Pulmonary Medicine

Image-guided drainage of intrathoracic air and fluid collections

General description of procedure, equipment, technique

In some patients with intrathoracic fluid collections, the use of sonography, computerized tomography (CT), or fluoroscopy to guide percutaneous placement of small-bore drainage catheters allows for a less invasive alternative to "blind," large-bore chest tube placement or surgical management . Sonography is typically used to characterize pleural fluid collections and guide diagnostic thoracentesis, and it aids in the proper placement of indwelling pleural catheters for fluid drainage.

CT provides a more comprehensive assessment of extent of pleural disease and is used in managing loculated pleural fluid collections and in drainage of intrapulmonary abscesses or infected bullae.

Fluoroscopy is useful for guiding evacuation of pneumothoraces and for catheter manipulation and exchange in patients with intrapleural devices placed to drain fluid collections.

Indications and patient selection

A variety of intrathoracic fluid collections can be managed with small-bore catheters placed percutaneously using imaging guidance. Examples include:

  • Complicated parapneumonic effusions and empyemas

  • Hemothoraces

  • Pneumothoraces

  • Malignant pleural effusions

  • Selected transudative pleural effusions, including those in patients with intractable effusions that are due to congestive heart failure or hepatic hydrothorax

  • Postoperative fluid collections, including pleural effusions, chylous effusions following esophagectomy, and loculated pneumothoraces

  • Lung abscesses, infected bullae, and infected bronchogenic cysts

In general, pleural effusions that are small and free-flowing usually require only simple drainage and routine studies for fluid characterization. In these cases, diagnostic thoracentesis may be enhanced by use of image-guided methods. On the other hand, image-guided catheter drainage of pleural space fluid collections is usually performed in patients in whom characteristics of the fluid suggest that the patient is at moderate or high risk of an adverse outcome if the fluid remains undrained, resulting in a "complicated parapneumonic effusion."

Moderate and high-risk effusions are characterized by large size, the presence of septations or loculations on sonography or CT, a biochemical profile showing a pH less than 7.2, LDH and greater than 1000 IU/ml or glucose less than 40 mg/ml, a positive gram stain or culture, or the presence of frank pus. Patients best suited to image-guided percutaneous drainage, as opposed to surgical drainage, are those with smaller, free-flowing effusions or unilocular collections.

Patients with larger collections who are poor surgical candidates or for whom small-bore catheter placement may function as a bridge to surgical drainage may also benefit from image-guided catheter drainage. Larger, multiloculated effusions are usually best managed surgically, as surgery is generally highly successful and cost-effective.

Hemothorax is best managed with a large-bore tube thoracostomy or thoracoscopy in an effort to prevent fibrothorax and trapped lung. The technique is similar to that used for drainage of parapneumonic effusions.

A pneumothorax can be drained using a small-bore catheter. Indications for small-bore catheter placement include the presence of large or progressive spontaneous pneumothoraces, including those that complicate percutaneous or transbronchial lung biopsy, central venous catheterization, or thoracentesis; and development of a loculated pneumothorax that requires precise drainage catheter placement using CT guidance. Patients with large air leaks that are due to a bronchopleural fistula are best managed using large-bore tube thoracostomy, and they may require surgical management for definitive therapy.

Most patients with malignant pleural effusions that persist or recur despite medical management of the underlying malignancy may be managed using small-bore catheter drainage and pleurodesis using a variety of sclerosing agents, including talc (Figure 1,Figure 2,Figure 3,Figure 4.Figure 5).

Figure 1.

Frontal chest radiograph in a patient with a malignant right pleural effusion.

Figure 2.

Lateral chest radiograph in a patient with a malignant right pleural effusion.

Figure 3.

Ultrasound of right chest confirms the moderate-size right effusion. A pigtail drainage catheter is placed sterily into the effusion for subsequent sclerosis.

Figure 4.

Repeat frontal (Fig. 4) and lateral (Fig. 5) radiographs after fluid drainage had diminished to 50 cc/24 hours shows minimal residual fluid. Sclerosis was performed using talc instillation.

Figure 5.

Repeat frontal (Fig. 4) and lateral (Fig. 5) radiographs after fluid drainage had diminished to 50 cc/24 hours shows minimal residual fluid. Sclerosis was performed using talc instillation.

Contraindications

There are no absolute contraindications to image-guidance thoracic drainage. A platelet count of less than 50,000, an INR higher than 1.2, or significant coagulopathy must be corrected prior to catheter placement.

Details of how the procedure is performed

The approach to drainage of pleural space collections varies according to the indication for the procedure.

Parapneumonic effusion drainage:

Image-guided drainage of a parapneumonic effusion is performed via sonography for small or free-flowing effusions. CT provides a more global evaluation of the chest. CT is particularly useful for multiloculated collections and for those that are apical or medial in location and difficult to visualize and access via a standard intercostal approach.

Drainage is performed using conscious sedation and local anesthesia to enhance patient comfort and cooperation. Small, 8-10-French pigtail drainage catheters are sufficient for serous, free-flowing collections and for use in children, whereas larger catheters (12-16-French) (Figure 6,Figure 7,Figure 8,Figure 9,Figure 10) or large-bore chest tubes (e.g., 28-French) are used for bigger, more viscous collections. Either a Seldinger technique, with gradual dilatation of the tract to the desired diameter, or a single-puncture, trocar-based technique can be utilized for catheter or tube placement.

Figure 6.

Frontal (Fig. 6) and lateral (Fig. 7) chest radiographs show a left posterolateral loculated effusion.

Figure 7.

Frontal (Fig. 6) and lateral (Fig. 7) chest radiographs show a left posterolateral loculated effusion.

Figure 8.

Axial contrast-enhanced CT shows a loculated pleural collection with enhancing pleural layers ("split pleura sign") indicative of an empyema.

Figure 9.

CT during catheter placement shows catheter within the loculated collection.

Figure 10.

Chest radiograph 3 months following drainage shows no residual pleural abnormality.

Multiloculated collections may require placement of multiple catheters into separate, noncontiguous locules that are unlikely to drain using a single catheter even with adjunctive use of intrapleural fibrinolytics. Once appropriate positioning of the catheter is documented (usually through repeat imaging), the catheter is affixed to the skin and attached to a collection device (e.g., a Pleur-Evac) for suction drainage.

Intrapleural fibrinolytics, usually in the form of tissue plasminogen activator (t-PA), may be instilled through the tube daily (6 mg in 50 ml sterile water or normal saline) to drain loculated collections, those with internal septations noted on sonographic imaging, or thick, purulent collections that do not drain adequately following initial catheter placement. Most recently, a study evaluating the combined use of intrapleural t-PA with DNAse suggests that this combination is superior to intrapleural fibrinolysis alone or no intrapleural therapy in the need for surgical referral and length of hospital stay for patients with parapneumonic effusions.

Pneumothorax drainage:

Non-loculated pneumothoraces are best drained using fluoroscopy or CT guidance. An anterior approach via the second intercostal space in the mid-clavicular line allows access to the pleural apex, where the drainage holes in the distal end of the catheter are optimally positioned. A lateral intercostal approach can be used to avoid the breast in female patients.

Once the catheter entry site has been marked and the skin prepared using sterile technique, lidocaine is administered superficially and deeply into the subcutaneous layers until air can be aspirated into the syringe. The needle is then withdrawn to the point at which air can no longer be freely aspirated. This position defines the level of the parietal pleura, which is heavily innervated so it must be optimally anesthetized to allow painless catheter placement. The Seldinger technique or use of a trocar-based catheter can be employed to insert a catheter into the pleural space apex or into a loculated pneumothorax. The catheter is then affixed to the skin and attached to a Pleur-Evac for suction drainage.

Malignant pleural effusion drainage:

Sonographic guidance is used for catheter placement for drainage of malignant pleural effusions and subsequent pleurodesis. The patient is placed in the sitting position. Ultrasound is used to select a catheter placement site along the lower posterolateral chest wall in order to prevent the patient from lying on the catheter when supine. Such catheter positioning also helps avoid injury to intercostal vessels, which tend to have a more reliably subcostal course then exists posteriorly, as they extend laterally from the paravertebral region.

A trocar-based technique similar to that used for drainage of other pleural fluid collections is performed using a sterile technique and local anesthesia. In order to minimize the risk of re-expansion pulmonary edema, care is taken to avoid removal of more than 1500 ml of fluid, unless intrapleural pressure is monitored during the procedure.

Interpretation of results

Not applicable to this procedure.

Performance characteristics of the procedure (applies only to diagnostic procedures)

Not applicable.

Outcomes (applies only to therapeutic procedures)

The success rate for image-guided drainage of parapneumonic effusions is reported at 67-83 percent, but the success rate is highly dependent on the nature of the fluid, the size and complexity of the collection, patient comorbidities. and the skill of the individual placing the catheter and caring for the patient.

While the literature does not support routine use of intrapleural fibrinolytics, many authors have reported series of selected patients in whom adjunctive intrapleural fibrinolytics allow for successful, nonsurgical management in the majority.

Small-bore catheters, which have been used successfully in draining pneumothoraces in more than 80 percent of patients, are associated with a lower complication rate compared with that of the use of large-bore thoracostomy tubes.

Several studies have shown partial or complete response rates higher than 70 percent in selected patients with malignant pleural effusions, several who have undergone small-bore catheter drainage and pleurodesis. Patients who have a persistently high volume of pleural fluid drainage (e.g., > 100 ml/day) and those who have significant pleural tumor burden or underlying parenchymal involvement, are least likely to respond. For these patients, a tunneled, indwelling catheter (e.g., PleurX catheter) may allow for better control of fluid re-accumulation on a palliative, outpatient basis.

Alternative and/or additional procedures to consider

Simple thoracentesis, when employed early in the course of a parapneumonic effusion, can be as effective as tube thoracostomy. Although repeated thoracenteses may allow for successful management of non-loculated collections, they may be uncomfortable and impractical for many patients.

Placement of a large-bore thoracostomy tube into the dependent aspect of a non-loculated parapneumonic effusion may be effective, but the procedure has a relatively high failure rate for complex, multiloculated collections. Surgical drainage of parapneumonic effusions using video-assisted thoracoscopic surgery (VATS) has become the procedure of choice for many patients who are operative candidates. VATS is associated with a high success rate and is a cost-effective means of management.

Small and asymptomatic pneumothoraces can be managed by observation, administration of supplemental oxygen, and simple needle aspiration when needed. Large tube drainage is reserved for large pneumothoraces in patients with air leaks. Patients with ongoing air leaks and those with recurrent spontaneous pneumothoraces are best managed using VATS for bleb resection and abrasive pleurodesis.

Malignant pleural effusions that are likely to respond to treatment of the underlying malignancy do not generally require drainage. In patients who require evaluation in order to establish a diagnosis of pleural malignancy, VATS pleural biopsy and talc pleurodesis are the most efficient means of management. Patients with a limited life expectancy who fail or refuse tube thoracostomy and pleurodesis can be managed using a tunneled, indwelling device (e.g., a PleurX catheter) that allows intermittent external drainage.

Complications and their management

Complications of image-guided catheter placement include bleeding, nerve injury, pneumothorax, and infection. Sonographic and CT guidance can help avoid injury to the intercostal neurovascular structures beneath the ribs.

What’s the evidence?

Moulton, JS. "Image-guided management of complicated pleural fluid collections". Radiol Clin North Am. vol. 38. 2000. pp. 345-74.

A review describing the use of cross-sectional imaging to localize and characterize parapneumonic fluid collections. Use of image-guided, small-bore catheters in successful closed drainage of these collections is discussed, and details on the technique of catheter placement, imaging follow-up, and use of adjunctive intrapleural fibrinolytics are covered.

Benton, IJ, Benfield, GF. "Comparison of a large and small-calibre tube drain for managing spontaneous pneumothoraces". Respir Med.. vol. 103. 2009. pp. 1436-40.

This prospective study of seventy-three patients who were managed over a two-year period with small- and large-bore chest tubes for spontaneous pneumothorax showed a similar success rate for both. The complication rate, including infection, was higher in the group treated with large-bore catheters. However, use of smaller catheters demonstrated a propensity for tube displacement (occurring in 21% of patients), as patients treated with the smaller tubes needed to be monitored regarding proper apical positioning of the drainage tip of the catheter .

Marom, EM, Patz, EF. "Malignant pleural effusions: treatment with small-bore-catheter thoracostomy and talc pleurodesis". Radiology. vol. 210. 1999. pp. 277-81.

Thirty-two patients with a symptomatic malignant pleural effusions underwent small-bore catheter drainage and talc pleurodesis. Eighty-four percent of patients had a complete or partial response. Fever, the most common complication, developed in 41 percent of patients.

Rahman, NM, Maskell, NA, West, A. "Intrapleural Use of Tissue Plasminogen Activator and DNase in Pleural Infection". N Engl J Med. vol. 365. 2011. pp. 518-526.

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