Interventional Pulmonology
Received: November 20, 2000
Respiration 2001;68:501–505
The Value of Small-Bore Catheter
Thoracostomy in the Treatment of
Malignant Pleural Effusions
Ünal Şahin Mehmet Ünlü Ahmet Akkaya Zafer Örnek
Department of Pulmonary Medicine, Süleyman Demirel University School of Medicine, Isparta, Turkey
Key Words
Pleurodesis W Catheter, small-bore W Talc W Pleural
effusion, malignant
Abstract
Background: Malignant pleural effusions can cause se-
vere debilitating symptoms and impair the quality of life.
Treatment is often palliative, usually consisting of se-
quential thoracenteses or tube thoracostomy with or
without sclerotherapy. Large-bore thoracostomy tubes
have traditionally been used for drainage and sclerother-
apy. More recently, the use of small-bore catheters has
been studied. Objectives: To assess the efficacy and
safety of small-bore catheter (Pleuracan®) thoracostomy
combined with talc sclerotherapy for palliative treatment
of malignant pleural effusions. Methods: Between May
1998 and March 2000, 24 consecutive patients present-
ing at our inpatient clinic were studied. Follow-up radio-
graphy at the end of the 1st month (immediate response)
and 3rd month (long-term follow-up) after talc pleurode-
sis was performed to assess the response rates. Results:
Of the 24 patients included, 2 patients did not show lung
expansion after pleural drainage. Two patients died with-
in 30 days after talc pleurodesis and 1 did not undergo
30-day postpleurodesis radiography. The remaining 19
patients made up the study group to assess the response
rates (8 men, 11 women). Overall response rates of talc
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Accepted after revision: June 27, 2001
pleurodesis via small-bore catheter were found to be
84.2% [complete response (CR): 68.4%, partial response
(PR): 15.8%] at 30-day and 78.6% (CR: 57.2%, PR:2 1.4%)
at 90-day follow-up, respectively. One patient reported
moderate pain during catheter placement. Four patients
experienced mild to moderate pleuritic chest pain, short-
ness of breath, or both within 4 h after instillation. Seven
of the 22 patients (31.8%) had a transient fever
(^39.0 ° C) 6–24 h after talc instillation that lasted less
than 24 h and was successfully treated with acetamino-
phen. One patient had significant subcutaneous emphy-
sema that resolved in 24 h. Four patients died because of
tumor progress (2 patients in the 1st month and 2
patients between 30 and 90 days). Conclusion: Pleurode-
sis can successfully be performed via a small-bore cathe-
ter in patients with recurrent malignant pleural effusion.
To validate the results of the study, a prospective ran-
domized study, comparing this device (Pleuracan) and a
‘standard’ 16- to 24-french chest drain, should be per-
formed.
Copyright © 2001 S. Karger AG, Basel
Introduction
Malignant pleural effusions are a common problem in
cancer patients with advanced disease. Most patients
present with progressive dyspnea, cough and/or chest pain
Dr. Ünal Şahin
Halıkent Mahallesi Ufuk Yapı Koop
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that compromises their quality of life [1, 2]. Treatment is Table 1. Demographic data of the studied population
often palliative, usually consisting of sequential thoracen-
Sex Age Cancer Right/left
teses, tube thoracostomy with pleurodesis or thoracoscop-
years distribution
ic pleurodesis [3].
Repeated thoracocentesis can be appropriate for pa- M 55 Bronchoalveolar carcinoma Right
tients with limited life expectancy or slowly recurrent M 60 Pulmonary adenocarcinoma Left
effusions. When thoracentesis is repeated frequently to F 62 Breast carcinoma Right
F 50 Malignant mesothelioma Left
treat dyspnea, the resulting depletion in ions, fluid and
M 63 Adenocarcinoma of unknown origin Right
proteins contributes to the deterioration in the patient’s F 58 Pulmonary adenocarcinoma Right
general condition. If the fluid reaccumulates after re- F 51 Malignant mesothelioma Left
peated thoracentesis, the options are chemical pleurodesis M 65 Malignant mesothelioma Right
via chest tube, thoracoscopy with pleurodesis, open thora- M 59 Epidermoid carcinoma Left
F 43 Breast carcinoma Right
cotomy with pleurectomy or pleuroperitoneal shunting.
F 53 Pulmonary adenocarcinoma Left
Pleurodesis is therefore the symptomatic treatment of F 60 Breast carcinoma Right
choice and should be considered as early as possible in the M 62 Malignant mesothelioma Right
course of malignant pleural effusions [4]. F 50 Pulmonary adenocarcinoma Left
The most common treatment for malignant effusion M 48 Colon adenocarcinoma Right
F 57 Breast carcinoma Left
has been large-bore chest tube drainage followed by instil-
F 49 Pulmonary adenocarcinoma Right
lation of a sclerosing agent. Large-bore chest tubes, how- M 66 Malignant mesothelioma Right
ever, limit patient mobility and can cause significant F 58 Breast carcinoma Right
patient discomfort. More recently, small-bore catheters M 59 Pulmonary adenocarcinoma Left
were placed with radiological guidance with no noticeable M 63 Epidermoid carcinoma Right
F 54 Pulmonary adenocarcinoma Left
difference in response rates [5–8]; the catheters were well
M 57 Epidermoid carcinoma Left
tolerated and accompanied by minimal complications. F 51 Breast carcinoma Right
Talc is the most effective and widely used agent for
chemical pleurodesis in the treatment of malignant pleu-
ral effusion. Its popularity has been growing due to the
low incidence of side effects, low cost and higher success
rate in comparison with other agents (tetracyclines, bleo- noma, 5 mesothelioma, 1 adenocarcinoma of unknown origin and 1
mycin, Corynebacterium parvum) [9–14]. The most fre- colon carcinoma (table 1). The response was assessed monthly. Pain,
quent adverse effects are chest pain and fever during and dyspnea and chest radiographs were all assessed before and after
treatment. All patients had undergone predrainage chest radiogra-
after the pleurodesis.
phy, and informed consent was obtained. Small-bore (10 french) all
The aim of the study was to assess the efficacy of talc purpose drainage catheters (Pleuracan, US$ 35, B. Braun, Melsung-
slurry with a small-bore catheter (Pleuracan®) and to com- en, Germany) were placed into the pleural space by using sono-
pare our results of controlling malignant pleural effusions graphic guidance (fig. 1).
with the literature. Catheters were placed in the midaxillary line at the sixth or sev-
enth intercostal space. The catheter was then placed in continuous
wall suction with a 2-liter sterile (Pleuracan) secretion collecting bag.
Drainage and lung reexpansion were assessed with chest radiographs
Material and Methods over the next 24 h. Sclerotherapy was performed when the small-bore
catheter output of the previous day was less than 150 ml and chest
In a prospective trial (May 1998 to March 2000) we performed radiography showed little or no residual fluid. Patients received 5 g of
talc pleurodesis via small-bore catheters in 24 patients (11 men and sterile talc mixed with 5 ml of 2% lidocaine hydrochloride in 50 ml of
13 women). Ages ranged from 43 to 66 years with a mean value of normal saline solution and the catheter was then flushed with 25 ml
56.37 B 6.72 years (males: 58.0 B 5.47, age range: 48–66; females: of sterile normal saline solution. Next, the tube was clamped for 2 h.
55 B 6.27, age range: 43–62). All patients had radiologically proven Following this, the clamp was removed and suction applied for up
pleural effusions. Patients who had prior sclerotherapy were ex- to an additional 24 h, at which time the catheter was removed if
cluded. No patient had systemic chemotherapy immediately prior to ! 150 ml had drained. Postsclerotherapy chest radiographs were
or during the 30-day interval following sclerotherapy. Ultrasound obtained 24 h after catheter removal and at the 30-day follow-up
and CT were used to assess the loculated pleural effusions. Patients visit.
with loculated effusions or trapped lung after drainage were excluded The 30-day postpleurodesis chest radiographs were compared
from the study. Of the patients presenting with malignant effusions, with the prepleurodesis and immediate postpleurodesis chest radio-
11 were secondary to primary carcinoma of the lung: 6 breast carci- graphs to assess the response. The response at 30 days was defined as

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Fig. 1. Photographical view of the catheter
(Pleuracan). Set for closed pleura and thorax
drainage according to Matthys.

complete response (CR; no reaccumulation of pleural fluid after post- Table 2. Results of talc pleurodesis at the
pleurodesis radiography), partial response (PR; reaccumulation end of the 1st and 3rd months
above the postpleurodesis level but below the prepleurodesis level),
or no response (NR; reaccumulation to or above the prepleurodesis At the end of At the end of
level) [15]. 1st month 3rd month
Data are given as means B SD. For analyzing statistical differ-
n % n %
ences Student’s two-tailed t test and nonparametric Kruskal-Wallis
¯2 test were performed. A p value ! 0.05 was considered significant.
CR 13 68.4 8 57.2
PR 3 15.8 3 21.4
Failure 3 15.8 3 21.4
Results Total 19 100 14 100%

Of the 24 patients included, 2 patients (1 adenocarci-

noma of unknown origin, 1 colon adenocarcinoma) did
not show lung expansion after pleural drainage. The
remaining 22 patients showed lung expansion (no impor-
tant residual fluid and pleural thickening) before and 24 h
after talc instillation on chest radiographs. Two patients
(primary lung carcinoma) died within 30 days after talc
pleurodesis and 1 did not undergo 30 days’ postpleurode-
sis radiography.
Overall response rates were given in table 2. Of the
remaining 16 patients at the end of the 1st month, 8
(57.2%) showed CR to talc pleurodesis, 3 (21.4%) PR, and
3 (21.4%) NR at the end of the 3 months. Therefore, the
success rate was found to be 78.6% at the end of the 3rd
month (table 2). Three relapses (21.4%) and 2 deaths
occurred at this time. In patients (n = 19) with CR, PR
and NR, the mean small-bore catheter output was 2,903
B 1,011, 3,066 B 814 and 3,233 B 808 ml, respectively.
This difference was not statistically significant (¯2 =
0.347, p = 0.841). Catheters remained in place for 2–10
days (5.1 B 1.9 days). In patients with CR, PR and NR
(n = 19), the mean time of catheter use was 5.3 B 2.2, 5.3
B 1.5 and 5.7 B 0.6 days, respectively; the differences
were not statistically significant (¯2 = 0.695, p = 0.706).
Five catheters became clogged; all of them were easily
cleared with a guidewire. Only 4 patients (16.6%) found
the insertion of the small-bore catheter more unpleasant
than thoracentesis. All patients reported a marked im-
provement in their respiratory symptoms after drainage
and sclerosis at their monthly outpatient visits. We en-

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Table 3. Complications following talc pleu-
rodesis
Complications Number (%)
Subcutaneous emphysema1 1 (4.5)
Pain2 1 (4.2)
Shortness of breath3 2 (9.1)
Chest pain3 2 (9.1)
Fever4 7 (31.8)
Figures in parentheses represent percent-
age.
1 Resolved in 24 h spontaneously.
2 Moderate pain during catheter place-
ment.
3 After talc instillation.
4 Transient fever (^39.0 ° C) 6–24 h after
talc instillation.
countered no significant problems during the procedure
and no major problems of pleurodesis resulting in major
morbidity or mortality. We had no cases of respiratory
failure, and no deaths directly attributable to pleurodesis.
Two patients with end-stage lung carcinoma died of respi-
ratory failure 7 and 18 days after the procedure. Another 2
deaths occurred within 9 and 12 weeks after talc slurry.
All were caused by critical illnesses that were present
before the pleurodesis procedure. Complications follow-
ing talc pleurodesis are shown in table 3.
Discussion
Malignant pleural effusion is a common problem that
causes significant morbidity and can negatively affect
patients’ quality of life. Current options for palliative
treatment of symptomatic effusions include repeated tho-
racenteses, large-bore (28- to 36-french) or small-bore (7-
to 16-french) chest tube drainage, chemical sclerotherapy,
or video-assisted thoracoscopic drainage and sclerosis.
Although repeated thoracentesis can give symptomatic
relief, the recurrence rate is reported to be high [16]. Inpa-
tient drainage with large-bore chest tubes connected to
wall suction followed by sclerosis is the most commonly
used palliative intervention [17–19]. The success rate
with small-bore chest tubes used on an inpatient basis
ranges from 62 to 95% [5, 8, 15, 20–23].
In the study of Marom et al. [24], in 1999, 32 patients
with a known primary malignancy and a symptomatic
504 Respiration 2001;68:501–505
malignant pleural effusion underwent small-bore catheter
thoracostomy and talc pleurodesis. Twenty-three patients
(72%) had a CR, and 5 (16%) NR. Our results were simi-
lar to those reported by other workers [5, 8, 10, 15, 21–
25].
Talc has been used to treat malignant pleural effusions
for over 30 years and is usually considered to be the most
effective chemical agent for pleurodesis [26–28]. Clinical
studies reported over the last decade reflect a continuing
interest in talc as a chemical agent and provide evidence
of its effectiveness with minimal side effects [29].
In the study of Clementsen et al. [30], of 18 evaluable
consecutive patients, 9 were randomized for pleurodesis
with the small and 9 with the large catheter. In the former
group, the majority (7 of 9) did not find the insertion of
the catheter more unpleasant than thoracentesis. In the
latter group only a few (2 of 9) found the insertion more
unpleasant than thoracentesis. In our study, only 4 pa-
tients (18.2%) found the insertion of the small-bore cathe-
ter more unpleasant than thoracentesis.
The most frequent adverse effect in the study of
Thompson et al. [25] was pleuritic chest pain. In the study
of Seaton et al. [15], 14% of patients showed mild discom-
fort at the chest tube site during drainage, pain during
instillation of talc occurred in 5% of patients, and a tran-
sient fever was observed in 5% of patients 1 day after scle-
rotherapy. In the study of Marom et al. [24], complica-
tions included fever in 13 patients (41%) and moderate
shortness of breath, chest pain or both in 6 (19%). More
notably, one report has described three cases of ARDS
attributed to pleurodesis with 12 g of talc slurry [31].
There were no problems with severe chest pain or pro-
longed pyrexia documented in any of our patients. One
patient had significant subcutaneous emphysema that
resolved in 24 h. One patient reported moderate pain dur-
ing catheter placement. Four patients (19%) experienced
mild to moderate pleuritic chest pain, shortness of breath
or both within 4 h after instillation. Three of them
required analgesics, antipyretics or both. Seven of the 22
patients (32%) had a transient fever 6–24 h after talc
instillation, the duration of which was shorter than 24 h. It
was easily controlled with acetaminophen.
In conclusion, pleurodesis in patients with recurrent
malignant pleural effusion can be performed with a small-
bore catheter (Pleuracan) with an effect similar to that
obtained with a large-bore chest tube as reported in the
literature. This study supports the use of small-bore tubes,
which were well tolerated, had satisfactory response rates
and minimal complications.
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