RESPIRATORY MEDICINE (1998) 92, 633-637

Curved chest tube for drainage of malignant pleural effusion [ MEDICINE j

H. ISHIKAWA”, H. SATOH”, Y. T. YAMASHITA*, H. KAMMA+, T. NAITO”, M. OHTSUKA’ AND S. HASEGAWA”

“Department of Respivatouy Medicine, Institute of Clinical Medicine, University of Tsukuba, Japan ‘Department of Pathology, Institute of Basic Medical Sciences, University of Tsukuba, Japan

Thoracentesis with a chest tube insertion and drainage of large pleural effusion is widely performed in patients with malignant lung diseases. One potential problem with a conventional chest tube placement is occasional incomplete evacuation of effusion owing to inappropriate position of the tip where the drainage holes opened. We have developed a curved chest tube and evaluated the position of tip placement just after the placement and before removal on plain chest X-ray in 20 patients with massive pleural effusions due to lung cancer. In 15 of the 20 patients, the tip of the tube was successfully positioned at the paravertebral gutter in posterobasal with higher drainage efficacy compared with other patients whose tube tips happened to be positioned at other sites. There were no significant complications. This study suggested that the curved chest tube would be safe and useful in completing drainage of pleural effusion.

RESPIR. MED. (1998) 9.2, 633-637

Introduction

Malignant pleural effusion is treated with chemical pleuro- desis and/or systemic chemotherapy (l-4). The key to successful chemical pleurodesis is complete evacuation of pleural effusion. Prompt and complete evacuation of effusion may relieve patients’ anxiety and discomfort and prevent complication (5).

Chest tube placement is a commonly performed procedure; however, incomplete evacuation of effusion is occasionally noted owing to inappropriate positioning of the tube, since the procedure is often performed without fluoroscopic guidance at the bedside (6-8). Incomplete evacuation of the effusion requires repeated subse- quent thoracentesis and insertion of another catheter. It is therefore imperative that a simple, safe and more effec- tive device is developed. The currently used chest tube is a straight plastic tube with its own central metal trocar (9).

We have developed a curved chest tube which consists of a curved plastic tube and its own straight central metal trocar. The efficacy of this unique device was tested in 20 patients. There were no significant complications.

Received 4 April 1997 and accepted in revised form 3 October 1997. Correspondence should be addressed to: H. Satoh, Department of Respiratory Medicine, Institute of Clinical Medicine, University of Tsukuba, Tsukuba-city, Ibaraki, 305 Japan.

Materials and Methods

PATIENTS

Over a 2 year period, 20 patients with histologically or cytologically proven malignant pleural effusions were entered into this study. Criteria for inclusion were malignant pleural effusion without ultrasonograph or CT scan confirmation of fibrin septa and/or multiloculation, no previous chest tube drainage, an expected survival time of more than 3 months, no evidence of severe heart failure; no evidence of life-threatening metastatic disease of other sites and no evidence of allergy to lidocaine and a sclerosing agent, OK-432 (Chugai Pharmaceutical Co. Ltd, Tokyo, Japan) (10-12).

DESCRIPTION OF THE CHEST TUBE

The newly developed chest tube is 40 cm in length and 18 French in size. It is made of clear plastic (Sumitomo Bakelite Co. Ltd, Tokyo, Japan). In order to place the tip of a tube that has drainage holes in an appropriate position in the pleural space, we have made the chest tube with smooth curved parts at 10 cm and 20 cm from the distal end (Plate 1). The tube is held straight with a central straight metal trocar; however, the tube becomes smoothly curved on removal of the metal trocar. Moreover, we made ten drainage holes at the distal part for effective drainage of pleural effusion.

0954.6111/98/040633+05 $12.00/0 0 1998 W. B. SAUNDERS COMPANY LTD

634 H. ISHIKAWA ET AL

TABLE 1. Patients’ characteristics

Variable Categories No. of patients

PLATE 1. The curved chest tube and the straight metal trocar. With the central straight metal trocar, the tube is held straight; however, the chest tube becomes curved smoothly on removal of the metal trocar. The trocar is held inside during penetration of the thoracic wall. The trocar is retracted after the penetration of the chest tube.

TECHNIQUE OF CHEST TUBE PLACEMENT

The technique of chest tube insertion is similar to conven- tional techniques (13,14). The chest tubes were inserted in the anterior axillary line and directed inferiorly and posteriorly. The procedures were done with neither fluoro- scopic nor CT guidance.

CHEMICAL PLEURODESIS

The chest tube was connected to underwater seal suction (10 cmH,O). After maximal evacuation of the pleural effusion, the chest tube was clamped and 10 ml of 1% lidocaine was instilled. Immediately thereafter, 10 Klinische Einheit units of OK-432 dissolved in 100 ml of 0.9% saline solution were injected into the chest tube. The tube remained clamped for 2 h, and the patient was repositioned every 30 min. The tube was then unclamped and placed again on suction. After 24 h, the drainage amount was assessed. If drainage was less than 50 ml per 8 h, the chest tube was removed. If the drainage amount was greater, a second dose was administered and then drainage was reassessed 24 h later. Treatment was considered unsuccess- ful if a large amount of fluid continued to drain.

EVALUATION

In order to evaluate the position of the tip of the chest tube, frontal and lateral chest X-rays (15) were taken after insertion and before removal of the tube. Evaluation of the position was defined based on the chest radiographs as (a) paravertebral gutter in posterobasal (13), (b) posterior and superior position of the pleural space (14) or (c) pleural space other than (a) or(b). We also assessed the evacuation efficacy of pleural effusion. The criterion was defined as (i) drainage efficacy more than 90%, (ii) drainage efficacy from 75% to 90% or (iii) drainage efficacy less than 75%.

Gender Male-female 14-6 Age (years) Median 66

Range 36-85 Histology Adenocarcinoma 18

Squamous cell carcinoma 2 Stage IIIB 12

IV 8

TABLE 2. Evaluation of the position of the tip of a chest tube

Position of distal end of catheter

No. of patients (%)

After insertion Paravertebral gutter in posterobasal Posterior and superior position Other position

Before removal Paravertebral gutter in posterobasal Posterior and superior position Other position

15 (75.0) 4 (20.0) 1 (5.0)

14 (70.0) 2 (10.0) 4 (20.0)

STATISTICAL ANALYSIS

Comparison between two groups was made by x2 test. PcO.05 was considered as significant.

Results

Patients with massive pleural effusion due to lung cancer were prospectively entered into this study. Twenty patients were entered in this study and the patients’ characteristics are summarized in Table 1. None of the patients were receiving systemic chemotherapy until the removal of the chest tube.

We evaluated the position of the tip of the chest tube after placement. In 15 patients (75.0%) it was positioned at the paravertebral gutter in posterobasal. The tip of the chest tube was found to be located at the posterior and superior position in four patients (20.0%) and at another position in the pleural space in one patient (5.0%) (Table 2). Just before removal, we evaluated again the position of the chest tube. In one out of the 15 patients whose tube had initially been placed at the paravertebral gutter in postero- basal and in two patients whose tube had been placed at the posterior and superior position the tip of the chest tube was noted to have been displaced during the drainage as documented on plain chest X-ray on removal of the tube (Table 2). All the patients were in a recumbent or seated position during drainage.

CURVED CHESTTUBE 635

TABLE 3. Position of the tip of the chest tube and the drainage efficacy

Drainage efficacy

More than 90% 75590% Less than 75%

Paravertebral gutter in posterobasal 13 2 0 Posterior and superior position 1 2 1 Other position 0 0 1

We assessed the relationship between the position of the tip of the chest tube and drainage efficacy. A drainage efficacy of more than 90% was achieved in 13 patients (86.7%) of the 15 patients whose tip was placed at the paravertebral gutter in posterobasal (paravertebral- positioned group). On the other hand, however, only one patient (25.0%) whose catheter tip was at the posterior and superior position (posterosuperior-positioned group) had a drainage efficacy of more than 90%. A higher drainage efficacy of pleural effusion was observed in the para- vertebral group than in the posterosuperior-positioned group (P=O.O24) or other-positioned group (P<O.OOOl) (Table 3). The average times of drainage before and after applying OK-432 were 5 days (range of 1-8 days) and 4 days (range l-8 days), respectively.

We did not find any disadvantages of this curved catheter such as tube obstruction by clots or excessive curving when the lung has been re-expanded. None of the 20 patients reported significant pain (grade 1 or more of the WHO toxicity criteria) during catheter placement, although there were two patients who complained of mild discomfort at the chest tube site during drainage (one patient whose tube was positioned in the paravertebral gutter and the other patient whose tube was positioned at the posterior and superior position).

After the effusions had been drained, all patients under- went chemical pleurodesis. The procedure was successful in all 20 patients according to the criteria of Paladine et al. (16). However, in six patients whose tube was mal- positioned before the removal, complete radiographic resolution of pleural effusion was not achieved, although no significant reaccumulation of effusion occurred for more than 4 weeks as defined by the criteria (16).

Discussion

Many approaches have been used to alleviate clinical symptoms from malignant pleural effusions. Because patients with malignant pleural effusion have a short life expectancy, less invasive methods are more desirable. How- ever repeated thoracenteses and tube thoracostomy alone are not sufficient, since pleural effusion reaccumulates quickly in these patients (2,3,17,18). Tube thoracostomy with a chest tube and instillation of a sclerosing agent into the pleural space is currently the most common method of treatment (4,19,20). Agents that have been used for chemical pleurodesis include talc, tetracycline, doxycycline,

bleomycin and CryneDacteviunz parvum (21). OK-432 is a streptococcal preparation and has been shown to be an effective immunotherapy for patients with malignant pleural effusion (12). As a chemical sclerosing agent, OK-432 was successful in 88-100% of patients when instilled through a conventional chest tube (lo,1 1). The success rate depends not only on sclerosing agent used but also on complete drainage of the effusion. Therefore, positioning of the tip of the catheter in the space where the accumulation of effusion is expected is essential. It has been reported that 15-26% of catheters had to be repositioned or replaced because of malposition (22, 23). In our study with the new chest tube, malposition was observed only in one of 20 patients (5%). There was no significant complication.

There have been conflicting views regarding the ideal positioning of the tip of a chest tube where evacuation holes have been opened. In the supine position, pleural effusion collects posteriorly in the paravertebral gutters (13). McFadden et al. reported that the posterior and superior position is preferred for effusions resulting from both malignant and inflammatory conditions (14). However, there has been no comparative study to prove where the ideal position of the tip of the chest tube is. In patients without pleural adhesions and/or loculated effusion, we would like to emphasize that it remains controversial as to where to place the tip of a chest tube.

Traditionally, tube thoracostomy and pleurodesis have been performed by using large-bore chest tubes; however, recent reports have suggested that small-bore catheters can be used with equal success for drainage and sclerosis (24-26). In addition to the overall efficacy of small-bore catheters, the advantages of using sonographic guidance for placement rather than blind insertion of large-bore chest tubes include less traumatic complication and better tolerance by patients of small-bore catheters than of the larger catheters. Use of small-bore catheters with ultrasono- graphic guidance also has an advantage of accurate place- ment especially for the treatment of pleural effusion with fibrin septation and/or multiloculation (26). In previous studies (24-26) no complication caused by tube obstruction by clots or excessive curving due to small calibre of the chest tube was reported. We did not find any disadvantage of this curved chest tube in the present study.

Recently, video-assisted thoracic management has been reported as another new approach to malignant pleural effusion. It is a procedure that affords excellent visualiz- ation of the entire pleural space (27729). With the tech- nique, all the pleural effusion can be completely drained

636 H. ISHIKAWA ET AL.

and chemical pleurodesis can be performed. Visual place- ment of the chest tube may also be easily accomplished using the videoscope. It is usually performed in an operat- ing room, and this approach is more time consuming and expensive than chest tube placement at the bedside. More- over, as the majority of the candidates may have serious and advanced disease, and the procedure is usually per- formed under local (30) or general (31) anaesthesia with selective one-lung ventilation (32), physicians and surgeons should keep in mind the risk of serious complications.

The procedure with this new curved chest tube is as simple as with the conventional one. It appears safe as we did not encounter any significant complication in the 20 patients. This study suggested that the curved chest tube is safe and useful obtaining the complete evacuation of pleural effusion; therefore, it is now necessary to perform controlled studies comparing this curved chest tube with the large-bore one or small-bore catheter with or without ultrasonographic guidance.

Acknowledgements

This study was supported by a Grant-in aid for Cancer Research from Ibaraki Prefecture. The authors thank Sumitomo Bakelite Co. Ltd for providing the technique and material to develop the new chest tube.

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