Chest Tubes and Indwelling Catheters

## **Chapter 3** Chest Tubes

*Mohit Kumar Joshi*

### **Abstract**

Insertion of intercostal drainage (ICD) tube is one of the commonest surgical procedure that is life saving in certain circumstances. Although the procedure is being used for long, yet there is no consensus in its management. The procedure is simple to perform but the incidence of the complications, which primarily occur due to improper positioning of the tube and poor post-procedural care, is as high as 40%. It is therefore essential that all clinicians should be familiar with this simple, common and lifesaving procedure. This chapter provides a comprehensive overview of various aspects of intercostal drainage including the prerequisites, technique of insertion, post-procedural care, complications and common pitfalls in the management of chest tubes in the light of the recent advances and updates.

**Keywords:** Chest tube, Tube thoracostomy, intercostal drainage tube, ICD tube, Thoracentesis, Thoracostomy drainage

#### **1. Introduction**

Insertion of intercostal drainage (ICD) tube is a common procedure that is required to drain the abnormal intrapleural collection. As the name implies, it is insertion of a tube through the intercostal space to facilitate the drainage of abnormal collection in the pleural cavity. The procedure is also known as tube thoracostomy and thoracostomy drainage. The earliest reports of thoracic drainage dates back to 5th century BC [1, 2].

The aim of thoracostomy drainage is to:


Although, the procedure has been in practice since long, there is still no consensus in the management of chest tubes and there remains great variability in practice. The procedure of inserting a chest tube is simple, definitive in treating a majority of thoracic pathologies and may be life-saving in certain situations. However, improperly placed chest tubes and poor post-procedural care may increase the morbidity and is associated with complications in up to 40% of patients [3, 4]. It is therefore imperative that all clinicians should be well versed with this simple yet life-saving procedure.

In this chapter, we will discuss various aspects of intercostal drainage including the prerequisites, technique of insertion, post-procedural care, complications and common pitfalls in the management of chest tubes in the light of the recent advances and updates.

#### **2. Characteristics of an ideal thoracostomy tube**

An ideal thoracostomy tube should:


#### **3. Indications for inserting chest tube**

Tube thoracostomy is required to drain any abnormal collection in the pleural cavity, that includes:


#### **4. Commercially available chest tubes**

The modern, commercially available chest tubes are soft and pliable that are either made up of Polyvinyl chloride (PVC) or silicone (**Figure 1**).

The red rubber or malecot tube drains (**Figure 2**) are sometimes used as thoracostomy tubes mostly in resource constraint settings because of their low-cost, however their use is not advisable as they are difficult to retain, get kinked easily, wither rapidly and at times may break.

Chest tubes come in various sizes from 6 French gauge (F) to 40 F. Larger the size of the tube, greater is its diameter. One F is equal to 0.033 cm. To know the diameter of the tube from the F size, one need to multiply F size by a factor of 0.033, so a chest tube of size 24 F will have an internal diameter of approximately 0.8 cm.

Some chest tubes are available with metallic trocar that has a pointed end (**Figure 3**).

#### **Figure 1.** *Intercostal drainage tube (chest tube).*

**Figure 2.** *Malecot (red rubber) tube drain.*

**Figure 3.** *Chest tube with metallic trocar.*

#### **Figure 4.** *Radiopaque line in the chest tube visible on x-ray (arrow).*

These are meant to insert in intercostal space after making a small skin incision, without dissecting the intercostal muscles. Although, this makes the procedure fast, there is a higher risk of injury to the intrathoracic organs and as such use of chest tubes with trocars should be discouraged [3, 5, 6]. Most of the chest tubes are open from one end while the other end is sealed. There are side holes or eyes on the tube and the markings are printed on it. There also is a radiopaque line all along the length of the tube that helps in identifying the position of the chest tube on X-ray (**Figures 1** and **4**).

#### **5. Before inserting the chest tube- the preparation**

#### **5.1 Consent**

Insertion of ICD tube is a surgical procedure and like any other surgery, a written informed consent is required prior to the procedure. Consent may not be possible in cases where the patient requires urgent tube thoracostomy as a lifesaving measure and when he/ she is unconscious, unattended or is in extremis.

#### **5.2 Preparing the trolley: Equipment required**

Following instruments and equipment are required for inserting the chest tube. One must ensure the availability of all necessary equipment beforehand to avoid any difficulty during the procedure.

1.5 ml syringe with a suitable local anesthetic. Preferably 2% lidocaine with adrenaline.

*Chest Tubes DOI: http://dx.doi.org/10.5772/intechopen.100047*


#### **5.3 Selecting the size of chest tube**

The chest tubes are available in various sizes ranging from 6 F to 40 F. There is a general understanding that large-bore tubes are required to drain fluid and smallbore tubes are sufficient to drain air. There have been numerous studies on this issue, however there is no conclusive scientific data to support this idea. Large-bore tubes have been related to higher incidence of pain and patient discomfort without any significant advantage in draining the intra-pleural fluid. In various studies, small-bore tubes have been found to be equally effective to drain pleural effusion and hemothorax [7–11]. This has generated wider interest in use of small-bore tubes for thoracostomy. Conventionally, for most of the clinical conditions requiring tube thoracostomy a 24–32 F chest tube is inserted, depending on the expected underlying pathology, however tubes smaller than 24 F may be sufficient to drain pneumothorax.

#### **5.4 Preparing the under-water seal**

The reservoirs for collecting the pleural drainage are available either in the form of bags or single or multiple chambered plastic bottles (**Figure 5A** and **B**).

In both of these reservoirs, there are markings for calculation of effluent. In addition, there is also a marking for 'initial fluid level'. Before connecting the reservoir to the chest tube, a sterile fluid like normal saline should be filled till this mark. As the chest tube is connected with the tube in the reservoir that remains below the 'initial fluid level', the air from the environment cannot gain access to the pleural cavity, however the intrapleural collection may egress easily into the reservoir, thus it functions as a one-way valve or 'under water seal'.

**Figure 5.** *A: Two chambered plastic bottle and B: ICD bag.*

#### **5.5 Local anesthesia: type, amount and technique**

Any suitable local anesthetic is appropriate for the procedure. Plain Lidocaine 2% solution and Lidocaine 2% with adrenaline are commonly used drugs for ICD insertion. A volume of nearly 5 ml is sufficient to anesthetize the local site. Local anesthesia may not be required where the patient is obtunded or unconscious and ICD insertion is required urgently.

### **6. Inserting the chest tube**

The step by step procedure is demonstrated in the video supplemented with this article.

```
Inserting Intercostal drainage tube: step by step.
```
#### **6.1 Position of the patient**

Although the ICD can be inserted while the patient is sitting, leaning forward with the forearms resting over a stool, the supine position is less cumbersome and more comfortable for both patient and the doctor. In addition, the patient may not be able to sit for the procedure due to the underlying clinical condition. We prefer to insert ICD tube in supine position. The patient lies on the table close to the edge with arm abducted over the head if possible.

#### **6.2 Identifying landmarks**

The ideal site of inserting ICD is 4th or 5th intercostal space just anterior to the mid axillary line. One may calculate the desired intercostal space by considering sternal angle as landmark. The rib attached to the level of sternal angle is the second rib, subsequent ribs can be counted while palpating the chest wall distally and laterally. There is an alternative way of counting the ribs and the intercostal

#### *Chest Tubes DOI: http://dx.doi.org/10.5772/intechopen.100047*

spaces which is quick and is particularly helpful in obese patients and in presence of subcutaneous emphysema. The level of the nipple in males and inframammary crease in females can be taken as a reference point- a line drawn from this point laterally to a point where it intersects the mid-axillary line is marked and the site for insertion of the chest tube is just anterior to this.

In case, the chest tube is being inserted prophylactically during thoracic surgery, the site of insertion is selected under vision in appropriate intercostal space.

#### **6.3 Steps of the procedure**

A wide area around the predetermined site of ICD insertion is painted with a suitable antimicrobial solution (Chlorhexidine or Povidone-iodine) and is draped. If the patient is awake and conscious, 5 ml of local anesthetic solution (preferably 2% lidocaine with adrenaline) is infiltrated in the overlying skin, intercostal muscles and pleura at the site of ICD insertion. Before injecting the local anesthetic, one should ensure that the needle is not in a blood vessel by pulling the plunger of the syringe back. For the adequate effect of local anesthesia, it is prudent to wait for at least 2 minutes before making the incision.

An incision measuring nearly 1.5–2 cms is made by a number 11 surgical blade at the predetermined site of ICD insertion along the long axis of the rib in the intercostal space just over the upper border of the lower rib. This is done to prevent injury to the neurovascular bundle that runs along the lower border of the ribs.

Using a medium sized curved hemostatic clamp, the subcutaneous tissues and inter-costal muscles are dissected bluntly till the parietal pleura is reached. By the tip of the closed hemostatic clamp, gentle pressure is then applied till there is a feeling of 'give way' which marks the entry into the pleural cavity. The entry into the pleural cavity is also confirmed by the escape of intra-pleural collection like air, fluid or blood (as the case may be). One should be careful enough not to apply undue force while puncturing the pleura as this may cause injury to lungs or mediastinal structures. The jaws of the hemostatic clamp are then opened while withdrawing the instrument to increase the size of the thoracostomy wide enough to allow the entry of index finger. This should be followed by 'finger thoracostomy'. The index finger is inserted through the thoracostomy site to explore the pleural cavity for presence of any pleuro-pulmonary adhesions. In case they are present, adhesiolysis is performed to create space inside the pleural cavity for the chest tube. This step is important as attempts to insert a chest tube without ensuring space between the lung and the chest wall may injure the lung, cause air leak from the damaged lung parenchyma and such improperly placed tube may fail to drain the intra-pleural collection.

Following finger thoracostomy and ensuring safe space inside the pleural cavity to accommodate the chest tube, an adequately sized chest tube is then taken. The tip of the tube from the open end (the end that should lie inside the thoracic cavity) is held with the tip of the hemostatic clamp and the rest of the tube is held parallel to the instrument. The tube is introduced inside the pleural cavity, the instrument is then released and the tube is inserted gradually by guiding it to lie posteriorly and superiorly by using the same instrument aided by the index finger of the opposite hand to the point till the last eye (hole) on the chest tube is at least 5 cms inside the pleural cavity (this can be confirmed by looking at the markings over the chest tube). The limit to which the ICD tube needs to be put in depends on the build of the patient. In a patient with an average built a length till 8–12 cms inside the chest is sufficient.

The tube is then clamped by using an artery forceps (hemostatic clamp) close to its distal (closed) end. The end of the chest tube is now cut and is connected with

the tubing of the underwater seal using the connector provided with the chest tube. The length of the tube of under-water seal apparatus should not be unduly long as the fluid column in the tube will provide resistance to the egress of intrapleural collection compromising the drainage. A good rule is not to allow any loop in the draining tube between the connector and the tubing of the reservoir.

The chest tube is then fixed by silk suture no.1. For better fixity, it should be anchored on either side. While fixing, one must ensure to take deep bites through the soft tissues close to the tube. Fixing the tube by taking superficial bites (including skin only) may leave potential space around the tube at the site of entry in the intercostal space which may lead to subcutaneous emphysema in cases of pneumothorax and may increase morbidity. Some clinicians prefer purse string suture for fixation of the tube but that leaves an ugly scar following removal of the chest tube and as such is not necessary. A dressing is now applied at the ICD site and the tube may then firmly be reinforced at the site by using adhesive tapes. This completes the procedure.

The free drainage of the collected material from the pleural cavity and the movement of the column of the fluid in the tube confirms the adequate position of the chest tube. The chest should now be auscultated, improvement in the breath sounds suggests success of the procedure. A chest X-ray is then performed for confirmation of proper positioning of the tube radiologically.

Some authors advocate creation of an oblique passage or 'tunnel' in the chest wall to insert the tube, primarily to decrease the incidence of recurrent pneumothorax following removal of the chest tube [12]. In this technique incision is made one intercostal space below the pre-determined site of thoracostomy, the skin and soft tissues of the chest wall are then bluntly dissected to reach the site of thoracostomy thereby creating a curved passage through the chest wall for introduction of the chest tube. This requires additional time at the expense of no added advantage and therefore is not required.

#### **7. Post-procedural care**

#### **7.1 Nursing the patient with chest tube**

Utmost care should be exercised while nursing a patient with chest tube. The reservoir should remain below the level of the chest at all times. Raising the reservoir above the chest level may result in passage of the fluid from the reservoir back into the pleural cavity. While turning or shifting the patient, one must ensure that the tube is not held or entangled in the patient's bed. This may result in accidental displacement or dismantling of the tube. The outlet of the reservoir should remain open at all times especially in patients with pneumothorax or air leak. The closed outlet of the reservoir may lead to failure of decompression of pneumothorax leading to development of life-threatening tension pneumothorax. For the same reason, the tube should not be clamped at any time except while changing the fluid in the reservoir, collecting a sample of effluent or while planning to remove the chest tube. The patient should be closely monitored during this period.

The patient should be motivated for active physiotherapy and incentive spirometry (**Figure 6**).

This aids in faster resolution of pleural collection and thereby early removal of the ICD tube. In case, the patient is unable to do active physiotherapy, passive physiotherapy should be performed. All efforts must be made to ambulate the patient early. The chest tube must be secured carefully while patient mobilizes and the drainage bag (reservoir) should be kept well below the thoracostomy site.

**Figure 6.** *Patient performing incentive spirometry.*

The ICD site should be carefully examined every day for signs of local infection like peri-tubal inflammation or tenderness. The dressing needs to be changed in case it is soaked. Extreme care must be taken while dressing the ICD site lest the tube is displaced or dismantled. The patient should be clinically monitored every day and the volume of drained fluid should be charted carefully in the patient's record. The reservoir should be emptied once it is full up to 3/4 of its capacity. A new reservoir with prepared under water seal or disposable reservoir (in case of digital chest tube drainage systems) is kept ready while changing the reservoir. In resource constraint settings the same reservoir may be reused. It is important to follow universal precautions while changing the reservoir. The chest tube is clamped and the filled reservoir is disconnected from the tube, the new reservoir is then connected or fluid is filled up to the 'initial water level' mark (or till the outlet tube is at least 2 cms below the water level) in case one contemplates to use the same reservoir. Once the reservoir is reattached, the tube is unclamped. It is important to prepare the equipment beforehand while changing the reservoir to keep the time of occlusion of the chest tube to minimum possible.

The practice of performing daily x-ray has been questioned by many authors and it is suggested that this may not be required if there is pleura to pleura apposition in the post-procedure x-ray and the patient is improving clinically [13].

#### **7.2 Use of analgesics and antibiotics**

Appropriate oral or parenteral analgesics are administered depending on the underlying condition for which tube thoracostomy was necessitated. There has been much debate on the use of antibiotics following tube thoracostomy. There is no evidence to support the routine use of prophylactic antibiotic therapy following the procedure [14, 15]. However, the antibiotics may be needed for other associated causes for which tube thoracostomy was performed like in empyema thoracis or in a patient of trauma with soft tissue injuries.

#### **7.3 Use of suction**

The use of controlled suction (10 to 15 cm saline) to the outlet of the reservoir may help in faster resolution of intrapleural collection and promote early pleura to pleura approximation. This is most useful following pulmonary resections and may decrease the incidence of persistent post-operative space problems. In our practice, we apply overnight suction in patients undergoing pulmonary resection surgery (except following pneumonectomy). At times, the application of suction may result in pleural pain, the amount of suction should be decreased in such situations. In case of increased air leak on application of suction, the suction may be decreased or avoided altogether.

#### **7.4 What to do in case the tube is blocked?**

Blockage of thoracostomy tube is not uncommon and occur frequently in hemothorax. Careful observation of the ICD tube and the ensuring drainage of the fluid are paramount to detect this complication early. If appropriate measures are taken in time, the possibility of maintaining the tube patency are high.

Various manipulations can be performed to restore the patency of blocked ICD tube. These include tapping, milking and stripping of the tube. These measures are successful only with partial blockage of the tube and should not be performed routinely to prevent blockage. There is theoretical possibility of generation of high intrapleural pressures with stripping and milking. Some authors have raised concern that this may cause pulmonary injury, however we have not observed any clinically significant adverse effects of these procedures. The practice of flushing the blocked tube by instilling sterile solutions should be discouraged as this may increase the chances of introducing infection from outside with resultant increase in the incidence of empyema. Some clinicians have used novel methods like using a fogarty balloon catheter to unblock the chest tube [16] or use of advanced systems to either prevent clot formation inside the tube [17] or wipe the inside of tube to unblock it [18].

#### **7.5 How to collect a sample from the chest tube**

A loop is formed in the ICD tube and the intrapleural fluid is allowed to accumulate in this loop. The tube is then clamped proximal to this collected fluid. With all aseptic measures the external surface of the ICD tube near its connection with the tubing of the reservoir is cleaned with alcohol based antiseptic solution. The tube is then disconnected from this end and the sample is collected in a sterile container. The ICD tube is then reconnected with the reservoir tube and is unclamped.

#### **8. Removing the chest tube: when and how?**

There are no fixed or universally agreed criteria that applies to all patients for guiding removal of the thoracostomy tube. There is great heterogeneity in practice, however the rule of thumb is that the chest tube should be removed once it has served its purpose. If the patient is clinically well, there is no more air leak than on forced expiration, no expanding subcutaneous emphysema, no blood, pus or chyle in the effluent and the volume of the fluid being drained is less than 250 ml, the tube can be safely removed. In case of residual space following pulmonary resection with persistent low volume air leak (no more than on forced expiration) beyond day 5, the chest tube may be clamped for up to 24 hours and a repeat x-ray is performed. The patient should be closely monitored during this period for tachypnoea or dyspnea. In case the patient remains asymptomatic and the pneumothorax does not worsen, the chest tube may be removed. The same may be done in case of persistent non-expanding effusion. This practice however, carries the risk of serious side effects if the patient monitoring following clamping of the tube is not diligent. The use of digital chest tube drainage devices might obviate this risk. The chest tube

#### *Chest Tubes DOI: http://dx.doi.org/10.5772/intechopen.100047*

may be safely removed if the air leak is <40 ml/ min over 24 hours [19]. Alternatively, in patients with prolonged air leak (beyond day 5), a Heimlich valve may be applied to the chest tube and the patient may be followed on outpatient basis with a plan to remove the tube later allowing more opportunity for the residual lung to expand. We have recently proposed a protocol for removal of chest tubes following thoracic surgery that have enabled us to decrease the chest tube indwelling time [20].

In some specialties like Colorectal and Gynecological Surgery, the Enhanced Recovery After Surgery (ERAS) protocol has been well established. This has recently been proposed for patients undergoing oncological major lung resection surgery too. The guidelines suggest that chest tubes may safely be removed with a non-chylous fluid output of up to 450 ml/ day in absence of air leak or minimal air leak detected by the digital chest tube drainage systems [21].

The view is equally divided regarding removal of the chest tube during endinspiration or end-expiration [22, 23]. In a Randomized Controlled Trial by Bell RL et al., there was no significant difference between the complications following removal of the chest tube at either the height of inspiration or expiration and both methods were considered safe [23]. The incidence of recurrent pneumothorax is likely to be multifactorial and correlates poorly to the method of chest tube removal alone [23, 24]. We prefer to remove the chest tube by a swift motion followed immediately by sealing of the thoracostomy wound by appropriate dressing material irrespective of the phase of respiration.

#### **9. Complications**

The complications of tube thoracostomy may be divided into 3 phases:

	- i. Hemorrhage from the ICD site
	- ii. Injury to the lung and the mediastinal structures
	- iii. Misplacement of the tube
	- i. Displacement or dislodgement of the tube
	- ii. Subcutaneous emphysema
	- iii. Kinking
	- iv. Blockage
	- v. Fracture of the tube
	- vi. Empyema thoracis
	- vii. Wound infection
	- viii. Re-expansion pulmonary edema

#### 3.Following removal of the tube


Hemorrhage from the ICD site may be avoided by carefully siting the thoracostomy incision on the upper border of the lower rib in the desired intercostal space. This avoids the damage to the neurovascular bundle that runs along the lower border of the rib. All aseptic measures should be taken while inserting the chest tube and later while handling the tube during the post procedural care to prevent wound infection and empyema. Care should be exercised while nursing and mobilizing the patient with chest tube to prevent accidental displacement or dislodgement of the tube.

To prevent re-expansion pulmonary edema, the pleural cavity should be gradually decompressed. Sudden evacuation of more than one liter of fluid from the thoracic cavity should be avoided. It is desirable to monitor the intrapleural pressure while draining large amount of fluid from the pleural cavity. The intrapleural pressure should not be allowed to fall below 20 cm saline at any point of time.

#### **10. Common pitfalls in chest tube management**

A pitfall is different from complication and is defined as a hidden or unsuspected danger or difficulty that may lead to adverse events. The awareness of a pitfall and preparation to act swiftly in such eventuality may help in averting the complication arising from it. Following are the common pitfalls in ICD tube management:

i. Missed diagnosis: ICD tube placed in a patient with large diaphragmatic hernia suspecting it to be a loculated pneumothorax. A careful history and diligent look at the x-ray will avoid this pitfall (**Figure 7A** and **B**).

**Figure 7.**

*A: Left sided diaphragmatic hernia with large gastric shadow. B: Chest tube inserted in a patient of diaphragmatic hernia misdiagnosed as hydropneumothorax.*

	- a. Too in: may impinge on to the mediastinal structures (**Figure 9A** and **B**).
	- b. Too out: the eye (hole) of the tube may lie in the subcutaneous tissues with resultant subcutaneous emphysema (**Figure 10**).
	- c. Mispositioned or kinked resulting in poor drainage (**Figures 11**–**14**).

**Figure 8.** *A kinked chest tube.*

#### **Figure 9.** *A & B: Chest tube impinging on mediastinal structures.*

**Figure 10.** *Eye of chest tube in subcutaneous tissues with subcutaneous emphysema.*


g. Clamping the tube while shifting or mobilizing the patient may result in tension pneumothorax. The outlet of the reservoir should be kept open at all times to prevent this.

**Figure 11.** *Chest tube (arrow) about to come out.*

**Figure 12.** *Chest tube lying outside the chest wall.*

**Figure 13.** *Mispositioned tube over the diaphragm (arrow).*

**Figure 14.** *Mispositioned tube lying in abdomen (arrow).*

#### **11. Advances in chest tube drainage systems**

With the advancement in technology, newer equipment has become available that may help in decreasing some of the complications associated with the tube thoracostomy, make the assessment of drainage more objective and accurate thus helping in better management of ICD tubes. Some of the advancement in the recent times are:


The use of these drainage systems has been associated with improved decisionmaking regarding chest tube management, decrease complications, improved quality of life and reduce the hospital stay [27–29] These are light weight, portable system with a disposable reservoir that may be replaced once full. The main advantages of this system are:

• It does not require an 'underwater seal' thus eliminating the risk of accidental pneumothorax and passage of drained material from the reservoir back to the chest.

**Figure 15.** *A patient being managed on digital chest tube drainage system following thoracotomy.*

• It allows accurate measurement of drained fluid and air over time and thus helps in assessment of the trend of drainage (**Figure 16A** & **B**).

This may help the clinician in making decision for removal of chest tube more objective and accurately.

	- i. Chest tube systems with inbuilt mechanism to keep the inside of the tube clean to prevent clogging [16, 18].
	- ii. Motion activated systems for prevention of clot formation inside the chest tube: This system uses motion-activated energy (vibration) primarily to prevent early adhesion of clots within the internal chest tube surface and thus maintains the patency of the chest tube [17].

### **12. Conclusion**

Insertion of ICD is a common, simple yet lifesaving procedure. All clinicians should be well versed with the appropriate technique of inserting the thoracostomy tube and various aspects of its management. Although simple, it is associated with high rate of complications that primarily occur due to improper technique of insertion or poor post-procedural care. Awareness of these factors will make the procedure safer with improved outcome.

### **Conflict of interest**

There are no conflicts of interest.

### **Author details**

Mohit Kumar Joshi Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, India

\*Address all correspondence to: drmohitjoshi@gmail.com

© 2021 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

#### **References**

[1] Hughhes J. Battlefield medicine in Wolfram's Parzival. J Medieval Military History.2010;8:119-130.

[2] Christopoulou-Aletra H, Papvramidou N. "Empyemas" of the thoracic cavity in the Hippocratic corpus. Ann Thorac Surg 2008;85: 1132-1134.

[3] Kesieme EB, Dongo A, Ezemba N, Irekpita E, Jebbin N, Kesieme C. Tube thoracostomy: complications and its management. Pulm Med. 2012;2012: 256878. doi: 10.1155/2012/256878. Epub 2011. PMID: 22028963; PMCID: PMC3195434.

[4] Hernandez MC, El Khatib M, Prokop L, Zielinski MD, Aho JM. Complications in tube thoracostomy: Systematic review and meta-analysis. J Trauma Acute Care Surg. 2018;85(2): 410-416. doi: 10.1097/ TA.0000000000001840. PMID: 29443856; PMCID: PMC6081248.

[5] Ortner CM, Ruetzler K, Schaumann N, Lorenz V, Schellongowski P, Schuster E, Salem RM, Frass M. Evaluation of performance of two different chest tubes with either a sharp or a blunt tip for thoracostomy in 100 human cadavers. Scand J Trauma Resusc Emerg Med. 2012;20:10. doi: 10.1186/1757-7241-20-10. PMID: 22300972; PMCID: PMC3395864.: chest drain insertion with trocars is associated with a 6-14% operator-related complication rate

[6] John M, Razi S, Sainathan S, Stavropoulos C. Is the trocar technique for tube thoracostomy safe in the current era? Interact Cardiovasc Thorac Surg. 2014;19(1):125-128. doi: 10.1093/ icvts/ivu071. Epub 2014 Mar 19. PMID: 24648468.

[7] Light RW. Pleural controversy: optimal chest tube size for drainage. Respirology. 2011;16(2):244-248. doi: 10.1111/j.1440-1843.2010.01913.x. PMID: 21166742.

[8] Fysh ET, Smith NA, Lee YC. Optimal chest drain size: the rise of the smallbore pleural catheter. Semin Respir Crit Care Med. 2010;31(6):760-768. doi: 10.1055/s-0030-1269836. Epub 2011 Jan 6. PMID: 21213208.

[9] Inaba K, Lustenberger T, Recinos G, Georgiou C, Velmahos GC, Brown C, Salim A, Demetriades D, Rhee P. Does size matter? A prospective analysis of 28-32 versus 36-40 French chest tube size in trauma. J Trauma Acute Care Surg. 2012;72(2):422-427. doi: 10.1097/ TA.0b013e3182452444. PMID: 22327984.

[10] Cooke DT, David EA. Large-bore and small-bore chest tubes: types, function, and placement. Thorac Surg Clin. 2013;23(1):17-24, v. doi: 10.1016/j. thorsurg.2012.10.006. PMID: 23206714.

[11] Orlando A, Cordero J, Carrick MM, Tanner AH 2nd, Banton K, Vogel R, Lieser M, Acuna D, Bar-Or D. Comparing complications of small-bore chest tubes to large-bore chest tubes in the setting of delayed hemothorax: a retrospective multicenter cohort study. Scand J Trauma Resusc Emerg Med. 2020;28(1):56. doi: 10.1186/s13049-020- 00754-5. PMID: 32571367; PMCID: PMC7310264.

[12] Porcel JM. Chest Tube Drainage of the Pleural Space: A Concise Review for Pulmonologists. Tuberc Respir Dis (Seoul). 2018;81(2):106-115. doi: 10.4046/trd.2017.0107. Epub 2018 Jan 24. PMID: 29372629; PMCID: PMC5874139.

[13] Reeb J, Falcoz PE, Olland A, Massard G. Are daily routine chest radiographs necessary after pulmonary surgery in adult patients? Interact

#### *Chest Tubes DOI: http://dx.doi.org/10.5772/intechopen.100047*

Cardiovasc Thorac Surg. 2013;17(6): 995-8. doi: 10.1093/icvts/ivt352. Epub 2013 Aug 15. PMID: 23956264; PMCID: PMC3829488.

[14] Kong VY, Sartorius B, Oosthuizen GV, Clarke DL. Prophylactic antibiotics for tube thoracostomy may not be appropriate in the developing world setting. Injury. 2015;46(5):814-816. doi: 10.1016/j. injury.2015.01.030. Epub 2015 Jan 22. PMID: 25669963.

[15] Olgac G, Aydogmus U, Mulazimoglu L, Kutlu CA. Antibiotics are not needed during tube thoracostomy for spontaneous pneumothorax: an observational case study. J Cardiothorac Surg. 2006;1:43. doi: 10.1186/1749-8090-1-43. PMID: 17101034; PMCID: PMC1647271.

[16] Boyacıoğlu K, Kalender M, Özkaynak B, Mert B, Kayalar N, Erentuğ V. A new use of Fogarty catheter: chest tube clearance. Heart Lung Circ. 2014;23(10):e229-e230. doi: 10.1016/j.hlc.2014.04.255. Epub 2014 May 28. PMID: 24958597.

[17] Karimov JH, Dessoffy R, Fukamachi K, Okano S, Idzior L, Lobosky M, Horvath D. Development and Evaluation of Motion-activated System for Improved Chest Drainage: Bench, In Vivo Results, and Pilot Clinical Use of Technology. Surg Innov. 2020;27(5):507-514. doi: 10.1177/ 1553350620927579. Epub 2020 Jun 3. PMID: 32490739.

[18] Perrault LP, Pellerin M, Carrier M, Cartier R, Bouchard D, Demers P, Boyle EM. The PleuraFlow Active Chest Tube Clearance System: initial clinical experience in adult cardiac surgery. Innovations (Phila). 2012;7(5):354-358. doi: 10.1097/IMI.0b013e31827e2b4d. PMID: 23274869

[19] George RS, Papagiannopoulos K. Advances in chest drain management in thoracic disease. J Thorac Dis. 2016 Feb; 8 (Suppl 1):S55-64. doi: 10.3978/j. issn.2072-1439.2015.11.19. PMID: 26941971; PMCID: PMC4756232.

[20] Oberoi, A.S., Parshad, R., Suhani, Seenu V, Joshi MK, Kashyap L, Singh KJ. Prospective Study to Evaluate the Role of Protocol-Based Management of Chest Tubes in Patients Undergoing Elective Thoracic Surgery. Indian J Surg.2020; 82:1050–1057.doi: . https://doi.org/ 10.1007/s12262-020-02182-2

[21] Batchelor TJP, Rasburn NJ, Abdelnour-Berchtold E, Brunelli A, Cerfolio RJ, Gonzalez M, Ljungqvist O, Petersen RH, Popescu WM, Slinger PD, Naidu B. Guidelines for enhanced recovery after lung surgery: recommendations of the Enhanced Recovery After Surgery (ERAS®) Society and the European Society of Thoracic Surgeons (ESTS). Eur J Cardiothorac Surg. 2019 Jan 1;55(1): 91-115. doi: 10.1093/ejcts/ezy301. PMID: 30304509.

[22] Cerfolio RJ, Bryant AS, Skylizard L, Minnich DJ. Optimal technique for the removal of chest tubes after pulmonary resection. J Thorac Cardiovasc Surg. 2013;145(6):1535-1539. doi: 10.1016/j. jtcvs.2013.02.007. Epub 2013 Mar 15. PMID: 23507121.

[23] Bell RL, Ovadia P, Abdullah F, Spector S, Rabinovici R. Chest tube removal: end-inspiration or endexpiration? J Trauma. 2001;50(4): 674-677. doi: 10.1097/00005373- 200104000-00013. PMID: 11303163.

[24] Kong V, Cheung C, Rajaretnam N, Sarvepalli R, Weale R, Varghese C, Xu W, Clarke DL. Recurrent pneumothorax following chest tube removal in thoracic stab wounds: a comparative study between end inspiratory versus end expiratory removal techniques at a major trauma centre in South Africa. ANZ J Surg. 2021;91(4):658-661. doi: 10.1111/

ans.16717. Epub 2021 Mar 15. PMID: 33719141.

[25] Yang MX, Ault MJ. A Punctureless and Secure Method of Chest Tube Fixation. Ann Emerg Med. 2018;72(1): 106-107. doi: 10.1016/j. annemergmed.2018.02.019. PMID: 29929649.

[26] Eisenkraft A, Gavish L, Wagnert-Avraham L, Gertz SD, Milner I, Shaylor R, Kushnir D, Kedar A, Mintz Y. Novel self-fixation chest drain device tested in a swine model of pneumohemothorax. Minim Invasive Ther Allied Technol. 2021;30(1):40-46. doi: 10.1080/13645706.2019.1671456. Epub 2019 Sep 30. PMID: 31566510.

[27] Chiappetta M, Lococo F, Nachira D, Ciavarella LP, Congedo MT, Porziella V, Meacci E, Margaritora S. Digital Devices Improve Chest Tube Management: Results from a Prospective Randomized Trial. Thorac Cardiovasc Surg. 2018;66 (7):595-602. doi: 10.1055/s-0037-1607443. Epub 2017 Oct 27. PMID: 29078230.

[28] Wang H, Hu W, Ma L, Zhang Y. Digital chest drainage system versus traditional chest drainage system after pulmonary resection: a systematic review and meta-analysis. J Cardiothorac Surg. 2019;14(1):13. doi: 10.1186/s13019-019-0842-x. PMID: 30658680; PMCID: PMC6339372.

[29] Miller DL, Helms GA, Mayfield WR. Digital Drainage System Reduces Hospitalization After Video-Assisted Thoracoscopic Surgery Lung Resection. Ann Thorac Surg. 2016;102(3):955-961. doi: 10.1016/j.athoracsur.2016.03.089. Epub 2016 May 25. PMID: 27234573.

#### **Chapter 4**

## Indwelling Pleural Catheters

*Yuvarajan Sivagnaname, Durga Krishnamurthy, Praveen Radhakrishnan and Antonious Maria Selvam*

#### **Abstract**

Indwelling pleural catheters (IPC) are now being considered worldwide for patients with recurrent pleural effusions. It is commonly used for patients with malignant pleural effusions (MPE) and can be performed as outpatient based day care procedure. In malignant pleural effusions, indwelling catheters are particularly useful in patients with trapped lung or failed pleurodesis. Patients and care givers are advised to drain at least 3 times a week or in presence of symptoms i.e. dyspnoea. Normal drainage timing may lasts for 15–20 min which subsequently improves their symptoms and quality of life. Complications which are directly related to IPC insertion are extremely rare. IPC's are being recently used even for benign effusions in case hepatic hydrothorax and in patients with CKD related pleural effusions. Removal of IPC is often not required in most of the patients. It can be performed safely as a day care procedure with consistently lower rates of complications, reduced inpatient stay. They are relatively easy to insert, manage and remove, and provide the ability to empower patients in both the decisions regarding their treatment and the management of their disease itself.

**Keywords:** indwelling pleural catheters, recurrent pleural effusion, malignant effusion, pleurodesis

#### **1. Introduction**

Indwelling pleural catheters (IPC) are now being considered worldwide for patients with recurrent pleural effusions [1]. It is commonly used for patients with malignant pleural effusions (MPE) and can be performed as outpatient based day care procedure. Talc pleurodesis and indwelling pleural catheters are the standard of care therapeutic options for the patients presenting with symptomatic malignant pleural effusions. In malignant pleural effusions, indwelling catheters are particularly useful in patients with trapped lung or failed pleurodesis. IPCs are effective, both in terms of symptom control and costs, and can dramatically improve the quality of life for patients who have traditionally needed lengthy hospital admissions.

#### **2. Background**

Indwelling pleural catheter (IPC) is a multi-fenestrated flexible silicone elastomeric chest drain with a polyester cuff which envelops the medial portion of the

tube. The proximal end of tube has a one-way access valve designed to be attached to vacuum drainage bottles. Its distal part is tunneled through the subcutaneous tissue before placing it in the pleural space (**Figure 1**). Most widely used IPCs are pleurx catheter and IPC by Rockett medical. Pleurx catheter was approved by FDA in 1997 for patients with symptomatic malignant pleural effusions to relieve Dyspnea [2].

Before the advent of IPCs, conventional method for managing recurrent pleural effusions is to place a large bore chest drain with pleurodesis/multiple pleural aspirations. Some centers were able to offer more invasive procedures, such as parietal pleurectomy or pleuro-peritoneal shunting, but these inevitably carried a risk of morbidity and were limited to patients who were fit enough to undergo general anesthesia [3, 4].

#### **3. History of indwelling pleural drains**

A widely recognized precursor to indwelling pleural catheter was first described in 1994. Robinson et al. [5] treated 9 patients with recurrent MPE, who had previously failed pleurodesis, with a Tenckhoff catheter, which was tunneled into the pleural space under local anesthesia. Implantable Porta cath was also used in olden days for some patients for intrapleural immunotherapy used in mesothelioma [6].

#### **4. Indications**


#### **5. Contraindications**


#### **6. IPC insertion**

Most of this procedure can be performed as a day care procedure in outpatient settings. There is no need to admit the patient for IPC insertion unless clinically warranted. It is advisable to stop antiplatelet/antithrombotic medications before the procedure to minimize the risk of bleeding (Aspirin-withheld for 5 days, Clopidogrel—withheld for 7 days. IPC can be inserted in any position which is suitable for drainage. It is preferable to moniter his oxygen saturation and vitals during the procedure. Supplemental oxygen can be given to those patients who are dyspneic with hypoxemia. We often prefer to give supplemental oxygen to all our patients during the procedure.

It can be performed under conscious sedation with local anesthesia. The patient is typically placed in the lateral decubitus position, with the patient lying on the side contralateral to the effusion, although they can be inserted in other patient positions. Bedside ultrasound thorax is to be done which facilitates the site of entry and also helps to quantify the pleural effusion.

Under aseptic precaution, after local anesthetic (Lignocaine 1–2%) infiltration, two small incision are made, one at the pleural insertion point and another one 7–10 cm anterior to this, which will form the proximal end to the tunneled track. The IPC catheter is tunneled along this track with the pro-fibrotic cuff which promotes tissue growth and keeps the drain in-situ, situated approximately a third along the track.

The distal end of the catheter is then inserted into the pleural cavity, using the Seldinger technique. The incisions are then sutured closed, although the catheter itself is not sutured in place. A one-way valve on the external end is then attached to a drainage bag or vacuum bottle system.

#### **7. Drainage**

Patients and care givers are advised to drain at least 3 times a week or in presence of symptoms i.e. dyspnoea. Normal drainage timing may lasts for 15–20 min which subsequently improves their symptoms and quality of life. Drainage bottles are commercially available which are connected to proprietary one-way access valve on the external portion of the drain. Training to the patients and their family members has to be done for proper dressing and drainage by connecting the bottles with aseptic precautions. This drainage bottle is primed with a vacuum (**Figure 2**) in order to draw out the pleural fluid usually to a maximum of 1000 ml.

**Figure 2.** *Vacuum drainage bottles.*

#### **8. Complications**

Complications which are directly related to IPC insertion are extremely rare [11].

#### **9. Immediate complications**

It is common to see a small pneumothorax in the post procedure chest X ray as a result of air being drawn into the chest during insertion. Such appearances may also be produced by trapped lung if significant volumes of fluid have been removed or trapped lung itself is seen in 20–30% of patients with malignant pleural effusion.

Large significant pneumothorax should prompt consideration of Iatrogenic injury to underlying lung and may warrant an extended period of observation before discharge.

Subcutaneous emphysema is also been documented post procedure. This demonstrates another reason why careful consideration should be given to track length, as if it is made too long there is the possibility of a fenestration remaining in the extrapleural space.

Post procedure pain can be seen in significant number of patients which can be usually managed with analgesics. Severe pain and discomfort should prompt concerns over irritation or damage to intercostal nerves. Patient may experience pain and discomfort at the end of drainage which indicates complete drainage of the pleural space which is often seen in those with underlying trapped lung. Wound Dehiscence in IPC is rarely reported.

#### **10. Late complications**

Initially there was a concern surrounding the risk of associated infections with indwelling pleural catheters. However, data from the observational and randomized studies have demonstrated a reassuring low incidence of associated infection

#### *Indwelling Pleural Catheters DOI: http://dx.doi.org/10.5772/intechopen.100645*

with one large multicenteric multinational retrospective study of over a 1000 patients, demonstrating a 4.8% IPC-related pleural infection rate [12]. Common organisms implicated are *Pseudomonas aeruginosa*, *Staphylococcus aureus*, and Enterobacteriaceae which differ from the pattern what we usually expect in parapneumonic effusions [12].

Usually the infectious complications are reported after 6 weeks after the insertion of IPC which indicates they are not secondary to the insertion but due to later spread of pathogens from the patient's skin or lung parenchyma [13]. Proper care, IPC dressing and drainage techniques would help to minimize the risk. Reassuringly, the mortality rate from IPC-related infection is low (0.29%) and most of these patients can be managed with oral antibiotics [12]. There is no need to remove IPC as most patients responds very well to the therapy. If this approach is unsuccessful, then patient may require hospital admission for intravenous antibiotics and placing the catheter on continuous free-drainage to facilitate resolution of the infection. In case of loculated pleural effusions, Intrapleural thrombolytics like tissue plasminogen activator and DNAase can also be given via IPC [13].

In malignant pleural effusion insertion of IPC may lead to track metastasis usually occurs in malignant mesothelioma [14]. Reported cases in the literature are sparse, but the incidence of metastasis occurring appears to be just below 1% [15]. Diagnosis can be made clinically or using ultrasound-guided biopsy [16], followed by prophylactic radiotherapy to prevent track metastasis. There is nothing to suggest that radiotherapy damages the IPC [14] and treatment, based upon small case series, tends to be successful, obviating the need for drain removal [17].

IPC blockage is another concern one need to consider since patency of the tube is important for effective drainage. This can be managed by daily saline flushing and on rare occasions in presence of thick loculated collection, one may use intrapleural fibrinolytics. The loss of electrolytes, immune factors or proteins has occasionally been raised as a concern of the long-term use of IPCs [18].

Catheter fracture is rare and may occur when an IPC is removed. The polyester cuff promotes inflammation and fibrosis which leads to tight anchoring of the catheter makes it difficult to remove. The risk of catheter fracture is reported to be about 10% [19]. This is usually managed by surgical exploration or just leaving the catheter fragments inside the body. No complications have been reported from retained fragments of IPC.

#### **11. Use of IPC in malignant pleural effusions (MPE)**

Conventional approach to the patients with symptomatic MPE is therapeutic pleurocentesis and subsequent pleurodesis. Various pleurodesis agents can be used but the most commonly used agent is talc which can be guided by thoracoscopic talc poudrage or instillation via standard chest tube. Option of IPC insertion is given to the patients who had developed trapped lung. IPCs are the ideal way for palliative care as they can be sited easily and quickly, and can be drained as often as is required to alleviate symptoms, allowing for consistent improvement in the breathlessness which will afflict the vast majority of patients with a malignant effusion [20] and improvements seen even in those with trapped lung [21].

Davies et al. [22] compared the use of IPCs to standard talc slurry via chest drain in patients who had not previously undergone pleurodesis. The trial used self-reported dyspnoea scores as its main outcome measure, showing that 6 weeks after randomization there was no significant difference between the two treatment arms. Some of the secondary endpoints appeared more favorable in the IPC group, including the proportion of patients who achieved a clinically significant relief

in their symptoms (86 vs. 74%); the median length of initial hospital stay (0 vs. 4 days), and the median number of days spent in hospital for drainage over the following 12 months (1 vs. 4.5 days). Eventhough the study is underpowered, similar findings were reported elsewhere. Intrapleural Fibrinolytics can also be guided with IPC in case of multiloculated/septated effusion.

It also holds the potential to allow direct anti-cancer therapy. Sterman et al. [23] showing that patients with MPE or mesothelioma can be safely given both single- and repeated-dose interferon-β gene therapy and another group reporting the administration of monthly rituximab via an IPC for a patient with non-Hodgkin's lymphoma [24]. Jones et al. [25] and Rahman et al. [26] studied the use of Docataxel and Lipotechoic acid -T via IPC (Pleurx) respectively with favorable clinical response.

IPC can be combined with pleurodesis agents to achieve higher success rates and early pleurodesis in patients with high output effusion. Tremblay et al. [27] have demonstrated that low-level, repeated doses of intrapleural silver nitrate in a rabbit model can maintain the pleurodesis efficacy of a drug without raising the side effect profile. Dierdre B Fitzgerald et al. studied the use of talc via IPC with malignant pleural effusion and concluded that IPC combined with inpatient talc slurry pleurodesis, followed by daily home drainage provided good success rates [28].

#### **12. Spontaneous pleurodesis**

Spontaneous pleurodesis is also possible in patients with IPC which is an added advantage. In a study by Yuvarajan et al. [29] Spontaneous pleurodesis was achieved in 55% of the patients with hepatic hydrothorax who were placed on IPC. Mean time for spontaneous pleurodesis is around 120.8 days. Collated data from various studies suggest an overall spontaneous pleurodesis rate of around 45% for patients with MPE [15], however, some studies have reported significantly higher [30, 31] or lower values [32]. Higher pleurodesis rates, often exceeding 70%, have been noted when more aggressive drainage regimens (daily or more frequent) have been used, or when patients undergo a talc pleurodesis at the same time as IPC insertion [31].

#### **13. Impact of chemotherapy in patients with IPC**

Usage of IPC significantly improves the dyspneoa, quality of life and their performance status which is crucial for initiating chemotherapy, as chemotherapy is usually deferred in patients with poor performance status. In spite of this, there is huge concern in the risk of infectious complications post chemotherapy in those patients with IPC. There was no difference in the pleural infection rates in a retrospective analysis of 170 patients who were receiving chemotherapy with IPC when compared to those patients who did not receive chemotherapy [33]. But the decision to place an IPC in those who is already on chemotherapy needs multidisciplinary discussion with oncologist, oncosurgeon, pulmonologist and infectious disease specialist.

#### **14. IPC in benign effusions**

The most common causes for nonmalignant pleural effusions are Parapneumonic effusions, effusions due to congestive heart failure (CHF), hepatic hydrothorax (HH) secondary to cirrhosis of the liver and effusions due to renal failure. IPC's are

#### *Indwelling Pleural Catheters DOI: http://dx.doi.org/10.5772/intechopen.100645*

being recently used even for benign effusions in case hepatic hydrothorax and in patients with CKD related pleural effusions. Yuvarajan et al. [29] did a retrospective analytical study on the use of IPC in hepatic hydrothorax. 30 patients with hepatic hydrothorax were placed with indwelling pleural catheters. Spontaneous pleurodesis was achieved in 18 patients (60%) and IPCs were removed in these patients. Most of the patients (70%) who achieved spontaneous pleurodesis with IPC received at atleast one TIPS (Transjugular Intrahepatic porto systemic shunt) procedure. Mean time in which pleurodesis achieved was 120.8 days (range, 15–290 days). Thus TIPS procedure increases the success rate of pleurodesis with indwelling pleural catheters in hepatic hydrothorax.

IPC placement may be a reasonable clinical option for patients with refractory HH, but it is associated with significant adverse events in this morbid population. Potechin et al. [34] did a cohort study on IPC usage in patients who presented with recurrent effusion in end stage renal disease and concluded that IPC insertion for pleural effusions associated with end-stage renal disease appears safe and effective.

### **15. IPC removal**

Removal of IPC is often not required in most of the patients. However, spontaneous pleurodesis is one of the potential causes for considering its removal. Other indications include pleural sepsis, nonfunctional/defective IPC and Severe pain with local cellulitis which cannot be managed with conservative approach. Removing indwelling pleural catheter is not an easy task. Since the polyester cuff attached to the drain is designed to promote local fibrosis and the removal of a drain can become more difficult with long standing IPC. In addition, advanced malignancy promotes ingrowth of fibrotic strands into the fenestrations of IPC further making the extraction of catheter difficult. For removal, one need to do careful and meticulous dissection of the fibrous material around the cuff following appropriate incisions. In those circumstances of difficulty in removal of IPC, an alternative is to simply leave the drain and to remove only the proximal portion. Fysh et al. [35] described 2 cases of this being undertaken in a small series of complicated removals. In none of the cases in which tubing was left intrapleurally did the patient experience any infective or pain-related complications during follow-up.

#### **16. Conclusion**

So IPCs plays a major role in patients with recurrent pleural effusions especially malignant pleural effusions. It is particularly useful in palliative care of the patients with trapped lung and failed chemical pleurodesis. It can be performed safely as a day care procedure with consistently low rates of complications, reduced inpatient stay and the recognition that significant improvements in patients' symptoms. They are relatively easy to insert, manage and remove, and provide the ability to empower patient's in both the decisions regarding their treatment and the management of their disease itself.

*Pleura - A Surgical Perspective*

#### **Author details**

Yuvarajan Sivagnaname1 \*, Durga Krishnamurthy2 , Praveen Radhakrishnan1 and Antonious Maria Selvam1

1 Department of Respiratory Medicine, Sri Manakula Vinayagar Medical College and Hospital, Puducherry, India

2 Department of Obstretrics and Gynaecology, Sri Lakshmi Narayana Institute of Medical Sciences, Puducherry, India

\*Address all correspondence to: nsivagnaname@yahoo.com

© 2021 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

### **References**

[1] Tremblay A, Michaud G. Singlecenter experience with 250 tunneled pleural catheter insertions for malignant pleural effusion. Chest. 2006;**129**:362- 368. DOI: 10.1378/chest.129.2.362

[2] Denver PleurX Home Drainage Kit. Summary of Safety and Effectiveness Denver PleurX Pleural Catheter Kit. Rockville: Food & Drug Administration; 1997

[3] Fry WA, Khandekar JD. Parietal pleurectomy for malignant pleural effusion. Annals of Surgical Oncology. 1995;**2**:160-164

[4] Genc O et al. The long-term morbidity of pleuroperitoneal shunts in the management of recurrent malignant effusions. European Journal of Cardio-Thoracic Surgery. 2000;**18**:143-146

[5] Robinson RD et al. Use of pleural Tenckhoff catheter to palliate malignant pleural effusion. The Annals of Thoracic Surgery. 1994;**57**:286-828

[6] Driesen P et al. Implantable access system for prolonged intrapleural immunotherapy. The European Respiratory Journal. 1994;**7**:1889-1892

[7] Mullon J, Maldonado F. Use of tunneled indwelling pleural catheters for palliation of nonmalignant pleural effusions. Chest. 2011;**140**:996A

[8] Depew ZS et al. The role for tunneled indwelling pleural catheters in patients with persistent benign chylothorax. The American Journal of the Medical Sciences. 2013;**346**:349-352

[9] Thornton RH et al. Tunneled pleural catheters for treatment of recurrent malignant pleural effusion following failed pleurodesis. Journal of Vascular and Interventional Radiology. 2010; **21**:696-700

[10] Davies HE et al. Use of indwelling pleural catheters for chronic pleural infection. Chest. 2008;**133**:546-549

[11] Suzuki K et al. Palliation and pleurodesis in malignant pleural effusion: The role for tunneled pleural catheters. Journal of Thoracic Oncology. 2011;**6**:762-767

[12] Fysh ET, Tremblay A, Feller-Kopman D, et al. Clinical outcomes of indwelling pleural catheter-related pleural infections: An international multicenter study. Chest. 2013;**144**(5): 1597-1602

[13] Lui MM, Thomas R, Lee YC. Complications of indwelling pleural catheter use and their management. BMJ Open Respiratory Research. 2016;**3**(1):e000123

[14] West SD, Foord T, Davies RJO. Needle-track metastases and prophylactic radiotherapy for mesothelioma. Respiratory Medicine. 2006;**100**:1037-1040

[15] Van Meter MEM, McKee KY, Kohlwes RJ. Efficacy and safety of tunneled pleural catheters in adults with malignant pleural effusions: A systematic review. Journal of General Internal Medicine. 2011;**26**:70-76

[16] Riker D, Sell R. Ultrasound-guided percutaneous biopsy to diagnose indwelling pleural catheter metastasis. Journal of Bronchology and Interventional Pulmonology. 2012; **19**:165-167

[17] Janes SM et al. Catheter-tract metastases associated with chronic indwelling pleural catheters. Chest. 2007;**131**:1232-1234

[18] Aelony Y. Tunnelled pleural catheters in malignant pleural effusion. Lancet. 2007;**370**:387

[19] Siddiqui F, Siddiqui AH. Intrapleural catheter. In: StatPearls. Treasure Island (FL): Stat Pearls Publishing; 2021

[20] Roberts ME et al. Management of a malignant pleural effusion: British thoracic society pleural disease guideline 2010. Thorax. 2010;**65**(suppl 2):ii32-ii40

[21] Efthymiou CA et al. Malignant pleural effusion in the presence of trapped lung. Five-year experience of PleurX tunnelled catheters. Interactive Cardiovascular and Thoracic Surgery. 2009;**9**:961-964

[22] Davies HE et al. Effect of an indwelling pleural catheter vs chest tube and talc pleurodesis for relieving dyspnea in patients with malignant pleural effusion: The TIME2 randomized controlled trial. JAMA. 2012;**307**:2383-2389

[23] Sterman DH et al. A phase I trial of repeated intrapleural adenoviralmediated interferon-beta gene transfer for mesothelioma and metastatic pleural effusions. Molecular Therapy. 2010; **18**:852-860

[24] Islam A, Takita H. Malignant pleural effusion and advanced stage low-grade non-Hodgkin's lymphoma successfully treated with intrapleural instillation of rituximab. Blood. 2012;**120**:4891

[25] Jones DR, Taylor MD, Petroni GR, Shu J, Burks SG, Daniel TM, et al. Phase I trial of intrapleural docetaxel administered through an implantable catheter in subjects with a malignant pleural effusion. Journal of Thoracic Oncology. 2010;**5**(1):75-81

[26] Rahman NM, Davies HE, Salzberg M, Truog P, Midgely R, Kerr D, et al. Use of lipoteichoic acid-T for pleurodesis in malignant pleural effusion: A phase I toxicity and dose—Escalation study. The Lancet Oncology. 2008, 10;**9**:946-952

[27] Tremblay A, Stather DR, Kelly MM. Effect of repeated administration of low-dose silver nitrate for pleurodesis in a rabbit model. Respirology. 2011;**16**:1070-1075

[28] Fitzgerald DB, Muruganandan S, Stanley C, Badiei A, Murray K, Read CA, et al. EPIToME (Early Pleurodesis via IPC with Talc for Malignant Effusion): Evaluation of a new management algorithm ERJ. 2019;**54**:OA493

[29] Yuvarajan S, Praveen R, Selvam AM. Role of indwelling pleural catheters in hepatic hydrothorax. IP Indian Journal of Immunology and Respiratory Medicine. 2019;**4**(3):147-149

[30] Chalhoub M et al. The use of the PleurX catheter in the management of non- malignant pleural effusions. Chronic Respiratory Disease. 2011; **8**:185-191

[31] Bazerbashi S et al. Ambulatory intercostal drainage for the management of malignant pleural effusion: A single center experience. Annals of Surgical Oncology. 2009;**16**:3482-3487

[32] Shah A et al. Tunneled indwelling pleural catheters in hematologic malignancies. Chest. 2011;**140**:702A

[33] Mekhaiel E et al. Infections associated with tunnelled indwelling pleural catheters in patients undergoing chemotherapy. Journal of Bronchology and Interventional Pulmonology. 2013; **20**:299-303

[34] Potechin R, Amjadi K, Srour N. Indwelling pleural catheters for pleural effusions associated with end-stage renal disease: A case series. Therapeutic Advances in Respiratory Disease. 2015; **9**(1):22-27

[35] Fysh ETH et al. Fractured indwelling pleural catheters. Chest. 2012;**141**:1090-1094

Section 4
