How to manage difficult pleural effusions
Ramesh Kaul, MD, FCCP, FACP, Master of Surgery.
This is a practical insight to my surgery in pleural effusions.
Effusions can become difficult if the effusions are very large, or loculated, or with thick viscous exudates, with blood or with clots or recurrent in presentation.
How were we successful? What really worked ? what did not work? .
It is wise to have a non contrast CT Chest done in most of the cases, contrasts are not essential unless mesothelioma or empyema is suspected.
Remember lungs are inside the body cavity called thorax with shining layer of thin membrane called visceral pleura wrapped around the lungs, also another membrane(Parietal Pleura) lines the inside of the chest cavity.
There is space between the two pleural layers which is collapsed by negative pressure and thin layer of fluid.
However there can be a large amount of collection between these two layers. This causes collapse of the chest cavity. There is no space for lungs to expand and thus shortness of breath ensues.
The cascade effect of disruption of lung function leads to stress on the heart and causes heart failure.
This further pools the blood in the lungs and causes inability of lungs to inflate with air and exchange oxygen with carbon dioxide in the blood.
This is a total collapse of Heart and Lung system and may lead to death.
Early collection of fluid is reversed or prevented by shrinking the blood volume by forcing kidneys to not to absorb water back.
The net liquid loss in the blood shrinks the blood volume and thus reabsorbs the fluids back from membranes and body spaces.
The problem starts when the diuretics and fluid restriction does not work.
Choice is to tap the chest and drain the fluid with a needle catheter or a tube; this does have its risks and benefits.
The needle may cause pain, puncture the lung, cause bleeding or even fail to relieve the problem by inability to drain the fluid.
The best option is place a small pig tail catheter, and leaves it in for 24 hrs or till your next visit.
Insertion of Pleural Catheter
The procedure is simple the catheter drains the fluid from pleural space by gravity rather than vacuum.
The pigtail ensures no sharp pointing structures damage the pleura or pierce the lung.
The syringe can work on the the three way valve attached to the bag and push fluid in to the back for measurement and testing.
We can also do talc, or chemical pleurodesis in patients unable to do VATS pleurodesis.
Pain should be managed with IV Morphine or oral pain killers.
Incentives help in good evacuation of fluid in the bag or water seal.
Three way valves attached to the catheter and keeping catheter in the chest with couple of 2-0 silk sutures or stay-fix tape helps.
If left in for some time catheter must be placed in the lower rib spaces of posterior axilla in posterior axillary line for safety of patient not laying on it.
Chest X rays are mandatory after the procedure for safety as well as legality. The best outcomes are to use a 2mgs of Cath-flo or Activase diluted in 20 mls of water in the pleural cavity, for few days at each visit this breaks the loculations and keeps the fluid flowing and blocking the catheter.
Rarely one can place a size 24 French tube and use a flexible pediatric bronchoscope as a
Pleuro-scope and evaluate the pleural cavity.
Pleuroscopy is a very successful method and safe with little IV Morphine given for pain.
One can make a small incision in the posterior axillary line after Lidocaine local anesthesia and
do a conventional chest tube placement procedure.
Fix the tube with a stay fix tape and guide the pleuroscope through a cap which I borrow from the Bronchoscopy Tube three way connector.