Pleurx Catheter Placement Experience - 1254521

It's not typical to have pain, and shortness of breath typically improves significantly once the fluid is drained, as long as the lung re-expands. Sometimes the lung is "trapped" because there may be fibrous material, possibly cancer, limiting the lung from re-expanding even when there isn't compression of the lung from fluid outside -- in that case, the shortness of breath wouldn't typically improve, or at least not much.

How often the fluid needs to be drained is completely individual, dependent on how much fluid the cancer is making. Some patients may need to drain the fluid every day or two and remove 500-1000 cc at a time. Other people will have relatively little fluid production and may only need to be drained every week, or even less frequently. however, if the fluid reaccumulates very slowly, we sometimes take out the catheter and just insert a needle to do a thoracentesis here and there when needed.

Good luck.

-Dr. West

meanie11:

My Mom had very little pain from the catheter itself, but had pain when they would drain the fluid. It was explained to us that there are a lot of nerve endings in the pleura. . .so there is a pressure/pain feeling if they drain too fast or too much at once (a vacuuming sensation). It's best to go slow (keep your thumb on the little switch-thingy and pace it slowly) - - even start stop start stop...etc. There shouldn't be a rush to get the fluid out as quickly as possible. Do it over a 15-20 minute period of time (for 300-400 ccs). Your Mom can tell when she starts feeling super uncomfortable and you guys should stop.

Good luck,
Laya

P.S. My Mom took some tylanol or advil about 15-20 minutes before we drained her. She said it helped with the draining pain. Of course, check with your Mom's doc first about any meds. for her.

Laya thanks for the info. It looks like I'll be getting one put in very soon! I was leaning toward the Talc procedure but from what I have heard a lot of time it doesn't work and then they have to do Catheter anyway. I had mine drained once in Oct. and then about 2 weeks ago and wasn't expecting to need it again for 3 or 4 months but for some reason it filled back up in 2 weeks. So had it drained yesterday and already I can tell it is filling up again. Of course no pain when they do it but that is because he gives a shot before inserting the Needle. One more reason to still go for the Talc procedure. Any pros and cons anyone? Lorrie.

Talc: pros -- when it works, it's one and done. Cons -- temporarily causes pain, fever, inflammation in most patients, doesn't work all the time. Isn't suitable if lung doesn't reinflate well when fluid is removed.

PleuRx: pros -- can be managed by patient and/or caregivers at home and have fluid removed on demand, can be removed if it resolves because of effective treatment of underlying cancer; cons -- some risk of catheter infection, catheter can get clogged; losing fluid over and over can lead to significant protein loss and increased risk of infection due to diminished immune function over time. Not ideal as long-term solution.

Repeat thoracenteses: pros -- done on demand only, no more than needed; cons -- some increased risk of pneumothorax (lung collapse) and/or bleeding when needle introduced over and over, same issue of long-term protein loss with removal of large volumes of fluid over time.

Good luck.

-Dr. West

Dr. West also wrote a post on management of pleural effusions a while back.

JimC Forum moderator

Honestly, it's hard to say if it would help. It might, but with so much going on, and with results from radiating of liver mets being not especially common, I think it would be hard to predict if it will help significantly or not. Good luck.

-Dr. West

Hello Dr. West,
My mother is a 72 yo non-smoker who developed stage 4 non-small cell lung cancer (pneumonic form; no mets outside of the lung, mostly present in left lower lung but tumor is present in B/L lungs) dx in Nov '16 that is EGFR positive (so she was on erlotinib for 1 year from Dec '16 until developing resistance to it in Jan '17 as well as developing a large pleural effusion in the left lower lower) and then found to be T790m positive in Feb '17 and has been on Tagrisso since Feb '17 (doing well with decreasing tumor burden), but has continued to need weekly thoracentesis to remove about 700 cc's of fluid from Feb '17 - Apr '17.

She had a PleurX catheter placed 4 days ago, but has had significant shoulder/upper back/chest wall pain since then (apparently it was a challenging PleurX placement; thoracic surgeon attempted it 3 times and ultimately Interventional Radiology had to place the PleurX). She had increasing pain today, and she went to the ED. She was diagnosed with a pneumothorax.

In general, what do you typically recommend to patients with malignant pleural effusions who have a symptomatic pneumothorax from a PleurX catheter placement? Remove the PleurX catheter and place a chest tube? I'm sure the effusion has filled up again by now, as well.

Thank you!

Eric

Hi Eric, I'm so sorry to know your mom is having difficulty with PE especially now that tagrisso is working to eliminate the tumor burden. A pleurx catheter is an indwelling chest tube. The needle puncture from consecutive thoracenteses can cause lung collapse. I'm not sure what if anything can be done to eliminate the collapse if it's not re-inflating after the fluid is drained. I'll ask one of our faculty to comment.

In any case comfort care is very important if you need to please do advocate for her on behalf of pain management. Supplemental oxygen may be in order. Too, it's good to know that opioid pain meds also act as a good cough suppressant and lowers the feeling of oxygen deprivation.

I hope your mom gets over this and looks back on it as a bump in the road.

All best,
Janine

Eric,

I don't think there's a clear reason to believe that the pneumothorax was caused directly by the PleurX catheter. It is very difficult, and by that I mean potentially impossible, to know how much of the problem is from the underlying cancer, a scarring reaction from the catheter, or some other process (the space can sometimes get infected). There is no standard approach for this very complex situation. It requires consideration of how significant the pneumothorax actually is (anything from major collapse of the lung, which may not be functioning well at all, to a small collapse with minimal impact), how rapidly the fluid is coming back, and other aspects.

I'm sorry we can't say what is best to do here, but any time you have a situation of a complex pleural space with lung collapse, loculated effusions, pain, sometimes shortness of breath and a low oxygen level in the blood, it always requires a very individualized approach with the best experts around. The most valuable input will need to be from a thoracic surgeon and potentially a pulmonologist, especially if there's an interventional pulmonologist around (they are a more limited subset and not as plentiful as we'd like).

Good luck.
-Dr. West