Fig. 31.12  (continued)

videos and handbooks are available from the IPC manufacturers and can complement hands-on training.

Complications of IPC Placement

Procedure

Complications during IPC placement are rare but should be discussed during the informed consent process as they can occur in up to 6% of procedures. Procedural complications are similar to those encountered with any pleural procedure and include bleeding, pain, subcutaneous emphysema, unintended malpositioning of the catheter, unsuccessful IPC placement, and pneumothorax

[31]. Pneumothorax during IPC placement is rarely secondary to visceral pleural injury and is usually related to aspiration of air into the pleural space. Specialized adapters allow for IPC connection to a pleural drainage device in the event a clinically signifcant pneumothorax is present.

Special Considerations

Malignant Pleural Efusion

Recurrent MPE is the most common indication for IPC placement and IPCs are well established as a means to provide signifcant symptom improvement in these patients [32–34]. Chemical

pleurodesis, either thoracoscopic or via chest tube, was the primary treatment modality for recurrent MPE prior to the development of IPCs and therefore many studies have compared the two in regard to pleurodesis rates, symptom improvement, and other clinical end points. The TIME2 (Second Therapeutic Intervention in Malignant Effusion) study was one of the largest randomized controlled trials to evaluate differences in dyspnea relief between the two groups [35]. Patients in both the IPC and talc pleurodesis group experienced an improvement in dyspnea and there was no signifcant difference between the two groups until 6 months when patients with an IPC had less dyspnea than the talc pleurodesis group [35]. Several other randomized controlled trials (RCTs) have compared the improvements in dyspnea or quality of life experienced by patients with IPCs versus chemical pleurodesis, either talc or doxycycline, and no signifcant difference has been identifed [36–38].

IPCs and chemical pleurodesis do, however, differ signifcantly in hospitalization rates, lengths of stay and need for repeat pleural procedures as evaluated in several studies. All studies clearly show there is a signifcant decrease in total hospitalization days and initial length of stay when an IPC is placed for the treatment of a recurrent, MPE compared to chemical pleurodesis [35–38] IPCs are also associated with a decreased need for repeat ipsilateral interventions [36, 37].

Non-expandable Lung

Non-expandable lung, often referred to as “trapped,” does not fully expand after pleuraluid drainage and can develop because of a variety of malignant and non-malignant conditions that cause signifcant visceral pleural thickening. As seen with other pleural effusions, patients with non-expandable lung are often symptomatic and require interventions. Guidelines recommend placement of an IPC over chemical pleurodesis in patients with non-expandable lung owing to the fact that adequate apposition of the parietal and visceral pleura is not achieved, mak-

ing chemical pleurodesis less effective [15, 17, 26]. Approximately 50% of patients with non-­ expandable lung achieved pleurodesis after IPC placement at 6 months in the AMPLE-2 (Australasian Malignant PLeural Effusion-2) trial; therefore, pleurodesis is still achievable in this patient population [33]. As with patients with fully expandable lung, daily IPC drainage is associated with higher pleurodesis rates compared to symptom-guided drainage in this patient population [33].

Pien et al. were the frst group to report on the use of IPCs for non-expandable lung in 11 patients with MPE. All patients experienced symptomatic beneft after IPC placement [39]. Several infectious complications were reported but only one was thought to result in patient death. Larger studies on this topic are now available with most reporting improvement in patient symptoms such as dyspnea and quality of life that are comparable to that achieved in patients with fully expandable lung after chemical pleurodesis [35]. In addition to patients with non-expandable lung, IPC placement may be the best treatment strategy for those with interconnected pleural loculations [26].

Non-malignant Pleural Efusion

Non-malignant pleural effusions (NMPE) are common and can contribute to signifcant morbidity in affected patients. Congestive heart failure (CHF), hepatic hydrothorax, and end-stage renal disease (ESRD) are the most common non-­ infectious causes and treatment is typically aimed at the underlying disease process [40]. Despite optimal medical management many pleural effusions are refractory and alternatives for symptom palliation must be pursued. As described earlier in the chapter, IPCs were initially designed for the management of recurrent, symptomatic MPEs but their use has now been expanded to the treatment of refractory NMPEs not responding to optimal medical management. This is a patient population with a high mortality rate and need for optimal symptom control [40, 41]. Available data pertaining to the use of IPCs for NMPEs is not as

robust as that for MPEs and has traditionally been composed of low-quality non-RCTs describing NMPE from a variety of etiologies. More recent studies have focused on the safety and effcacy of IPCs for NMPEs from specifc etiologies, primarily hepatic hydrothorax, and will be described here.

Hepatic hydrothorax is a complication of liver cirrhosis that can develop in the presence or absence of abdominal ascites. Medical management with diuretics, salt and uid restriction, repeated thoracentesis, transjugular intrahepatic portosystemic shunt, and liver transplantation are the mainstays of treatment but when unsuccessful or unavailable, IPCs may be used for symptom control. Shojaee et al. published a multicenter retrospective evaluation of IPC use in 79 patients with refractory hepatic hydrothorax [42]. The pleurodesis rate was lower than that observed in patients with MPE, but catheter removal was achievable and occurred in 28% of patients [42]. The observed infection rate in this population was 10% with an associated 2.5% mortality rate [42]. This infection rate is much higher than that observed with MPEs but lower than previously published rates.

Congestive heart failure is the most common cause of NMPE and is managed similarly to hepatic hydrothorax with uid and sodium restriction, diuretics, and afterload reduction [40, 41]. Available data suggests IPC-related infectious complications are much lower in patients with CHF compared to hepatic hydrothorax with most reported empyema rates ranging between 0% and 4% [43]. Pleurodesis rates may also be higher compared to those with hepatic hydrothorax and range from 25% to 44% with IPC alone to even higher when combined with talc administration [43–45]. Other important considerations that require monitoring when placing an IPC for the management of refractory NMPEs are electrolyte disorders, renal failure and protein loss, which seem to be more of an issue for hepatic hydrothorax compared to congestive heart failure.

Whereas available data specifc to IPC use for hepatic hydrothorax and congestive heart

failure is slowly increasing, only small case series are available for IPC use in patients with ESRD-­related pleural effusions. Potechin et al. reported outcomes of eight patients with IPCs placed for refractory ESRD-related effusions [46]. All patients experienced a signifcant improvement in dyspnea and 37.5% of patients achieved pleurodesis allowing for IPC removal after a median time of 45.5 days. No cases of empyema or other serious complications were reported [46].

IPC placement for the management of refractory, symptomatic NMPEs may be a good option in select patients as a bridge to transplant or in those where transplant or other advanced therapies are unavailable. Well-designed randomized controlled trials are necessary to determine how appropriate they are for long term use in these patient populations.

Chylothorax

Chylothorax is defned as a pleural effusion with a triglyceride level of >110 mg/dL or identifcation of chylomicrons within the pleuraluid. It can develop after trauma to the thoracic duct or in association with specifc malignant and non-­malignant conditions. Approximately 50% of patients with chylothorax have cancer with lymphoma being the primary cause in most patients [47]. Chylothoraces can be large volume and may rapidly reaccumulate after drainage causing debilitating symptoms for affected patients. Management often proves challenging and is complicated by protein and electrolyte loss and immunologic compromise secondary to the nature of this uid. Treatment is aimed at the specifc underlying cause and in non-traumatic cases, traditionally includes repeat thoracentesis procedures, medications such as octreotide, dietary restriction of fat and possible total parenteral nutrition. Other procedural interventions include thoracic duct ligation, pleuroperitoneal shunting, pleurectomy, thoracoscopic pleurodesis or more recently, consideration of IPC placement. Frequent large

volume drainage of a chylothorax has historically not been recommended given the aforementioned reasons and patients with an IPC were thought to be exposed to increased infectious complications, thus limiting their use. Small retrospective case series describing the use of IPC for refractory chylothorax are published but no large studies are available for this patient population [47, 48].

Jimenez et al. published their experience with 19 patients with refractory chylothorax related to malignancy [47]. Ten patients were managed with IPC placement and the other nine underwent repeat thoracentesis procedures, talc pleurodesis or pleuroperitoneal shunt for symptom management. Patients receiving an IPC were older, but the two groups were otherwise similarly matched in patient and pleural uid characteristics. Patients with an IPC drained daily until they experienced chest pain or persistent cough or there was no more uid to drain. Changes in weight, absolute lymphocytes counts and albumin levels in addition to pleurodesis and ­complication rates and time to second pleural intervention were compared. A signifcant decrease in albumin was seen following IPC placement but recovered to baseline at a median time of 46 days after IPC removal. Patients with an IPC underwent signifcantly fewer repeat pleural procedures as compared to the control group during the 500 days of follow-up. No signifcant differences in pleurodesis rates, symptom improvement or complications was seen between the groups [47].

De Pew et al. described a cohort of 11 patients with refractory non-malignant chylothorax managed with IPCs [48]. Pleurodesis was defned as the absence of a recurrent pleural effusion after IPC removal and was achieved in 64% of patients with a median time of 176 days. Reductions in total protein, albumin, and lymphocyte counts were observed but none resulted in signifcant infectious or nutritional adverse outcomes [48].

IPC placement for the management of a refractory, symptomatic chylothorax may be a reasonable and safe option based on available data, but larger prospective studies are needed prior to routine use.

Pleurodesis

Pleurodesis rates have historically been the focus of many studies, although patient-centered outcomes of quality of life and improvement in dyspnea are increasingly being evaluated. Pleurodesis, usually defned by radiographic absence of a residual pleural effusion and no recurrence within a pre-specifc amount of time, occurs at higher rates for patients with IPCs placed for MPE compared to other conditions as detailed above, but reported rates remain less than 50% [32–34]. IPC-related pleurodesis rates may also vary depending on drainage regimen and are important from a cost perspective. This has been evaluated in one study by Shafq et al. that determined daily IPC drainage was not cost-­ effective in any clinical scenario and symptom-­ guided drainage was cost-effective for patients with a life expectancy less than four months or an expected probability of pleurodesis greater than 20% [49].

The IPC-plus trial randomized patients to IPC plus placebo or talc slurry and found those treated with IPC plus talc slurry achieved pleurodesis at a signifcantly higher rate during the initial fol- low-­up period [50]. The safety of silver nitrate coated IPCs have also been evaluated in a small study which reported high pleurodesis rates [51]. IPC plus pleural sclerosant may be a good treatment option for some patients to maximize symptom relief while minimizing cost and risk of IPC-related complications.

Follow-Up and IPC Removal

A standardized follow-up schedule for patients with an IPC has not been established owing to a lack of formal studies, but regular follow-up is recommended even in the absence of catheter-­ related concerns. The frequency of follow-up should be individualized and considerations for determining a schedule include patient understanding of proper IPC care, reliability of caregivers to identify and communicate concerns, distance from healthcare providers and the fnancial, emotional and time burdens of treatment and