Volume 8 Issue 3 - Australasian Society for Ultrasound in Medicine

RP Davies, T McClymont and D BoshellSelection and placement of the intercostalcatheterIn previous studies involving chemical pleurodesis, largebore intercostal catheters (24–32F) have been used 8 . Thelarge bore catheters are prone to causing significant discomfortand as a result smaller bore catheters (10F) have beenused with success 18. For this study a 5 F sheathed cannulawith multiple side holes was used to minimise patient discomfortand facilitate easy placement of the cannula withinthe largest accessible locules of pleural fluid.Placement of the catheter was guided by ultrasound.Ultrasound is well recognised as an effective means of rapidlylocalising pleural fluid collections and monitoring cannulaposition to ensure effective and complete drainage 5 .Evacuation of the pleural fluidDrainage of the pleural fluid was limited to around 1500 mland drainage was discontinued sooner if the patient developeda cough, chest pain or shortness of breath.Published guidelines on the management of pleuraleffusions state that the most important requirement forsuccessful pleurodesis is complete lung re-expansion toensure adequate apposition of the parietal and visceralpleura 3 . However, even if complete lung expansion was notachieved, Robinson et al. demonstrated a successful outcomein nine out of 10 patients when using doxycycline forchemical pleurodesis.Confirmation of successful drainage of the pleural fluidand lung re-expansion was achieved using ultrasound. Theuse of ultrasound also facilitated the measurement of anyresidual pleural fluid volume estimate as a baseline for latercomparison 2 .SedationTo control patient discomfort, or in some cases anxietyassociated with chemical pleurodesis, conscious sedationmay be added. A protocol including a narcotic (suchas fentanyl 50–100 mcg) with a benzodiazepine (such asmidazolam 1–3 mg) can be administered using a conscioussedation protocol (including the use of pulse oximetry andO 2 ) during installation of pleurodesis medications.AnalgesiaThe intrapleural administration of doxycycline is associatedwith chest pain 20 . Published results describing the useof intrapleural lignocaine 19 reported that 19% of patientsexperienced moderate pain requiring additional analgesia.The safety of lignocaine has been examined in two studies.Wooten et al. 2 1showed that following the intrapleuraladministration of 150 mg of lignocaine the serum concentrationof lignocaine (1.3 μg/ml) was significantly below thelevel associated with central nervous system side effects (>3 μg/ml). In another study patients received up to 250 mgof lignocaine, while maintaining serum levels within thetherapeutic range 22 . Side effects were reported by only onepatient who experienced transient paraesthesia.In order to increase the duration of pain relief providedby the intrapleural local anaesthetic agent, this study utilisedbupivicaine hydrochloride instead of lignocaine. The doseof 2 mg/kg up to 150 mg in 30 ml is in accordance with thedrug product information provided on the MICROMEDEXweb site 23 . Use of the MICROMEDEX drug interaction toolrevealed no reports of interactions between Bupivicainehydrochloride and Doxycycline.DoxycyclineDoxycycline has been used and evaluated in numerousclinical trails, achieving a mean success rate of 76% fromthe 85 pleural effusions evaluated 3 (although the 29 patientslost to follow up are not included in this analysis). Thesuccess rate of those patients evaluated at one month was79%. In all cases except one, a dose of 500 mg mixed withsaline was used. Prevost et al. used a dose of 2000 mg 24 in16 malignant pleural effusions with a reported success rateof 82%. The side effects reported were fever and mild tomoderate pleuritic chest pain (40 to 60% depending on theanalgesia used). Heffner et al. used narcotic therapy for thecontrol of pain 25 .The method used in this study involved the injectionof doxycycline as supplied for intravenous injection (500mg in a solute volume totalling 25 ml), while other authorsdescribe the use of an infusion of doxycycline diluted in 30ml of saline 26 . No advantage conferred by dilution is identifiedfrom other reports.The major disadvantages of using doxycycline in thepast have been the prolonged intercostal catheter dwellingtimes and the need for repeated doses to prevent the effusionfrom recurring. All the past studies have left the intercostalcatheter in situ until the effusion resolved. Indwelling pleuralcatheterisation may increase the risk of infection, patientdiscomfort and certainly increases the length of hospitaladmission. The added facility of using ultrasound guidanceto assist in cannula placement negates the requirement toleave a catheter in situ. The patient is then able to go homeafter the procedure and return for outpatient assessmentby ultrasound of the quantity of residual pleural fluid. Theneed to repeat the pleurodesis is determined by recurrenceof symptomatic dyspnoea at clinical follow-up.References1 Antunes G, Neville E. Management of malignant pleural effusions.Thorax 2000; 55: 981–983.2 Eibenberger KL, Dock WI, Ammann ME, et al. Quantification ofpleural effusions: sonography versus radiography. Radiology 1994;191: 681–684.3 Antunes G, Neville E, Duffy J, N Ali N. BTS [British ThoracicSociety] guidelines for the management of malignant pleural effusions.Thorax 2003; 58 at http://thorax.bmjjournals.com/cgi/content/extract/58/suppl_2/ii29 accessed 12/04/05.4 Bonnefoi H, Smith IE. How should cancer presenting as a malignantpleural effusion be managed? Br J Cancer 1996 Sep; 74 (5):832–835.5 O'Moore PV, Mueller PR, Simeone JF, et al.. Sonographic guidancein diagnostic and therapeutic interventions in the pleural space. AJR1987; 149: 1–5.6 Sorensen PG, Svendsen TL, Enk B. Treatment of malignant pleuraleffusion with drainage, with and without instillation of talc. Eur JRespir Dis 1984; 65: 131–135.7 Zaloznik AJ, Oswald SG, Langin M. Intrapleural tetracycline inmalignant pleural effusions. Cancer 1983; 51: 752–755.8 Hausheer FH, Yarbro JW. Diagnosis and treatment of malignantpleural effusion. Semin Oncol 1985; 12: 54–75.9 Antony VB. Pathogenesis of malignant pleural effusions and talcpleurodesis. Pneumologie 1999; 10: 493–498.10 Bethune N. Pleural poudrage: new technique for deliberate productionof pleural adhesions as a preliminary to lobectomy. J Thorac26 ASUM Ultrasound Bulletin 2005 August; 8 (3)