Ram Gulrajani, BSc, Asthma Dip, COPD Dip, RSCN, RGN, is respiratory nurse specialist, West Essex PCT.
Gulrajani, R. (2008) Avoiding hospital admission to drain pleural effusions. This is an extended version of the article published in Nursing Times; 104: 14, 30-31.
This article describes the implementation of an initiative to allow patients with malignant pleural effusions to manage their condition in the community. The scheme has allowed them to avoid hospital admissions for the procedure and has resulted in cost savings and reduced bed occupation. It has also improved patient experience and established joint working between primary and acute care. The article also includes a case study that demonstrates the benefits for patients.
A pleural effusion (PE) is defined as excessive fluid between the visceral and parietal pleura. In a healthy person, there is normally a small quantity (15–20ml) of fluid present; any significant increase is known as a pleural effusion. The condition compresses the lung and is usually visible on X-ray. Symptoms of PE include dyspnoea, a persistent cough, chest pain and tightness. These can be distressing and frightening for both patients and carers.
In some cases they can become large enough to cause hypoxia, mediastinal shift and respiratory failure. Two types of effusions can develop. Transudative PEs are often caused by abnormal lung pressure, while exudative PEs form as a result of inflammation of the pleura, often caused by lung disease (see Box). This article discusses the treatment of patients with malignant effusions, which are a significant cause of morbidity and a poor prognostic indicator (Pollack, 2002). Most are caused by cancers of the breast, lung, gastrointestinal tract or ovary or by lymphomas (National Cancer Institute, 1998).
Box 1. Causes of pleural effusions
Very common causes:
Less common causes:
Exudative pleural effusions
Less common causes:
Source: Maskell et al (2003).
Management and treatment
Malignant PEs should be managed by identifying and treating the cause according to British Thoracic Society guidelines (Antunes et al, 2003; Maskell et al, 2003). Treatment options include thoracoscopy, long-term indwelling catheter and pleuroperitoneal shunt, and are determined by several factors:
- Symptoms and performance;
- Status of the patient;
- The primary tumour and its response to systemic therapy;
- Lung re-expansion following pleural fluid evacuation (Antunes et al, 2003).
Some patients experience recurrent malignant PEs, and may be treated by pleurodesis. This is the artificial obliteration of the pleural space and can be achieved by introducing chemicals such as tetracycline, bleomycin, povidone-iodine or a slurry of talc into the pleural space through a chest drain. The chemicals cause irritation between the parietal and visceral layers of the pleura, which closes off the space between them and prevents further fluid accumulation.
Traditionally, management of patients suffering from recurrent PEs has consisted of repeated and often extended hospital admissions. This is stressful and inconvenient for patients and carers and costly to the NHS. With the advent of new technologies, we identified patients with recurrent malignant PEs as a group that could benefit significantly from new management techniques.
In patients with recurrent exudative PEs for whom talc pleurodesis has failed on two attempts, at West Essex PCT we have been using a long-term indwelling catheter to drain the effusions in patients’ own homes.
Within West Essex PCT’s catchment area when this programme was set up, an average of 12 patients a year required repeat admissions to acute wards due to recurrent PEs, usually for three days or longer. Such admissions are stressful and inconvenient for patients and their carers, and costly for the health service. The number of admissions for each patient depended on diagnosis, symptoms and bed availability.
The PCT addressed the situation by commissioning a service to manage this patient group in the community, allowing them to receive treatment in their own homes. The service launched in April 2006 and uses a combined acute care and primary care approach involving the community-based respiratory nurse and the consultant chest physician based in the acute hospital. A Pleurx indwelling catheter is inserted in hospital under local anaesthetic, which is performed as a day-case procedure. This normally remains in situ throughout patients’ palliative state, although it depends on the individual diagnosis and prognosis. In my experience, the catheters remain in situ until the patient’s death, unless pleurodesis is achieved, in which case the catheter is removed.
The catheter is soft and flexible and well tolerated by patients. It has a two-way safety valve to prevent the inadvertent passage of air/fluid through the catheter. A polyester cuff promotes tissue ingrowth to reduce infection risk and holds the catheter securely in place once the sutures are removed. The catheter also has a fenestrated length of 24cm, while large, smooth and bevelled edges promote drainage and avoid plugging. The Pleurx device is tunnelled to reduce infection and sutured in place.
The Pleurx is a closed system, which reduces the risk of infection. The Pleurx mini kit consists of a 500ml or 1,000ml plastic vacuum bottle with drainage line. It is highly portable and comes complete with a gauze pad, foam catheter pad, alcohol pads, gloves, blue emergency slide clamp, self-adhesive dressing and valve cap, so no extra equipment is needed. This enables practitioners or patients to manage pleural effusions in a home setting. Although the drainage procedure is safe for patients to carry out at home, for the trial period it was carried out by trained nursing staff. Since then, some patients have undertaken the task for themselves, but most agree a schedule for the community respiratory nursing team to visit and manage the procedure.
The cap on the catheter is removed and the valve cleaned with an alcohol wipe, then the vacuum bottle drainage line is attached to the catheter to drain fluid from the pleural space. Up to 1L can be drained at each procedure, though typically it is an average of around 400ml.
Effectiveness of tunnelled catheter placement
The indwelling catheter system has been widely and successfully used in the US. In a recent study of 250 patients Tremblay and Michaud (2006) concluded that tunnelled pleural catheter placement is an effective means of palliation for malignant PE that allows outpatient management and low complication rates. They advocated that the insertion of a tunnelled pleural catheter should be considered as a first-line treatment option in management of patients with malignant pleural effusions.
This built on the work of Pien et al (2001), who found that, in a small sample of 13 patients, placement of a permanent pleural catheter provided a convenient, effective alternative to other procedures available. Patients in the study reported good symptomatic relief following catheter placement with few major complications, including infections.
Putnam et al (1999) compared a long-term indwelling pleural catheter with doxycycline pleurodesis via a standard intercostal tube. They found that the length of hospital stay for the indwelling catheter group was significantly shorter (one day) than that of the doxycycline pleurodesis group (six days). Putnam et al (2000) also concluded that an indwelling pleural catheter is an effective option for controlling recurrent malignant effusions when length of hospital admission needs to be kept to a minimum, and where expertise and facilities exist for outpatient management.
Potential complications tend to be rare, minor and easily managed. The most common is pain during drainage, which is easily managed by administering analgesia before commencing drainage and by regulating the flow of drainage. In a study by Murthy et al (2001) catheter-related complications occurred in four of 58 patients (7%) and included one each of pneumothorax, seroma, empyema and pain syndrome. Staff and patients in the programme reported here were taught to manage these complications through practical teaching and observation, backed up by training videos provided by the manufacturer. All patients included in the programme were willing to take part and confident about the intervention because of the clear benefits to their quality of life and symptom control and management.
Outcomes to date
Six patients were recruited into the programme initially, with a range of diagnoses causing recurrent pleural effusions. Comparison of the number of admissions required by these patients while being treated at home with the number needed previously suggests a total of 161 potential admissions were avoided over one year. Of these it is likely that 71 would have been without and 90 would have been with complications. Table 1 shows the costs these admissions would have entailed, based on the payment-by-results tariff for 2007–2008 (DH, 2006). Since admissions times cannot be precisely calculated, figures are included for both short-stay and longer non-elective admissions. In addition to these hospital admissions, the patients are likely to have attended outpatient clinics due to PEs.
Table 1. Savings resulting from 161 avoided admissions
|Admission type||Cost||Number||Total cost|
|Short stay without complications||£475||71||£33,725|
|Short stay with complications||£622||90||£55,980|
|Non-elective admission without complications||£2,375||71||£168,625|
|Non-elective admission with complications||£3,111||90||£279,990|
Bearing in mind that the number, length and nature of admissions can only be assumed based on information from previous admissions, it is not possible to calculate exactly how much the initiative has saved the PCT. However, the the 161 avoided admissions would cost between £89,705 if all were short-stay and £448,615 if all were longer-stay. Of course, the real figure would be somewhere between the two figures. Excluding staffing, the initiative incurred costs of around £9,000 for the Pleurx drainage kits.
Before the project
Mrs Jenkins* was diagnosed with malignant empyema and needed regular pleural lavage and drainage that required twice-weekly admission to hospital. The admission meant she had to call the ward and/or bed manager a day in advance to check whether a bed was available, then arrange travel to the hospital where she would be formally admitted. The procedure was carried out when the bed became available. The total time before her PE was drained depended on staff availability, workload, equipment availability and a bed space, which could mean she was left waiting for hours after arriving at the hospital. This was further complicated by Mrs Jenkins’s positive MRSA status, which meant she needed a side room.
Mrs Jenkins complained of increased anxiety and pain as a result of all these issues. Her quality of life was negatively affected and despite having a limited life expectancy much of her time was being spent on managing her PE. Her children were also affected as they had to take time off work to take their mother to hospital and support her through the procedure.
Management under the project
Mrs Jenkins has now been managed in the community for almost two years. She spends her time with family and friends, her quality of life has improved immensely and, although she is terminally ill, her outlook on life is more positive and less despairing. Her hospital visits are confined to the outpatient department only. Her pain is well controlled by the community team and her opiate use has been reduced as her symptoms are controlled more quickly with the pleural drainage being undertaken at home. Mrs Jenkins is positive about the scheme and she has control over her life again. She says she is no longer ‘just a patient’ but an active member of her family and the community, and is able to go out shopping and take part in ‘normal’ activities.
*The patient’s name has been changed
Benefits of the scheme
The case study above describes the most successful intervention that this programme offered. Many patients have needed the service for a far shorter time due to their disease being end-stage, while one had the catheter removed after achieving pleurodesis.
A PCT merger has taken place and the programme has now been extended to the neighbouring localities. Patient management is predominantly based in primary care but with access to acute care for further management and advice should there be any significant changes in the fluid consistency, colour, viscosity or amounts. This has further reduced the need for outpatient reviews, which is not only beneficial to patients but also allows more capacity in outpatient services.
Pleural drainage with this scheme is efficient and effective to meet the needs of patients, the service and the NHS. The service is also very easy to adopt.
An additional pleural lavage procedure has proven effective in reducing the viscosity of pleural fluid and, although we have only needed to use this for one patient, it has, in combination with the Pleurx drainage, proven extremely effective in reducing infection rates, readmission rates and extending the patient’s life expectancy.
The programme has been easy to operate, and now forms part of the services that the primary care nursing team offers. It adds value and quality to the PCT’s services with the added bonus of financial savings. With the increasing numbers of patients with mesothelioma, it is likely to prove invaluable tool to improve future patients’ quality of life while reducing the financial burden.
If a patient’s lifespan is reduced through disease, the insertion of a long-term pleural catheter allows more independence, increased quality of life and reduced admissions. This is achieved without compromising on mobility and aesthetics, as the drain is discreet and cannot be seen once the dressing is in place. Our patients have expressed satisfaction with the service as it addresses their individual needs.
The resources required to offer this service are: willingness among primary and acute care staff to work closely to ensure a quality initiative for patients; a willingness to change practice; and financial investment that is easily recuperated.
This project was the winter of the 2007 Innovation in Your Specialty NT Award
Antunes, G. et al (2003) BTS guidelines for the management of malignant pleural effusions. Thorax; 58: Suppl II, ii29–ii38.
Department of Health (2006) Payment by Results National Tariff 2007–2008. www.dh.gov.uk
Maskell, N.A. et al (2003) BTS guidelines for the investigation of a unilateral pleural effusion in adults. Thorax; 58: Suppl II, ii8–ii17.
Murthy, S. et al (2001) Use of an implantable pleural catheter for trapped lung syndrome in patients with malignant pleural effusion. Chest; 119: 1641-1646.
National Cancer Institute (1998) Malignant Pleural Effusion. www.meds.com
Pollak, J.S. (2002) Malignant pleural effusions: treatment with tunneled long-term drainage catheters. Current Opinion in Pulmonary Medicine; 8: 4, 302-307.
Pien, G.W. et al (2001) Use of an implantable pleural catheter for trapped lung syndrome in patients with malignant pleural effusion. Chest; 119: 1641-1646.
Putnam, J.B. et al (2000) Outpatient management of malignant pleural effusion by a chronic indwelling pleural catheter. Annals of Thoracic Surgery; 69: 369-375.
Putnam, J.B. et al (1999) A randomized comparison of indwelling pleural catheter and doxycycline pleurodesis in the management of malignant pleural effusions. Cancer; 86: 1992–1999.
Tremblay, A., Michaud, G. (2006) Single-centre experience with 250 tunnelled pleural catheter insertions for malignant pleural effusion. Chest; 129: 362-368.