Article, Pulmonology

Ultrasound-guided pigtail catheters for drainage of various pleural diseases

Original Contribution

Ultrasound-guided Pigtail catheters for drainage of various pleural diseases

Yi-Heng Liu MD1, Yu-Chao Lin MD1, Shinn-Jye Liang MD, Chih-Yen Tu MD, Chia-Hung Chen MD, Hung-Jen Chen MD, Wei Chen MD?,

Chuen-Ming Shih MD, PhD, Wu-Huei Hsu, MD

Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, China Medical university hospital, Taichung 404, Taiwan

Received 24 March 2009; revised 21 April 2009; accepted 27 April 2009

Abstract

Objective: Little is known about the efficacy and safety of ultrasound-guided Pigtail catheters for the management of various pleural diseases in the emergency department, ward, and intensive care unit. Methods: We conducted a retrospective study in a university hospital during a 1-year interval.

Results: A total of 276 patients (178 men and 98 women) underwent 332 pigtail catheters (the drain size ranged from 10F to 16F) under ultrasound guidance. The mean +- SEM patient age was 59 +- 18 years, and mean duration of drainage was 6.1 +- 2 days. A total of 64 drains (19.2%) were inserted for pneumothoraces; 98 drains (29.5%), for malignant effusions; 119 drains (35.8%), for parapneumonic effusions/empyemas; and 38 drains (11.4%), for massive transudate Pleural effusions. The overall success rate was 72.9%. The success rate was highest when the drain was used to treat massive transudate effusions (81.6%) and malignant pleural effusions (75.5%), followed by parapneumonic effusions/empyemas (72.2%), hemothoraces (66.6%), and pneumothoraces (64.0%). Only 10 (3.0%) drains had complications due to the procedure, including infection (n = 4, 1.2%), dislodgment (n = 4, 1.2%), wound bleeding at the pigtail catheter puncture area complicated with hemothoraces (n = 1, 0.3%), and lung puncture (n = 1, 0.3%). There was no significant difference in success rate when different catheter sizes were used to treat pleural diseases.

Conclusions: Ultrasound-guided pigtail catheters provide a safe and effective method of draining various pleural diseases. We strongly suggest that ultrasound-guided pigtail catheters be considered as the initial draining method for a variety of pleural diseases.

(C) 2010

Introduction

* Corresponding author. Tel.: +886 4 22052121×2010; fax: +886 4

22038883.

E-mail address: [email protected] (W. Chen).

1 These authors contributed to this work equally.

There are a wide variety of etiologies in pleural diseases, including heart failure, malignancy, pneumothoraces, and empyemas, which occur in 3000 people per million population annually [1]. Ultrasound (US) has been proven to be a reliable, efficient, and informative imaging modality for the evaluation of pleural lesions [2-4]. Major advantages

0735-6757/$ - see front matter (C) 2010 doi:10.1016/j.ajem.2009.04.041

of US include the absence of radiation, low cost, flexibility, bedside availability, and a short examination time compared with computed tomography [5-6]. Therefore, US is now being used in emergency departments and Intensive care units to assess the possibility of pneumothorax in patients with chest trauma by emergency department physicians, intensivists, and surgeons [7-10]. Several studies have also shown how useful US can be in identifying the correct place for thoracentesis [11-14].

In our experience, a US-guided pigtail catheter is a useful and safe method for drainage of primary or Secondary spontaneous pneumothoraces [15-17] and pleural effusions in ICUs [18]. However, there is a paucity of data regarding a comprehensive review of US-guided pigtail catheters for drainage of various pleural diseases. In this study, we conducted a retrospective study about the efficacy and safety of US-guided Pigtail drainage in a university hospital.

Materials and methods

Patients

We retrospectively reviewed all adult patients who underwent chest US examinations at China Medical University Hospital, a 1700-bed tertiary care, university- affiliated hospital in Taiwan, from January 1 to December 31, 2006. During this period, 1700 patients underwent chest US examinations at China Medical University Hospital because a diagnosis of pleural or chest wall disease was considered likely on the basis of physical examinations and/or chest radiography. Of the 1700 patients, 276 who received US- guided pigtail catheter drainage were enrolled in the study. Data collected included several clinical, laboratory, and ultrasonographic parameters.

Indications for pigtail catheter drainage

All patients’ chest radiographs were evaluated by an attending physician (experienced pulmonologist). If pleural disease was suspected in the chest radiograph, we performed chest US for a complete pleural survey. Light’s [19] criteria were used to determine transudative or exudative pleural effusions. Massive transudative pleural effusions were drained when patients had significant symptoms caused by the effusions (eg, liver cirrhosis and congestive heart failure) despite adequate medication. The criteria for draining parapneumonic effusions and empyemas were based on the guidelines recommended by Colice et al [20]. Malignant pleural effusion is an exudative effusion with positive malignant cells found by cytological examination. Diagnosis of hemothorax is based on evidence of chest trauma in patients who underwent operations in the preceding 24 hours, had bleeding tendency, had hematocrit pleural/

serum greater than 50%, and others. Diagnosis of pneu- mothorax is based on evidence of air in the pleural space or pleural line shown in chest radiographs or chest computed tomography.

Position and procedure for pigtail catheter insertion

Usually, chest US examination was performed by experienced pulmonologists with the patients in a seated position (Fig. 1). The transducer was started on the posterior axillary line between the 9th and 11th ribs to identify the liver on the right side, the spleen on the left side, and the diaphragm. Thereafter, multiple scans were obtained in transverse, oblique, and sagittal planes to locate the insertion site. In ICUs, the patient was left in a dorsal decubitus position. Longitudinal scans of the intercostal spaces were performed at the lateral chest wall. If not detected, effusion was sought more posteriorly by slightly lifting one side of the patient’s back to slide the probe as far as possible between bed and back, with the head pointing upwards (Figs. 2 and 3).

In our hospital, Large-bore chest tubes were usually inserted by surgeons, and US-guided pigtail catheter insertions were usually performed by pulmonologists, medical intensivists, or emergency department physicians at the bedside or chest US room. Percutaneous pigtail catheters (SKATER, PBN Medicals, Stenlose, Denmark) were all single-lumen, polyurethane coiled catheters, sized 10F to 16F, used in conjunction with a wire and dilator and

Fig. 1 With patients in seated position, the transducer was started on the posterior axillary line between the 9th and 11th ribs to identify the solid organs.

Fig. 2 Chest x-ray showed ground-glass opacity over the right lower lung field in a 78-year-old man with acute respiratory failure. Chest US showed minimal pleural effusion and limited safe insertion width in the patient’s supine position.

connected to a 1-way valve drainage bag or a negative- pressure drainage system. Chest US was performed to locate the puncture site, and the ultrasonographic pattern of the pleural effusions was recorded using the classification of Yang et al [21] before inserting the catheter. After determining the insertion site (either lateral in a Supine patient or posterior in a lateral decubitus or sitting patient), the catheters were inserted using the modified Seldinger technique, with insertion of the needle and syringe over a rib and gentle aspiration with the syringe to locate fluid or air in the pleural space. Finally, the pigtail catheter was attached to a 1-way valve drainage bag or a water seal chest drain system.

Success of pigtail catheter drainage was defined as improvement in the pleural diseases by image findings (chest x-ray or US) and/or clinical symptoms without

requiring further drainage or insertion of a large-bore chest tube. Failure was defined as the persistence or exacerbation of clinical and/or laboratory findings related to pleural diseases or required for further drainage, insertion of large- bore chest tube, or operation. Pigtail-associated complica- tions included Wound infection, pneumothorax, a kink or obstruction in the catheter, disconnection of the tubing, subcutaneous hematoma, or organ perforation.

Statistical analysis

Data were analyzed using a commercial statistical soft- ware (SPSS for Windows, version 10.0; SPSS, Chicago, IL). We report all continuous variables as mean +- SD and compared these using 2-tailed Student t test. We report categorical variables as the number and percentage of

Fig. 3 When the patient was placed in a dorsal decubitus position with the head slightly pointing upward, the US showed massive pleural effusion and obviously increased insertion width for pigtail drainage.

patients. Differences in categorical variables were examined using Fisher exact test. All tests of significance were 2 sided; P <= .05 was considered statistically significant.

Results

Patient characteristics, underlying diseases, and clinical features

During the study period, 325 patients received pigtail catheters for drainage. Among these 325 patients, complete data were available on 332 drainages in 276 patients (178 men and 98 women). Forty-nine patients were excluded because of incomplete data (lack of record of the pigtail catheter size, pattern of US, nature of effusions, etc). The mean age of the 276 patients was 59.31 +- 18.2 years (range, 15-97 years), and we summarize additional patient demo- graphic features in Table 1.

Table 2 shows the etiologies of the pleural diseases associated with placement of thoracostomy tubes in our hospital. The most common indications for pigtail catheter drainage were infective pleural effusion (119/332, 35.8%) and malignant pleural effusion (98/332, 29.5%). Most (200/ 332, 60.2%) drains were size 12F (range, 10F-16F) (Fig. 4). Forty-seven patients required more than 1 drain placement (39 patients required 2 drains, 7 patients required 3 drains, and 1 patient required 4 drains). Among these 47 patients, 18 patients required further drainage because the initial failed.

Table 1 Clinical characteristics of the 276 enrolled patients treated with 332 pigtail catheters

Effectiveness

Table 2 also shows that therapy was successful in a total of 242 cases in which pigtail catheters were inserted to treat various diseases. Drains were most likely to be successful when used to treat massive transudate pleural effusions

(81.6%), parapneumonic effusions/empyemas (72.2%), or malignant pleural effusions (75.5%). The success rates were lower when drains were used to treat pneumothoraces (64.0%) and hemothoraces (66.6%). Among these 90 patients whose pigtail catheter failed as their initial treatment,

20 patients received large-bore chest tube for further management. In addition, in our analysis of the success rates among different pigtail catheter sizes used in treating different diseases, there were no significant statistical differences (P N .05).

Fig. 4 shows the pattern of US compared with success rate. The highest success rate was 83.3% (25/30) in the anechoic pattern group, and the lowest success rate was 70.2% (80/114) in the complex-septated pattern group. However, there were no significant statistical differences (P N .05) between these 4 groups in success rate.

Complications

In our study, the rate of complications was 3.0% (10/332). We recorded 4 (1.2%) cases of infection, and the most

Variable Value

No. of patients 276

No. of pigtail catheter insertions 332

Age (y) 59.21 +- 18.2 (15-97)

Hospital stay (d) 29.23 +- 29.6 (1-187)

Duration of pigtail drainage (d) 6.1 +- 2 (1-54)

Success rate 242 (72.9)

Male 178 (64.5)

Patients requiring N1 catheter insertion 47/276 (17.0) Placed on the right side 199 (59.9)

Values are presented as mean +- SD (range) or no. (%), where appropriate.

Parapneumonic effusion/empyema (n = 119)

Malignant pleural effusion (n = 98)

Massive transudate pleural effusion

(n = 38)

Hemothorax (n = 9)

Nonspecific (n = 4)

Pneumothorax (n = 64)

Insertion side

Left side of chest Right side of chest Pattern

Anechoic

Complex nonseptated Complex septated Homogenously echogenic Success, no. (%)

duration of admission (d)

Duration of pigtail catheter insertion (d)

40

42

16

4

1

30

79

56

22

5

3

34

4

14

10

2

0

-

29

61

19

3

1

-

75

23

9

4

3

-

11

0

0

0

0

-

86 (72.2)

74 (75.5)

31(81.6)

6 (66.6)

4 (100)

41 (64.0)

32.97

26.74

36.39

20.89

90.25

21.60

8.53

9.77

10.30

6.78

13.50

6.22

commonly found infection pathogen was oxacillin-resistant Staphylococcus aureus (2/4). Another 4 (1.2%) patients had minor insertion complications (dislodgment), none of which were clinically significant. One (0.3%) patient had wound bleeding at the pigtail catheter puncture area complicated with hemothorax in the surgical ICU, but the condition resolved spontaneously several days later. One (0.3%) patient had small local empyema in the posterior chest wall, and pigtail catheter puncture perforation into the lung parenchyma occurred, but without pneumothorax. No hollow organ perforation occurred, and there were no deaths related to complications resulting from drain insertion.

Table 2 Summary of conditions for which drains were used (n = 332)

Discussion

Detection of pleural effusion has been one of the major successes of US since the description of Joyner et al [22] more 30 years ago, and there are a few studies prescribing the efficacy of pigtail catheter in draining pleural diseases [23- 25], but there have been few studies prescribing the patient’s position during thoracentesis or pigtail catheter drainage insertion. This is a retrospective and comprehensive study focusing on the efficacy and safety of position and US- guided pigtail catheter drainage in various pleural diseases in outpatient departments, emergency departments, general

Fig. 4 Size of pigtail catheter inserted (n = 332).

wards, and ICUs. Our data suggest that US-guided pigtail catheter drainage of pleural diseases is an important, effective, and safe therapeutic method.

Ultrasound-guided thoracentesis has been proven to be a safe procedure in several studies [26,27], and the use of US- guided pigtail catheters to drain various pleural diseases is an important therapeutic management option [28-30]. Our retrospective study shows the safety and efficacy in various pleural diseases, with success rates from 64.0% to 81.6%. Our success rates in different diseases are similar to those of previous studies [23], but with a lower number of complications. The most common complication in previous studies is iatrogenic pneumothorax, with a range from 2.5% to 5.4% [27,31]. However, no pneumothorax was noted in our study. Our low complication rate (3.0%) may have been due to ultrasonic guidance with well Body position for pigtail catheter drainage. Especially in patients who cannot be in seated positions, we can found that an optimal position (dorsal decubitus position with slight head-sided lifting) provides a wider and safer space for thoracentesis or catheter drainage (Figs. 2 and 3).

Fig. 5 Comparison between the ultrasonic pattern of pleural effusions and success rate: (1) anechoic pattern, (2) complex- nonseptated pattern, (3) complex-septated pattern, and (4) homo- genous echogenic pattern.

For a fluid or air collection to be drained, large-bore chest tubes seem to remain optimal for adequate drainage flow. However, traditional large-bore chest tubes, placed by either blunt dissection or by trocar assistance, may have significant morbidity. Small-bore chest tubes have become more popular recently because of their effectiveness in a variety of pleural diseases [23,25,28-30]. The British Thoracic Society now recommends small-bore chest tubes (10F-14F) for pneumothoraces [32], parapneumonic effusions, and malignant effusions [33]. We compared different US patterns with success rate (Fig. 5). In these 4 groups, we found that the highest success rate was in the anechoic pattern group (83.3%) and the lowest success rate was in the complex- septated pattern group (70.2%). However, there were no significant statistical differences (P N .05) between these 4 groups. In our experience, we usually used 10F to 12F pigtail catheters to treat patients with anechoic and complex- nonseptated patterns and 14F to 16F to treat patients with complex-septated and homogenous echogenic patterns. This may be the reason why there is no statistical difference among these 4 groups.

Intrapleural distance indicates the volume of pleural fluid, and the intrapleural distance by US is different in different positions. Optimal position for procedure approach could provide enough space for thoracentesis and decrease complications. There have been few studies describing the importance of optimal position for US-guided pigtail catheter drainage. We performed the invasive procedure in 3 kinds of positions (Figs. 1-3). The training of the ultrasonographer was task specific and aimed at the positive identification of pleural fluid and surrounding organs. These simple and well- defined skills have been readily acquired by experienced pulmonologists, medical intensivists, and emergency depart- ment physicians, without any training from radiologists in our hospital. This also may be why there was a low complication rate in our study.

There are some limitations to this study. First, the study was retrospective in nature, so documentation of minor complications was probably not completely recorded, and even minimal pneumothorax may have been lost. Second, we have no direct comparison to conventional chest tubes. However, our success rate with pigtail drainage was similar to that of large-bore chest tubes in previous reports. Third, we have no data on patient comfort during the placement of the pigtail catheters; however, it has been our observation that pigtail catheters are more comfortable for patients than large-bore chest tubes are. Fourth, we did not record the intrapleural distance. A suitable distance will be safe and easy to approach and decrease complications.

In conclusion, US-guided pigtail catheters provide a safe and effective method of draining various pleural diseases. We strongly suggest that pulmonologists, intensivists, and emergency department physicians receive training for US and US-guided pigtail catheters and that US-guided pigtail catheters be considered as the initial draining method for a variety of pleural diseases.

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