Indwelling Small Pleural Catheter Needle Thoracentesis in the Management of Large Pleural Effusions

Charles J. Grodzin and Robert A. Balk Chest 1997;111;981-988 DOI 10.1378/chest.111.4.981 The online version of this article, along with updated information and services can be found online on the World Wide Web at: http://chestjournal.chestpubs.org/content/111/4/981

Chest is the official journal of the American College of Chest Physicians. It has been published monthly since 1935. Copyright1997by the American College of Chest Physicians, 3300 Dundee Road, Northbrook, IL 60062. All rights reserved. No part of this article or PDF may be reproduced or distributed without the prior written permission of the copyright holder. (http://chestjournal.chestpubs.org/site/misc/reprints.xhtml) ISSN:0012-3692

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Indwelling Small Pleural Catheter Needle Thoracentesis in the Management of Large Pleural Effusions*
Charles J. Grodzin, MD; and Robert A. Balk, MD, FCCP

Study objectives: To evaluate the clinical safety, efficacy, and cost of a small indwelling pleural catheter (7F, Turkel Safety Thoracentesis System [Sherwood, Davis, and Geek; St. Louis]) vs repeated needle thoracentesis or closed tube thoracostomy as a means to drain a large-volume pleural effusion. in a Setting: Inpatients tertiary care university teaching hospital in urban Chicago. Design: Prospective, consecutive patient comparative study using historical controls. as defined Patients: Fifty-seven therapeutic aspirations in 23 patients with large pleural effusions third of the radiography. Patients were by opacification of at aleast one of thoracic hemithorax on chest loculations, structural chest documented excluded if they had history surgery, abnormalities, severe coagulopathy, or refused to give informed consent. Measurements: Volume of each pleural aspiration, total fluid removed, pleural fluid lactate dehydrogenase, protein, glucose, cytologic analysis, microbiologic stains, and cultures based on clinical indications. Results: We found that initial thoracentesis and repeated pleural drainage using the indwelling catheter system is a safe, efficacious, and cost-effective procedure that may aid the evacuation and management of a large-volume pleural effusion. There were fewer adverse effects and pain, dry tap, hemopneumothorax, localrate was 12% complications such as pneumothorax, splenic laceration,The overall and hematomas, as compared with previous reports. complication closed tube (7/57). There were two pneumothoraces detected (3.5%), one of which required benefit comes thoracostomy for treatment (1.75%). A further needle-catheterin the form of a significant cost at our institution ($80 vs $240) when this system is used in place of closed savings tube thoracostomy in the drainage of a large-volume pleural effusion. Conclusion: An indwelling pleural catheter with the Turkel safety needle-catheter (as described in the study) can be used to successfully drain the pleural space with reduced morbidity and a significant cost saving in comparison to repeated needle thoracenteses or closed tube
thoracostomy. (CHEST 1997; 111:981-88)
Key words: needle drainage; pleural effusion; pleural fluid; thoracentesis; tube thoracostomy Abbreviations: PA=posteroanterior

TP horacentesis is an important procedure in the -*- evaluation and management of pleural effusions. In many cases, biochemical and/or cytologic analysis can yield or strongly support a definitive diagnosis. Furthermore, drainage of large pleural effusions can
*From the Sections of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Rush Presbyterian-St. Lukes Medical Center and Rush Medical College, Chicago. At no time did either of the investigators act as an agent of Sherwood, Davis, and Geek or benefit in any way professionally or monetarily (fees, gifts, or financial support) throughout the duration of this study or subsequently or act as a representative of the company. Manuscript received March 1, 1996; revision accepted Septem ber 10.

improve subjective dyspnea, gas exchange, pulmo nary mechanics and, in some cases of significantly

elevated intrapleural pressure, can provide immedi ate hemodynamic stabilization. The traditional method of thoracentesis entails the insertion of a sterile needle into the pleural space. While usually considered a very safe and effective procedure, needle thoracentesis is asso ciated with a small but significant incidence of morbidity. The usual approach to a large-volume pleural effusion is with needle thoracentesis. How ever, when persistent or if there is a need to effect complete drainage, closed tube thoracostomy may be required.
CHEST / 111 / 4 / APRIL, 1997

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Pneumothorax is one of the primary complica tions of thoracenteses. Despars et al1 studied 90 cases of iatrogenic pneumothorax. The most com mon causes were transthoracic needle aspiration (39%), thoracentesis (33%), subclavian venipuncture (25%), and positive pressure ventilation
closed tube thoracostomy. Two patients died; one was associated with a staphylococcal empyema that was believed to be related to the chest tube. COPD is an important risk factor for iatrogenic pneumothorax. In a study by Brandstetter et al,2 patients with COPD had a 41.7% rate of pneumo thorax after thoracentesis compared to 18.5% in those without COPD. Collins and Sahn3 found a 12% rate of pneumothorax in a series of 74 patients, three of whom required closed tube

Materials

and

Methods

(0.07%). Furthermore, 72% required therapeutic

Subjects The protocol used in this study was approved by the Human Investigations Committee and the Institutional Review Board of Rush Presbyterian-St. Lukes Medical Center. Patients were recruited from the inpatient population of Rush Presbyterian-St. Lukes Medical Center, a tertiary care university hospital on Chicago's near west side. Patients with a large pleural effusion who fulfilled the inclusion and exclusion criteria for study participation were enrolled between July 1, 1994 and June 30, 1995. The inclusion criteria included adult patients (age >18 years) who had a large freeflowing pleural effusion. A large effusion was defined by greater than one third opacification of the hemithorax on posteroanterior (PA) and lateral chest radiographs. Patients were excluded from entry if they had documented loculations, structural chest abnor malities, severe uncontrolled coagulopathy, or refused to give
informed consent.

thoracostomy. Seneff et al4 evaluated 125 patients and found an overall complication rate of 46% with pneumothorax seen in 11% of procedures. Grogan et al5 evaluated
thoracentesis done in several manners (needle aspi ration, needle-catheter system, and with ultrasound

Thoracentesis
The thoracentesis was performed in an identical manner by the individual (C.J.G.) using a thoracentesis tray (Turkel Safety Thoracentesis Tray; Sherwood, Davis, and Geek; St. Louis [Fig 1]). Prior to the procedure, PA and lateral chest radiographs were performed to establish the presence of a freely flowing pleural effusion. The patients were placed in the sitting position and allowed to drape their arms on a bedside table. In two patients, the procedure was performed in the lateral decubitus position because of physical limitations. Physical examination was used to determine the site for needle insertion. The skin was prepared with povidone-iodine (Betadine) solution and draped in a sterile fashion. Local anesthesia was accomplished with 1% lidocaine (1 to 5 mL) to the skin, subcutaneous tissue, bony periosteum, and parietal pleura. After satisfactory local anesthesia was confirmed, the safety needle-catheter system was assembled: the protective sheath was removed and the needle-catheter system was con nected via a three-way stopcock to drainage tubing and the collection bag to assure a closed system. A small "cross"-shaped stab incision was made in the skin with the point of a No. 11 scalpel blade. With the stopcock in the "off
same

related to the number of passes made with the thoracentesis needle. Our objective was to perform thoracentesis in patients with large-volume pleural effusions using a new safety catheter-needle system and to com pare complication rates and cost to that of repet itive needle thoracenteses and closed tube thora costomy. The needle-catheter system was designed to perform thoracentesis in a safer man ner compared to traditional needle thoracentesis. Specific safety features of this needle-catheter system include a colored flag, an audible clicking mechanism designed to signal entry into the pleu ral space, and a spring-loaded blunt tip that extends as the needle passes through the parietal pleura, thus protecting the lung from the sharp needle tip. We hypothesized that this indwelling needle-catheter system could be placed with less morbidity and decrease the cost of draining a large with pleural effusion as compared that historical con the small cath trol. In addition, we believed eter used for drainage would be more comfortable for the patient and would have a higher degree of successful complete drainage of the pleural space in comparison with repeated needle thoracenteses.
982

guidance). Overall, complications were seen in 46% pneumothorax occurred in between 20% and 39% using these three methods. We believe that repeated thoracenteses will lead to increased costs and risk of complications. Doyle et al6 reported that the risk of pneumothorax was
and

Figure 1. Turkel

Safety Thoracentesis System.

Clinical

Investigations

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needle was then placed through the stab wound and carefully advanced. The initial goal was contact of the needle tip with the superior margin of the lower rib. The needle-catheter system was then aimed slightly cephalad, just superior to the upper edge of the inferior rib and advanced until entry into the pleural space. Penetration of the parietal pleura and entry into the pleural space was indicated by a change of the "flag" color from "red" to "green" and the "popping" sound of the spring-loaded valve system. One to 3 mL of fluid was aspirated to confirm that the tip of the needle was in the pleural fluid. The catheter was advanced slowly over the needle as the needle was carefully withdrawn. The catheter was advanced until the hub was flush with the chest wall. The syringe was then removed from the needle and placed on the open port of the stopcock. The stopcock was then opened and fluid was allowed to drain into the tubing/collection bag to an arbitrarily set maximum of 1,000 mL/d. If drainage was slow, fluid could be drained manually using the attached syringe. If persistent fluid was present after the drainage procedure, the catheter was secured in place and a dressing applied for contin ued intermittent drainage. Subsequent drainage of the persistent pleural fluid was accom plished using the indwelling catheter system. If an additional liter of fluid was collected, drainage was stopped and continued evacuation was addressed the next morning. If <1 L was collected, a chest radiograph was done to assess the presence of residual pleural fluid. If the pleural space was dry, the catheter was subsequently removed. Postprocedure chest radiographs were performed to assess drainage and to identify the presence of complications such as pneumothorax. Fluid Analysis
was sent for routine chemistry analysis (lactate and protein) to determine if it was a transudate or dehydrogenase an exudate according to the criteria of Light.7 Additional studies were performed as clinically indicated (eg, pH, cytology, Gram and acid-fast stain and culture).

position with regard to the patient, the blunt tip of the safety7

Pleural fluid

Parameters Followed

kept of complications (pneumothorax, bleeding, car diac arrhythmia, and need for closed tube thoracostomy), the number of aspirations for each patient and total for the group, the total volume of fluid removed in each patient, the number of days the catheter remained in the pleural space, patient complaints, and the ability to perform complete drainage of the pleural space.
A record was

infection, pain, hematoma development, splenic laceration,

Results
A total of 23 patients were studied with a mean age of 57.7 years (range, 40 to 96 years). Comorbidities included the following: renal failure (two); conges tive heart failure (five); respiratory failure (two); hypertension (three); end-stage liver disease (two); diabetes mellitus (three); sepsis (two, bacterial, fun

trauma; and anemia. Of the 23 patients, 8 had transudative effusions and 15 patients had an exuda

gal); cancer (six, lung, colon, breast, Kaposi's sar renal cell, and non-Hodgkins lymphoma); inflammatory processes (postpericardiotomy syn drome, pancreatitis); AIDS; Budd-Chiari syndrome; chest
coma,

presented in Figures 2 to 4. At our institution, the cost of this catheter and insertion kit is approximately $80. The cost of a single-use thoracentesis kit is also $80 while the cost associated with the insertion of a closed tube thora costomy is $284. The cost of a daily chest radiograph is an additional charge. Although use of a simple needle and syringe would be much cheaper, probCHEST/111 / 4/APRIL, 1997

group, aspiration this small residual fluid was deemed advanta geous to the patient. Of the 23 subjects, 17 reported resolution of dyspnea during or soon after complete drainage of the pleural space; additionally, one pa tient reported increased ambulatory capacity. The overall complication rate was 7 of 57 (12%). The incidence of major complications was 3.5% and reflects two patients who developed a pneumotho rax. One of these patients (1.75%) required closed tube thoracostomy placement for management, whereas the other was treated by air aspiration using the indwelling pleural catheter. There was no de tected empyema, hemothorax, splenic laceration, shearing of the catheter tip, cardiac arrhythmias, need for thoracotomy, or death related to the drain age thoracentesis procedure. Minor complications occurred in 5 of 57 (8.7%) and were as follows. One (1.75%) patient com plained of local pleuritic chest pain for the time the drainage catheter was in place. Two patients (3.5%) noted mild discomfort on placement of the pleural catheter. One (1.75%) patient complained of pain on instillation of lidocaine; a dry tap occurred on one (1.75%) occasion. A second procedure was necessi tated in four patients owing to subsequent discovery of a loculated pleural effusion (two patients), clotting of the catheter (one patient), and a dry tap (one patient). There were no occurrences of subcutane ous hematoma or seroma, persistent cough, or inad equate fluid yield. A summary of the overall, minor, and major complications and a comparison with historical reports of complications encountered with both diagnostic and therapeutic thoracentesis are
even

study popula The average number of aspirations required to drain the pleural space was 2.5 (a total of 57 aspiration procedures). The catheter was left in place for a mean of 3.0 days with removal of an average of 1.70 L per patient. One would expect that if the average number of days the catheter was present was 2.5, with the goal to remove 1 L/d, the total average of fluid removed should be close to 2.6 L. This discrepancy results from the presence of <1 L of fluid in the pleural space at the time of the final aspiration or because fluid continued to accumulate while a final chest radiograph was obtained but prior to catheter removal. In the latter of
tive effusion. Table 1 summarizes the tion and the thoracentesis results.

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Table
Patient No.

1.Summary of Patients*
Complications
Transudate/ Exudate Exudate Comorbidities
Renal failure,

Days

Serial Aspirated

Total Volume

Volumes, L

Aspirated, L
2.2
None

1/1/.2

respiratoiy failure, staghorn renal calculi, urosepsis,

1/0.8
None

quadriplegia,

Transudate CAD and CABG, AF, CHF,

hypothermia
cancer

NIDDM, HTN,
0.8/0.5/0.25/0.165/0.21
0.9 0.5/0.3 1/.02 7 8 9
10 11 12 13 14 15 16

1.925
0.9 0.8 1.02
1.2 2.825 0.7 1.0 1.0 1.81 1.0 1.0 1.1

Local erythema
None

Exudate1

Colon

cholecystectomy
metastases

with liver

3 5 3
2 2

1/0.2 1/0.5/0.4/0.425/0.5 0.5/0.15/0.05

1/0 1/0

catheter Catheter kinked, would not draw necessitating removal Pleuritic pain
None None None

Slight discomfort when lying on

Transudate IBD, CAD, arthritis, CHF Exudate Non-Hodgkin's lymphoma

Exudate

Exudate1

CHF, renal insufficiency, anemia, DM, MVR, PUD, RVD, AF

Transudate CHF, colon cancer Exudate Postpericardiotomy syndrome,

CAD

Lung cancer, HTN

5
2 2 4 3 2 3 2

0.99/0.25/0/0.27/0.3 1.0 0.750/0.25

Difficulty lying on the back

None None
None

1/0.1*
1.2/1.1/1.2 1.1/0.65

17*
18 19

3.5 1.75 3.85 1.95

Pneumothorax treated by air aspiration via same catheter

None

Exudate CHF, CAD, dyspnea Transudate Cirrhosis Transudate None Exudate Hypoalbuminemia, pancreatitis, duodenal hematoma, fungemia, fungal elements in ascites fluid Exudate Lung cancer Transudate HIV+, KS
Transudate ESLD Exudate CHF, arthritis

1.2/1.3/1.35

0.85/1.1

20
21 22

3
3 3
1

1.0/.275/.250
1.0/1.1/.125 1.05/1.15 1.2/0.4/0.075

1.525
2.225
2.22

day no. 2 Slight pain on insertion; removed for impending cardioversion procedure Tube clot after first night, then removed and replaced for days 2 and 3 Flow stopped spontaneously at end
Dry tap on first attempt with mild
discomfort, second attempt successful without complication
of second aspiration

on instillation of lidocaine, very- Exudate histrionic at the time Pain on instillation of lidocaine; tube Exudate malfunction, needed to be replaced to adequately drain on

Pain

Slight pain on insertion of tube, loculation precluded full drainage, pneumothorax required chest tube

Hepatic hydrothorax, Budd-Chiari

RCC metastatic to

syndrome

pleura/lung

Transudate CHF, MVR, AF, breast cancer,

bradycardia
Exudate Exudate

DM, CHF, diabetic retinopathy,

LE occlusive disease Status post chest trauma with rib

23^

fracture, bronchitis

1.675
1.70

Exudate

DM, anemia, VF/AICD with pocket infection, DVT, HTN, AF, CVA

Average

2.91 2.47 aspirations per

Malignant effusion. an additional 3 days to ensure that the lung remained reinflated and then it was removed without further complication. ht was discovered that there was a large loculated effusion not drained after removal of 1.75 L of fluid. Loculated effusion, upon retapping, caused iatrogenic pneumothorax requiring tube thoracostomy. "Tube clotted overnight; required removal and replacement of a new catheter with subsequent full evacuation of the effusion; tube removal and replacement accomplished without morbidity.
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Clinical

patient *CAD=coronary artery disease; CABG=coronaiy artery bypass graft; CHF=congestive heart failure; IBD=inflammatory bowel disease; AF=atrial fibrillation; DM=diabetes mellitus; NIDDM=noninsulin-dependent diabetes mellitus; HTN=hypertension; MVR=mitral valve replacement; PUD=peptic ulcer disease; RVD right ventricular dysfunction; HIV+ HIV infection; KS Kaposi's sarcoma; ESLD=end-stage liver disease; RCC renal cell carcinoma; LE=lower extremity7; VF/AICD ventricular fibrillation/automatic implantable cardioverter defibrillator; DVT=deep venous thrombosis; CVA^cerebrovascular accident. f
=
= =
=

^Pneumothorax treated with aspiration of 180 mL of air via pleural catheter with full reexpansion of the lung. The catheter remained in place for

Investigations

250

Grogan
<n=X22S>
EJ Major (n52)

Grodzin
UK inor

Complicaiione

Complicatioi

Figure 2. Overall complication rate of thoracentesis in the current series by Seneff et al4 and Grogan et al.5

study population compared with

Seneff

Grogan
(needlecatheter

Grogan
(needle

Grodzin

syistex*0

syst.s:m>

Pain

Drytap

Hematoma

Figure 3. Minor complication rate in the current

Grogan et al.5

study population compared with Seneff et al4 and

need for pleural space,the needlecontinued separation of the for drainage, difficulty as syringe from suring full evacuation of the pleural space, and lack of built-in drainage tubing can lead to clinical risk and cost that outweigh the cost and safety benefits of
the needle-catheter system.

lems, including the presence of the needle

in the

If the same number of thoracenteses had been carried out using a single-use thoracentesis kit for each aspiration, patients would have undergone 57 27 using the procedures as opposed to This would Turkel Safety increase the needle-catheter system. and translate into a cost chances for complications savings of $2400 (30 procedures X $80). If a closedCHEST/111 I A! APRIL, 1997

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Seneff

Grogan
(needlecatheter

Grogan
(needle system)

Grrodzin

system)
Pneumothorax DTube Thoracostomy Required B Splenic Laceration Hemopneumothorax
Figure 4.

Major complication rate of the current study compared with Seneff et al4 and Grogan et al.s

tube thoracostomy had been used for the same number of days as there were individual aspirations, the total cost would be approximately $284 (plus the cost of a daily portable chest radiograph) as com the Turkel Safety pared with $80 forto two chest needle-catheter (plus one system radiographs per pa tient). In addition, a significant investment of time is required on the part of the medical and nursing staff for care of the apparatus. Although not specifically tested as part of this trial, the use of this needle-catheter system could have allowed for multiple aspiration procedures through out the day to effect more rapid clearance of the effusion while still protecting the patient from de addition, veloping reexpansion pulmonary edema. In in the needle-catheter system could be used outpa tient management to effect even greater cost savings in comparison with inpatient care.
Discussion

The goal of this study was to assess the efficacy of complete drainageasof a large pleural effusion, the complication rate compared with historical data, and the cost savings of allowing a small catheter to remain in place for serial taps until the pleural space is dry. We found that initial thoracentesis and re peated pleural drainage using an indwelling catheter system is a safe and cost-effective procedure that may aid the evacuation and management of a large pleural effusion.
986

Seneff et al4 evaluated 125 thoracentesis proce dures in 91 patients with pleural effusion. The overall complication rate was 58 of 125 (46%). Major complications included pneumothorax in 14 of 125 (11%) of which 3 of 125 (2.4%)) required tube thoracostomy for management. One patient died precipitously. Splenic laceration occurred in 1 of 125 (0.8%), shearing of the catheter tip (requiring tho racotomy for removal) occurred in 1 of 125 (0.8%), and delayed discovery of a hemopneumothorax oc curred in 1 of 125 (0.8%). Minor complications included pain in 28 of 125 (22%), cough in 14 of 125 (11%), dry tap in 16 of 125 (13%), development of a subcutaneous hematoma in 3 of 125 (2.4%), and seroma in 1 of 125 (0.8%). Grogan et al5 evaluated thoracentesis performed with a needle-catheter system (14-gauge needle through a 16-gauge catheter) in comparison with the traditional needle (20-gauge) procedure. Patients study if qualified for the PA chest a pleural effusion was demonstrated on radiograph that obliter ated more than half of the hemidiaphragm and was freely flowing on a lateral decubitus radiograph. In 52 patients, 46% of the procedures were associated with at least one complication. Using their needlecatheter system pneumothorax occurred in 7 of 18 (39%) patients. Two of these patients required closed tube thoracostomy for management of un
tions occurred in 11 of 18

complicated large pneumothoraces. Minor complica (61%) patients and included pain in 7 of 18 (38%), dry taps in 2 of 18
Clinical Investigations

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(11%), and subcutaneous hematoma in 1 of 18 (5.5%). In the group that underwent needle aspira tion, 3 of 15 (20%) developed pneumothorax without

needle and insertion of the soft catheter. sures that the needle is never more than a few millimeters into the pleural space and is unlikely to puncture the visceral pleura. Since a one-way valve is built into the catheter, air entry from the atmosphere is obviated. Both of these features minimize the risk of pneumothorax. With proper instructions to the patient and nursing staff, patients were able to tolerate the presence of the catheter with minimal discomfort. The result was a low incidence of pneu mothorax (3.5%) that is less than previous reports.26'810 The reported incidence of pneumo thorax ranges from 5.2 to 19.2%. These reports included both diagnostic and therapeutic thoracen teses. It would be anticipated that there would be a greater risk for inadvertent lung puncture or air entry during procedures directed at completely draining the pleural space as opposed to a single diagnostic procedure. Further study withtoa concur rent control group would be necessary evaluate this potential for improved safety using this needlecatheter system. Whether the intent is to use this catheter as an indwelling pleural drain or perform simple aspira

drainage. In this study, thoracentesis was done in the same manner by the same individual (C.J.G.). Past studies have yielded conflicting data concerning the impact of the operator on the development of complications. In two studies,68 the pneumothorax rate was the same whether the thoracentesis was performed by a pulmonary specialist or by a nonpulmonary special ist. Even though the needle-catheter system is spe cifically designed for maximal safety, the level of acquired expertise was undoubtedly instrumental in our low complication rate. The most important feature of the safety needle is the ability to identify passage through the parietal pleura and into the pleural fluid collection without contacting the vis ceral pleura. At that point, one begins removal of the This en

need for tube thoracostomy. In the series of Grogan et al,5 minor complications occurred in 4 of 15 (27%) and included pain in 2 of 15 (13.5%), and a dry tap in 2 of 15(13.5%). Patient movement due to pain, cough, or reexpan sion of the lung increases the risk of pneumothorax. Uncooperative patients and sudden patient move ment may also increase the risk of a pneumothorax with or without an accompanying puncture or lacer ation of the lung. In addition, as the fluid is removed, it becomes increasingly difficult to completely drain the pleural space and may necessitate performance of tube thoracostomy to successfully complete the

tion, the safety features of the needle-catheter sys tem reduce the rate of complications. Situations in which single use may be attractive are the acute relief of dyspnea or chest pain, diagnostic thoracen tesis in an undiagnosed pleural effusion (in the hospital or in the outpatient setting), serial aspira tions for the purpose of microbiologic or cytologic drainage of a small study, and complete which the catheter pleural effusion. Situations in may be left include large indwelling accumulation ofpleural effusion (>1 L), pleural fluid (eg, hepatic persistent

patients receiving mechanical ventila Positioning may be difficult in these patients and risk of pneumothorax carries the necessity for placement of a closed-tube thoracostomy. In our experience, aspiration of fluid with this apparatus
effusion for
tion.
was

hydrothorax, pancreatitis, nephrotic syndrome), or to facilitate pleurodesis. This catheter may be useful in either the inpatient or outpatient setting. In the hospital, the catheter has important potential use in both the ICU and on the general medical floor. In the ICU, this catheter offers an additional option in the approach to pleural

procedure was successfully performed in patient 15. Another use of the needle-catheter drainage tech nique also has potential advantage in the outpatient setting, thus providing an even greater cost savings. Potential outpatient uses of this catheter include a malignant drainage of treatment of pleural effusion prior to a persistent pleural effu pleurodesis, sion from cirrhosis, congestive heart failure, pancre atitis, or nephrotic syndrome, serial sampling of for cytologic analysis or culture in the pleural fluidclinical appropriate settings, and outpatient manage ment of large pleural effusions. Use of an indwelling catheter placed via the needle-catheter system (Turkel Safety) is an effective strategy for draining the pleural space with reduced morbidity and offers the potential for a significant cost savings over more traditional methods. The needle-catheter design offers safety features that minimize the potential for pneumothorax in compar ison with single-needle thoracentesis. A large pro spective trial that compares this needle-catheter system to standard needle thoracentesis is required to confirm our pilot observations. As the practice of medicine becomes more outpatient based, this method of pleural fluid management offers a poten tial for reduced cost and increased patient comfort compared to repeated thoracentesis procedures or closed tube thoracostomy. Direct comparisons of these two strategies is not possible from these data. A of
questionnaire concerning patient tolerance
the
CHEST / 111 / 4 / APRIL, 1997

carried out without complication. Another po tential use for this needle-catheter system is in the treatment of pneumothorax via air aspiration. This

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not indwelling pleural catheter was not included in this rendered immo However, patients were study. bile, had fewer complaints of pain, did not have or a scar, and had long-lasting discomfort believe that the minimal irritation. We pleural in this procedure described study has potential advantages over serial needle thoracentesis procedures and closed tube thoracostomy and is likely to have reduced morbidity, increased patient comfort, and reduced cost.

3 Collins TR, Sahn SA. Thoracentesis:

Dis

1983; 127:A114 4 Seneff MG, Corwin RW, Gold LH, et al. Complications associated with thoracentesis. Chest 1986; 90:97-100 5 Grogan DR, Irwin RS, Channick R, et al. Complications
associated with thoracentesis:
a

experience and diagnostic value [abstract].

complications, patient
Am Rev

Respir

References Sassoon CS, Light RW. Significance of iatrogenic Despars JA, pneumothoraces. Chest 1994; 105:1147-50 al. Pneumothorax Brandstetter RD, Karetzky M, Rastogi R, et
after thoracentesis in chronic obstructive pulmonary disease.
Heart

9 Kohan

tesis. Am Rev

thoracentesis. Arch Intern Med 1991; 151:2095 JM, Pie RH, Israel RH, et al. Value of chest ultra sonography versus decubitus roentgenography for thoracen

study comparing three different methods. Arch Intern Med 1990; 150:873-77 Doyle JD, Hnatiuk OW, Torrington KG, et al. Necessity of routine chest roentgenography after thoracentesis. Ann In tern Med 1996; 124:816-20 Light RW. Pleural disease. 2nd ed. Philadelphia: Lea & Febiger, 1990; 42 Swinburne AJ, Bixby K, Fedullo AJ, et al. Pneumothorax after
Respir Dis 1986; 133:1124-26

prospective, randomized

10

Lung 1994; 23:67-70

Shepard JW. Thoracentesis: a safer method. Am Rev Respir Dis 1980; 121(suppl):188-89

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Clinical

Investigations

Indwelling Small Pleural Catheter Needle Thoracentesis in the Management of Large Pleural Effusions Charles J. Grodzin and Robert A. Balk Chest 1997;111; 981-988 DOI 10.1378/chest.111.4.981 This information is current as of November 28, 2011
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