Canterbury DHB - Respiratory Service

Procedure and Protocol

Pleural Effusions

Nursing Procedures - see:

• Chest Drain Insertion and Management
• Nursing Management of Chest Drains and Related Procedures
  • Assisting with chest tube insertion (Assisting with a Wide Bore Chest Tube Insertion, Assisting with Seldinger Chest Tube Insertion)
  • Care of chest drains
  • Changing chest drainage collection system
  • Removal of chest drains
  • Flushing of chest drains
  • Assisting with pleural aspiration / biopsy
  • Assisting with intrapleural sclerosant therapy Pleurodesis
  • Assisting with intrapleural adhesiolysis (alteplase/DNase)
• Readings for chest drain management - Learning package for Christchurch Hospital Nurses
• Chest drain files: Chest drain insertion for medical officers (Dr B Rhodes 2006)
• For a review of the aetiology, investigations, diagnosis of pleural effusions please refer to the Blue Book and also Up To Date – the latest edition(s) both accessible via the CDHB Intranet > Clinical Info link or (for subscribers) www.utdol.com
• Please refer to the BTS Guidelines 2010 www.brit-thoracic.org.uk. The BTS guidelines include chapters on:
  • Investigation of a unilateral pleural effusion in adults
  • Management of pleural infection
  • Management of malignant pleural effusions
  • Management of spontaneous pneumothorax
  • Insertion of a chest drain

General Principles

• Patients with large pleural effusions are best managed by a respiratory team.
• Once a large effusion has been fully drained it will no longer be possible to perform a closed biopsy using an Abram‘s needle.
• A contrast enhanced CT thorax will be helpful to determine focal / nodular pleural changes that may be a target for image guided biopsy.
• In cases of thoracic malignancy the sensitivity of an image guided biopsy procedure is significantly higher than that of an Abram’s needle procedure (see NA Maskell et al in Lancet 2003;361:1326-31). Focal / nodular pleural change however is required for a “Trucut” biopsy.
• In cases of suspected tuberculosis a closed biopsy procedure is a test with a high sensitivity – mycobacterial culture is required- send samples to the laboratory in both saline and formalin.
• A thoracoscopy / pleuroscopy procedure with biopsy has the highest sensitivity for the diagnosis of pleural disorders.

Chest Drains/Tube Thoracostomy

• Prior to a chest drain insertion please discuss with the respiratory physician which type and size of drain and which collection system to choose.
• There are different recommendations in the literature - the BTS 2003 guidelines suggest that small bore chest tubes (10-14 French) may be just as effective as larger sized ones (>20 French) but caution will be required in cases with a significant broncho-pleural fistula /pneumothorax (in particular cases with secondary - rather than primary - pneumothorax), in those with a haemothorax (usually 28-32 Fr drains are suggested) and some cases with empyema.
• A chest drain insertion requires informed (written) consent.
• Consider using effective pre-medication in addition to the local anaesthetic.
• Prescribe appropriate analgesia after the insertion - if there is a lot of local (=at the insertion site) pain consider the use of (longer-acting) local anaesthesia such as Bupivicaine.
• After the drain insertion please document the choice of the drain, its size, how far (in cm) this was inserted.

  Note: needle diameters are measured using the British Standard Wire Gauge whose increments are in multiples of 4/1000 inch. The sequence of sizes of a gauge is not linear AND the diameter decreases as gauge size increases. Chest drain diameter is measured using the French Gauge or size (Charriere). This is linear and metric = 1/3 mm. A 12 Fr drain has an external diameter of 4 mm, a 21G needle has an external diameter of 32/1000 inches (~0.8 mm).

Pleural Infections

The treatment of thoracic empyema includes antibiotics, drainage of the effusion, thoracic surgical adhesiolysis, and other attempts to free up adhesions / loculation within the pleural space with Fibrinolytic therapy. Streptokinase treatment has been used and intrapleural (fibrinolytic) streptokinase (250,000 IU twice daily for 3 days) is still part of the 2003 BTS guidelines despite the largest clinical trial (RCT) not showing a significant benefit (NA Maskell et al in N Engl J Med 2005;352:865- MIST1 trial). The subsequent MIST2 trial comparing intra-pleural treatment with Alteplase, Dornase alpha (Pulmozyme) and saline has shown benefit, so Alteplase and Pulmozyme should be considered early in cases of loculated para-pneumonic effusion/ empyema. See Administering Intra-pleural Tissue Plasminogen Activator (Alteplase) and Dornase Alfa.

If fibrinolytic treatment is not used and the patient is managed with a small bore tube, regular instillation of normal saline flushes should be considered strongly e.g., 10 mL twice daily or more often.

Early consultation of the Cardio-Thoracic Surgical Service for consideration of surgical decortication may be helpful in certain cases.

Malignant Pleural Effusions

• Make sure a diagnosis has been obtained before proceeding to a pleurodesis procedure. Even if there is a report of malignant cells on cytology it may not be possible to differentiate between epithelioid mesothelioma and metastatic (adeno)-carcinoma. Immuno-cytochemistry markers (CK7, TTF1, calretinin….) are quite specific but often a histological sample is required. This does matter as there will be implications for the management and possible insurance related issues: cases with confirmed mesothelioma should be referred for drain site radiotherapy.
• An ACC claim should be considered (discuss with the respiratory social worker, see section on ACC claims for asbestos related disease): This may open a future source of funding for support services and, if possible, some restricted treatments such as chemotherapy. Since a change of legislation that came into effect in 2004 there now also is a potential for lump sum compensation.
• If a pleural aspirate is sent for cytological testing ensure sufficient fluid has been obtained (“as much as possible” but ideally >30 mL) and that the sample is being processed during working hours.
• A pleurodesis procedure may be considered once the effusion has been drained and the lung has re-expanded. If the lung does not re-expand it may be “trapped”. The risk of this seems to increase with the number of prior pleural procedures. Options at this point may be limited - consider insertion of a tunnelled pleural catheter after discussion with the respiratory physician.
• Thorascopic pleurodesis is slightly more efficacious than medical pleurodesis (Shaw PHS, Agarwal R. Pleurodesis for malignant pleural effusions. Cochrane Database of Systematic Reviews 2004, Issue 1. Art. No.: CD002916. DOI: 10.1002/14651858.CD002916.pub2) and for young patients with good performance status, referral to cardio-thoracic surgery should be considered in the first instance.
• A pleurodesis procedure requires patient consent and pre-medication (opiate analgesia ± intra-pleurallocal anaesthetic). Consent should include discussions about the estimated success rate (~"3/4", quoted to be up to 80-90% but in reality likely significantly less); the minimum time required / time the patient will require a chest tube (at least 2 nights may be longer if there is significant pleural fluid production after the sclerosant has been administered) and the side effects (pain, fever, inflammation).
• Check with the SMO which sclerosant /agent is to be used. Talc slurry is the most effective sclerosant available (see BTS 2003) but there have been concerns about potential risks - in particular ARDS (see A Brant, T Eaton in Respirology 2001;6:181). Some of these risks seem to relate to the dose used and to the particle size with large particle / "French" talc having a much lesser risk. The dose used here is 4 or 5g. The Cochrane review referred to above found talc to be the most effective sclerosant with no association with increased mortality post pleurodesis.

  Alternative sclerosant agents available here in Christchurch are: doxycycline and bleomycin. See Chest Drain Insertion and Management and Nursing Management of Chest Drains and Related Procedures.

• Published guidelines suggest that patient rotation after having instilled the agent is not necessary. This has only been studied with tetracycline and there may be some theoretical merit of rotating the patient when using talc slurry. The drain should be clamped for 1-2 hours.
• After the pleurodesis procedure allow free drainage for at least 24 hours. Some experts suggest to apply suction (?20 cm H₂O) but there is no evidence one way or the other. The drain is usually removed after the amount of drained pleural fluid is less than 150 mL /24h.
• If chemical pleurodesis fails, an alternative method may be considered, either an alternative sclerosant or referral to cardio-thoracic surgery for VATS pleurodesis.
• Insertion of a tunneled pleural catheter can also be considered, particularly where there is a strong suspicion of "trapped lung". TPC allows controlled release of pleural fluid as it reaccumulates whilst maintaining the patient’s independence at home. In many cases there will eventually be spontaneous pleurodesis. The patient support systems must be in place; this will involve Cardio-respiratory Integrated Specialist Services (CRISS) and community agencies such as Nurse Maude.

Persisting bronchopleural fistula

• Pneumothorax that fails to resolve, persisting “airleak”, development of surgical emphysema in a patient with a drain in situ.
• Ensure the size of the drain chosen is appropriate - ensure that you discuss the choice of drain prior to its insertion with the SMO in charge.
• Most primary pneumothoraces will be managed appropriately and successfully with a small bore drain.
• In cases with secondary pneumothorax (i.e. there is underlying lung disease such as emphysema) a 12F drain may not be sufficient and a large(r) drain may be required (>=24F using the blunt technique).
• The current BTS guidelines suggest an early referral for a thoracic surgical opinion (e.g. after 3 days).

Management options include:

• A larger drain.
• The use of suction.
• A surgical intervention i.e. thoracoscopy /VATS and a procedure to ensure a seal and to prevent recurrence:
  • Pleurectomy / Pleural abrasion
  • Stapling of (apical) blebs or bullae
  • Pleurodesis - this may be sterile water, talc poudrage

In selected cases who are not fit for a general anaesthetic an alternative approach may include:

• Flexible bronchoscopy: Use of a balloon catheter to identify the respective pulmonary segment where the causative fistula is located = if airleak stops when balloon is inflated. Once located one can try to obtain a seal by instilling autologous blood, or thrombin glue into the segmental bronchus.
• In Christchurch a few cases have been treated with an “autologous pleural blood patch” i.e. instillation of 50 mL of blood drawn from the patients immediately prior, the blood is then instilled (no heparin) into the drain (injected under sterile conditions while clamped distally if self-sealing rubber tubing), this is followed by a saline flush, the drain is then unclamped and left connected to the under-water-seal - however with the tubing kept (60 cm) ABOVE the patient for 2h. After that the tube is (re-)connected to suction. A risk of subsequent tension pneumothorax must be anticipated (and experienced at least twice here in our unit - one case being reported (Thorax 2005;60:1066-7- P Williams & R Laing; see also original paper by R Dumire in CHEST 1992;101:64-6 and also M Ando et al in Resp Med 1999;93:432-4)). A large drain may have a lesser risk of resulting tension pneumothorax.
• Overseas centres have used one-way bronchial valves in this context (also experimental use for “non-invasive” LVRS). This has not as yet been used by the Respiratory Service here.

Topic Code: 7376