissue, and parietal pleura with the 22G or 25G needle. Ensure aspiration of pleural uid and adequate anesthetization of the pleura.

\8.\ Advance the guidewire introducer with needle in the anesthetized area, while applying suction, until pleural uid is aspirated.

\9.\ Hold the needle and syringe stable and advance the guidewire introducer into the pleural space until it is ush against the patient’s skin. Remove the needle. Pleuraluid may drain out of the guidewire introducer at this point.

10\ .\ Insert the J-tip wire through the guidewire introducer and into the pleural space.

11\ .\ Remove the guidewire introducer, leaving the guidewire in place.

\12.\ Use a scalpel to make an approximate 1 cm incision around the wire in the patient’s skin and subcutaneous tissue. This is the pleural

entry site. Make a second incision approximately 5 cm from the pleural entry site. This will serve as the catheter exit site.

13\ .\ Attach the metal tunneler to the fenestrated end of the pleural catheter and tunnel the catheter under the skin and subcutaneous tissue, entering at the catheter exit site, and directing the tunneler toward the pleural entry site. Pass the tunneler out through the pleural entry site where the guidewire is located. Pull the tunneler through the pleural entry site until the catheter cuff is just under the skin at the catheter exit site. Once in position,­ remove the metal tunneler from the catheter. Note: tunnelling the catheter too superfcially can lead to excessive granulation tissue formation and diffculty with future removal.

\14.\ Advance the peel-away introducer and dilator over the wire and into the pleural space.

15\ .\ Remove the central dilator and the wire while leaving the peel away sheath in place. Pleural uid may drain out of the peel away sheath at this point.

16\ .\ Insert the fenestrated end of the catheter through the peel away sheath and into the pleural space.

\17.\ Peel away the sheath while advancing the catheter into the pleural space using a thumb.

18\ .\ Ensure the catheter is inserted fully into the pleural space and feel for any evidence of a kinked catheter.

\19.\ Attach the catheter tip to the specialized drainage bottle or suction using the appropriate adapter with access tip. Drain the pleural space. This ensures the catheter is functioning well after placement and allows for any necessary troubleshooting while the patient is in the procedure area.

\20.\ Remove the access tip and drainage line and place the specialized cap on the end of the catheter.

\21.\ Use the 2-0 silk, straight needle suture to secure the IPC to the skin.

22\ .\ Use the 4-0 absorbable, curved needle suture to close the insertion site incision.

\23.\ Place the foam catheter pad on the skin and coil the catheter on top of it, then cover with gauze.

24\ .\ Use the provided self-adhesive dressing for optimal coverage and catheter protection.

A post-procedure chest radiography is obtained to document proper IPC placement and the patient can often be discharged home the day of the procedure. It is customary to provide repeat IPC education prior to discharge to maximize the benefts of IPC placement while minimizing the risk of IPC-related complications. Instructional