Clinical
Malignant pleural effusion in the palliative care setting Anne Arber, Catherine Clackson, Susan Dargan
P Anne Arber is Senior Lecturer in Cancer and Palliative Care, University of Surrey, Guildford, Surrey, GU2 7TE, England; Catherine Clackson is Macmillan Nurse Specialist, Ashford and St Peter’s Hospital NHS Foundation Trust; Susan Dargan is Macmillan Senior Specialist Nurse, Ashford and St Peter’s Hospital NHS Foundation Trust Correspondence to: Anne Arber [email protected]
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leural effusion is a distressing condition that leads to poor quality of life for the patient and their family, causing pain and discomfort; severe breathlessness, especially when lying flat; emotional distress and anxiety; and tachycardia. Malignant pleural effusion (MPE) is present in 15% of patients with advanced cancer (Antony et al, 2001). It is one of the indicators of advanced disease and short life expectancy, with a median prognosis of 3–12 months depending on the stage of the disease and the underlying malignancy. Treatment for MPE is always palliative. The shortest survival is in those with MPE secondary to lung cancer and the longest survival is in those with ovarian cancer (Chan et al, 2010). The most common sources of metastatic tumours to the pleura are lung and breast cancer, which together account for 50–65% of all malignant effusions (Chan et al, 2010). Lymphomas and tumours of the genitourinary tract and gastrointestinal tract account for 25% of MPEs (Chan et al, 2010). Approximately 95% of patients with malignant mesothelioma
Formation of pleural effusion Pleural effusion is an abnormal collection of fluid in the pleural space. Pleural fluid collects in the space between the visceral pleural layer covering the lungs and the parietal pleural layer on the outer side covering the chest wall (Allibone, 2008). Usually there is 20 ml of fluid in the pleural space. This fluid provides lubrication when breathing and the volume is kept balanced by secretion from the parietal pleura and absorption by the visceral pleura via the lymphatic system. Normally up to 10 litres of low-protein fluid flows through the pleural space each day (Light, 2007); fluid only accumulates when there is decreased oncotic pressure, for example caused by reduced serum albumin, or when there is increased pressure in the lymphatic system. The latter occurs when there is direct infiltration by a cancer into the pleural space or metastases in the pleural space causing disruption of the pleural surfaces and inflammation. MPE accounts for 50–75% of all pleural effusions (Antunes et al, 2003).
Presenting symptoms and diagnosis The most common symptoms of MPE are shortness of breath, cough, sometimes a dry cough, an uncomfortable feeling in the chest, and pleuritic pain (Allibone, 2008). Patients may feel short of breath during activity or at rest depending on the size of the effusion. They may also
© 2013 MA Healthcare Ltd
Abstract
Malignant pleural effusion (MPE) is a distressing condition for the patient, causing many symptoms such as shortness of breath, dry cough, an uncomfortable feeling of heaviness in the chest, and pleuritic pain. MPE reduces quality of life and functional status. It indicates that the disease is now advanced and life expectancy is generally short, with a median prognosis of 3–12 months depending on the stage of the disease and the underlying malignancy. This paper discusses the palliative treatment options for MPE, which include thoracentesis, medical pleurodesis, and indwelling pleural catheter. It is important that decisions about treatment are made within the multidisciplinary team and alongside the patient and family. Treatment goals are concerned with the relief or elimination of dyspnoea, restoration of near-normal activity and function, and avoidance of inpatient care. Key words: Breathlessness l Malignant pleural effusion l Pleurodesis l Palliative care l Treatment
will develop a pleural effusion (Parker and Neville, 2003). This paper discusses the palliative treatment options for MPE, which include thoracentesis, medical pleurodesis, and indwelling pleural catheter. It is important that decisions about treatment are made within the multidisciplinary team and alongside the patient and family. Treatment goals are concerned with the relief or elimination of dyspnoea, restoration of nearnormal activity and function, and avoidance of inpatient care.
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Clinical
Table 1. Advantages and disadvantages of different drainage procedures* Drainage procedure
Advantages
Disadvantages
Technically straightforward. Can be performed at home or in outpatient setting.
Temporary measure, impractical if fluid quickly accumulates. Patient finds the procedure distressing. Avoid removal of >1500 ml
Thoracoscopy with talc
High success rate (>90%)
Inpatient procedure requiring surgery. Some potential complications, e.g. post-surgical pain, empyema, respiratory failure. Patients need to have good performance status
Permanent or semi-permanent catheter
Family can help manage catheter at home, achieving more time at home for patient. Can be continuous or intermittent drainage. Placed by interventional radiology or surgery
Local cellulitis most common problem
Chest tube insertion with intrapleural sclerosant
Success rate >60%
Requires hospitalisation. Side effects of sclerosant, e.g. severe pain
Pleuroperitoneal shunt
No external catheter
Occlusion, infection risk, tumour seeding. Patient or carergiver needs to press pump to be effective
Thoracentesis (therapeutic thoracentesis)
suffer with fatigue and chest heaviness. Some patients with a small pleural effusion may be asymptomatic, with the effusion only picked up on routine chest X-ray. Symptoms may arise gradually or with sudden onset. For patients with malignant mesothelioma, pleural effusion occurs in most cases. Therefore, pleural effusion management is a key patient management issue in malignant mesothelioma. A history of worsening dyspnoea, cough, and pleuritic chest pain is suggestive. On physical examination there will be decreased breath sounds, fremitus, and dullness to percussion. Chest X-rays establish the diagnosis of an effusion and identify its extent. Computed tomography may be used when radiography is inconclusive. Effusions can be bilateral or unilateral. Once a diagnosis of pleural effusion is made, a thoracentesis (removal of a sample of the fluid from the pleural effusion) may be done to determine the cause of the fluid accumulation. The fluid may be examined for composition and cytology and a complete cell count culture and sensitivities will be performed if infection is suspected (Light, 2002). In 25% of patients with cancer and recurrent pleural effusion the malignant cells may not be discovered during cytology (Prakash and Reiman, 1985), therefore thoracoscopy with pleural biopsy is more likely to result in a definitive diagnosis.
Clinical management of pleural effusion Treatment options for MPE are palliative and are determined predominantly by the patient’s symptoms and performance status. Performance status is an attempt to quantify cancer patients’ general wellbeing and their ability to perform activities
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of daily life. It is important to consider the management options that may be preferable for each individual patient. Discussions regarding a patient’s future clinical management usually occur along the patient’s pathway, and in the end-of-life situation this may be alongside an advance care plan. The context for discussions includes the tumour-specific multidisciplinary team meeting, where several qualified practitioners in different specialties including acute services and palliative care discuss a patient’s treatment options; the best or most appropriate route of treatment is then discussed with the patient in an outpatient clinic. The palliation of dyspnoea in MPE is managed by the removal of fluid from the pleural space by the least invasive procedure with minimal morbidity. Drainage of pleural effusion improves symptoms but does not affect survival (Putnam, 2002). The ideal treatment for MPE enables the patient to avoid hospital admission; relieves distressing symptoms, especially breathlessness, with minimal side effects; and results in an improved quality of life that enables the patient to remain at home (Olden et al, 2010). Treatment options to be considered for MPE are identified in Table 1. Therapeutic pleural aspiration (also known as therapeutic thoracentesis) is considered when MPE is symptomatic (Held-Warmkessel and Schiech, 2008). The aim is to relieve breathlessness, determine the contribution of the effusion to symptoms, and assess lung re-expandability. It is the most common procedure for the management of pleural effusion. The amount of fluid aspirated should be limited to 1–1.5 litres each time. The benefits to the patient are that it provides immediate symptom relief and it can be
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*Adapted from Allibone (2008)
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Clinical
performed as an outpatient procedure or in the patient’s home. It is usually performed for those with a short life expectancy, but the recurrence rate at even just 1 month after pleural aspiration is close to 100%. Repeating pleural aspiration is recommended only for those with a very short life expectancy and a poor performance status. Patient education after a thoracentesis includes monitoring for acute shortness of breath and assessing for signs of pneumothorax and haemoptysis, including changes in heart rate. Other monitoring includes signs of hypoxia, cyanosis, and changes in breath sounds, which could mean that there is re-accumulation of the pleural effusion (Held-Warmkessel and Schiech, 2008). The current standard treatment for MPE is pleurodesis (Van Meter et al, 2010). Medical pleurodesis is recommended for palliation of breathlessness where life expectancy is longer than weeks (Chan et al, 2010). Medical/chemical pleurodesis by chest catheter is used for symptomatic effusions that respond to a therapeutic thoracentesis that allows expansion of the lung and chest wall. Its aim is to cause an irritation between the two layers covering the lung. The procedure involves the insertion of a chest drain and instillation of an intrapleural sclerosant, causing the mesothelial cells to bring about a pleural fibrosis (Sahn, 2000) resulting in the pleurodesis. The instillation of the sclerosant causes irritation and adhesion of the pleural linings and prevents further fluid accumulating. This intervention can be done at the bedside of the patient and involves a variety of agents, including talc and bleomycin. It is useful in managing pleural effusions in patients who are not candidates for video-assisted thoracoscopy. Chemical pleurodesis is effective in recurrent MPE if relief of dyspnoea is evident after thoracocentesis in those with a satisfactory performance status. The sclerosants commonly used are talc, tetracycline hydrochloride, doxycycline, minocycline, bleomycin and Corynebacterium parvum. The preferred sclerosant agent has been found to be talc followed by tetracycline and bleomycin (Lee et al, 2003). A key factor in the treatment of malignant mesothelioma is early intervention in the form of pleurodesis (British Thoracic Society Standards of Care Committee, 2007). This prevents the pleural space from constantly refilling and palliates the patient experience of breathlessness and anxiety. The most common strategy in malignant mesothelioma treatment is pleurodesis through the introduction of talc slurry. Long-term followup of patients having undergone talc pleurodesis has shown positive results (Cardillo et al, 2002).
International Journal of Palliative Nursing 2013, Vol 19, No 7
Box 1. Guidelines for safe practice and administration of a talc pleurodesis* Preparing the patient ●
Explain the procedure fully and offer reassurance
●
Position the patient comfortably in a sitting position with good access to the chest drain and the site
●
Give analgaesia in the form of morphine sulphate 10–20 mg or pethidine 50–100 mg, with an anti-emetic if required. Thereafter, continue with medication regularly as necessary
Draining the effusion ● Any
existing effusion should be completely drained before the procedure and this should be confirmed by X-ray
Preparing the slurry ● The
dose of large-particle talc should not exceed 4 g and will be mixed into a smooth slurry with up to 40 ml of sodium chloride 0.9% solution. Up to 30 ml of 1% lidocaine can be added to the slurry
Preparing the tube ●
Check the chest drain site to ensure correct positioning of the tube
●
Check the outer tube for excessive exudate and flush if necessary
●
Check for drainage levels (effusion should be completely drained)
Administering the slurry ● Administer
the preparation slowly and gently
●
Observe for excessive pain or breathlessness
●
Look for any leakage around the insertion site
●
Clamp the drain for a minimum of 1 hour and a maximum of 4 hours, according to local protocol
● After
this time the drain can be unclamped but should be left in until there is minimal drainage (less than 150 ml in 24 hours)
●
Following the procedure, the chest drain should be flushed with a further 20 ml of sodium chloride to ensure the slurry has been introduced into the cavity and the tube remains patent
Rotation ●
Patient rotation is possibly helpful to ensure good spread of the slurry and is recommended although not seen as essential. If the patient is physically able, encourage movement from side to side every 15–20 minutes while the drain is clamped
Side effects ●
Minor: fever, chest pain
●
Major: adult respiratory distress syndrome (ARDS), respiratory failure
*Adapted from Braithwaite (2008)
Box 1 provides details of nursing care for a patient receiving medical pleurodesis with talc slurry. The slurry is a mixture of sterile talc, sodium chloride, and a local anaesthetic such as lidocaine 1% (Stefani et al, 2006). The mixture is introduced via a chest drain and is useful in patients who wish to avoid surgery or for whom there would be an increased risk of complications. It is a relatively simple procedure and is successful in the treatment of recurrent effusions (Doddoli et al, 2004). It can be performed successfully by nurses as well as doctors, and
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suitably trained and experienced nurses carrying out the procedure is becoming common. Nurses who perform this procedure should have more than 6 months’ experience in respiratory care and should follow evidence-based protocols (Munday et al, 2007). Munday et al (2007) concluded that nurses are as safe and effective as doctors in performing the procedure, and patients are equally satisfied with nurses and doctors. It is very important that an experienced doctor or nurse performs the procedure—in some research patients have reported that having a junior doctor carry out the procedure added to their anxiety (Clayson, 2007). Video-assisted thoracoscopy has many advantages over other surgical procedures as it provides detailed visualisation of the hemithorax, allowing directed biopsies, therapeutic pleurectomies, mechanical and chemical pleuro desis, and improved distribution of the sclerosing agent and catheter placement for drainage (Antunes et al, 2003; Tan et al, 2006). It is an effective approach in patients with a good performance status who are able to undergo more interventional procedures, resulting in effective control of MPE and palliation of distressing symptoms (Arber and Spencer, 2013). Patients have to be fit enough to tolerate general anaesthesia and surgical intervention. They normally have to attend a specialist centre where video-assisted thoracoscopy is carried out, which involves travelling to the specialist centre and hospital admission. MPEs that require repeated thoracentesis or for which pleurodesis has failed can be managed with a tunnelled small-bore indwelling pleural catheter (IPC), such as Carefusion’s PleurX. Treatment goals concern the relief or elimination of dyspnoea, restoration of nearnormal activity and function, and avoidance of inpatient care. This is a new approach that allows management to be continued at home and is one of the least intrusive interventions for the palliative patient. The placement of the indwelling catheter is minimally invasive and can be performed as an inpatient or outpatient procedure (Lombardi et al, 2010). The system involves minimal physician intervention, reduces hospital stay, and improves quality of life for patients with a life expectancy of 2–3 months as it enables more control over their life and more time can be spent at home. However, there are implications for ongoing care, which involves training carers in device management. Every 1–2 days the IPC needs to be connected to a vacuum drainage bottle, which has a safety valve that prevents air entering when draining
the accumulated fluid (Olden and Holloway, 2010). There are also implications for the patient nearing the end of life regarding when to stop draining and knowing which symptoms are related to approaching death rather than to the accumulation of pleural fluid. The issues around discontinuing drainage from an IPC near the end of life are similar to those regarding stopping artificial hydration and nutrition. Patient and carer expectations need to be addressed at the planning stage when offering this approach—i.e. there needs to be an explanation that the approach is palliative, with time-limited benefits. Sensitive discussion with the patient and their carers is required when symptoms of breathlessness previously relieved by the drain are no longer being palliated by it.
Nursing management From the practitioner’s perspective it is important to work in partnership with the patient and their family so that they are actively involved in care and decision making. Caring for patients receiving treatment for MPE involves monitoring them for signs of bleeding, increased shortness of breath, and infection. Changes in breath signs can indicate that the effusion is re-accumulating, and the patient may be experiencing discomfort. It is important to prescribe opioid pain medications as there is some evidence that patients’ pain may not be well managed during these procedures. Patients have reported feeling frightened and unprepared for thoracentesis and experiencing pain as the lung expanded during the procedure (Fox et al, 1999; Hughes, 2006). According to Gray (2000), analgesia should be provided prior to thoracentesis, the procedure should be explained to the patient and their relatives, and use of an anxiolytic should be considered. Supplemental oxygen may help the patient’s symptoms by improving hypoxaemia and reducing the workload of the heart and lungs (HeldWarmkessel and Schiech, 2008). Fatigue can be a problem, so the care needs to be planned together with carers so that the patient does not need to expend too much energy until their lung function returns, for example after the lung has re-expanded. To meet nutritional needs small meals at regular intervals are best, comprising high-calorie foods that are easy to swallow (Held-Warmkessel and Schiech, 2008). Use of a fan on the side of the face may reduce feelings of breathlessness. Teaching appropriate positioning and maximal lung expansion is helpful (Bredin et al, 1999). Pursed lip breathing helps to reduce the feeling of breathlessness and helps with
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❛Treatment options for malignant pleural effusion are palliative and are determined predominantly by the patient’s symptoms and performance status.❜
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control of respiratory rate. These techniques can also be taught to carers. The patient needs to be helped to pace themselves so that their activity can be management and their shortness of breath reduced (Joyce et al, 2008). Referral to hospice and other supportive care services will help patients access breathlessness clinics and other resources to maintain a good quality of life and to manage associated symptoms such as dry cough, anorexia, pain, and psychosocial distress (O’Driscoll et al, 1999; Adlard et al, 2001; Department of Heath, 2007). For patients approaching the last days of life, for whom interventional management may not be appropriate, the goals of care are to keep the patient comfortable with drug therapy, including opioids and benzodiazepines, and to provide emotional support for the patient and their family to help them manage the totality of symptoms at the end of life.
Conclusion An MPE generally points to a poor prognosis and developing end-of-life situation requiring palliative care and optimum management of symptoms. Palliation of MPE results in relief of distressing symptoms. In addition to managing breathlessness and pain with opioids, drainage of the fluid will relieve symptoms quickly. Pleurodesis may prevent fluid re-accumulation. A semi-permanent catheter can be placed where pleurodesis is not possible. Adequate supportive care is also a key aspect of successful palliation JPN of symptoms for patients with MPE. I●
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Declaration of interests: none declared. Adlard JW, Joseph J, Brammer CV, Gerrard GE (2001) Open access follow-up for lung cancer: patient and staff satisfaction. Clin Oncol 13(6): 404–8 Allibone L (2008) Assessment and management of patients with pleural effusion. Br J Nurs 17(22): 1382–8 Antony VB, Loddenkemper R, Astoul P et al (2001) Management of malignant pleural effusions. Eur Respir J 18(2): 402–19 Antunes G, Neville E, Duffy J, Ali N (2003) BTS guidelines for the management of malignant pleural effusions. Thorax 58(Suppl 2): ii29–38 Arber A, Spencer L (2013) ‘It’s all bad news’: the first 3 months following a diagnosis of malignant pleural mesothelioma. Psycho Oncology (in press) Braithwaite W (2008) Performing talc pleurodesis in patients with mesothelioma. Nurs Times http://bit. ly/15ii9K2 (accessed 11 July 2013) Bredin M, Corner J, Krishnasamy M, Plant H, Bailey CA, Hern R (1999) Multicentre randomised controlled trial of nursing intervention for breathlessness in patients with lung cancer. BMJ 318(7188): 901–4 British Thoracic Society Standards of Care Committee (2007) BTS statement on malignant mesotherioma in the UK, 2007. Thorax 62(Suppl 2): ii1–9 Cardillo G, Facciolo F, Carbone L et al (2002) Long-term
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follow-up of video-assisted talc pleurodesis in malignant recurrent pleural effusions. Eur J Cardiothorac Surg 21(2): 302–5 Chan K-S, Tse DMW, Sham MMK, Thorsen AB (2010) Palliative medicine in malignant respiratory diseases. In: Hanks G, Cherny NI, Christakis NA, Fallon M, Kaasa S, Portenoy RK (eds) Oxford Textbook of Palliative Medicine. 4th edn. Oxford University Press: 1107–44 Clayson H (2007) The experience of mesothelioma in northern England. MD thesis. Academic Unit of Supportive Care, University of Sheffield, UK Department of Health (2007) Mesothelioma Framework. DH, London Doddoli C, Barlesi F, Fraticelli A et al (2004) Video-assisted thoracoscopic management of recurrent primary spontaneous pneumothorax after prior talc pleurodesis: a feasible, safe and efficient treatment option. Eur J Cardiothorac Surg 26(5): 889–92 Fox V, Gould D, Davies N, Owen S (1999) Patients’ experiences of having an underwater seal chest drain: a replication study. J Clin Nurs 8(6): 684–92 Held-Warmkessel J, Schiech L (2008) Caring for a patient with a malignant pleural effusion. Nursing 38(11): 43–7 Hughes N (2006) The first time I told my story. A phenomenological study of the lived experience of mesothelioma. MSc thesis, University of Surrey, Guildford, UK Gray E (2000) Pain management for patients with chest drains. Nurs Stand 14(23): 40–4 Joyce M, Schwartz S, Huhmann M (2008) Supportive care in lung cancer. Semin Oncol Nurs 24(1): 57–67 Lee YC, Baumann MH, Maskell NA et al (2003) Pleurodesis practice for malignant pleural effusions in five Englishspeaking countries: survey of pulmonologists. Chest 124(6): 2229–38 Light RW (2002) Clinical practice. Pleural effusion. N Engl J Med 346(25): 1971–7 Light RW (2007) Pleural Diseases. 5th edn. Lippincott Williams & Wilkins, Philadelphia, PA Lombardi G, Zustovich F, Nicoletto MO, Donach M, Artioli G, Pastorelli D (2010) Diagnosis and treatment of malignant pleural effusion: a systematic literature review and new approaches. Am J Clin Oncol 33(4): 420–3 Munday H, Rintoul R, Laroche C, Buttery R, Hunter C, Lau-Walker M (2007) Talc pleurodesis: doctor versus nurse-led procedure. A prospective randomised non-inferiority, multi-centre pilot study. J Int Assoc Study Lung Cancer 51(1): 16 O’Driscoll M, Corner J, Bailey C (1999) The experience of breathlessness in lung cancer. Eur J Cancer Care 8(1): 37–43 Olden AM, Holloway R (2010) Treatment of malignant pleural effusion: PleuRx catheter or talc pleurodesis? A cost-effectiveness analysis. J Palliat Med 13(1): 59–65 Parker C, Neville E (2003) Lung cancer 8. Management of malignant mesothelioma. Thorax 58(9): 809–13 Prakash UB, Reiman H (1985) Comparison of needle biopsy with cytologic analysis for the evaluation of pleural effusion: analysis of 414 cases. Mayo Clin Proc 60(3): 158–64 Putnam JB (2002) Malignant pleural effusions. Surg Clin North Am 82(4): 867–83 Sahn SA (2000) Talc should be used for pleurodesis. Am J Respir Crit Care Med 162(6): 2023–4 Stefani A, Natali P, Casali C, Morandi U (2006) Talc poudrage versus talc slurry in the treatment of malignant pleural effusion. A prospective comparative study. Eur J Cardiothorac Surg 30(6): 827–32 Tan C, Sedrakyan A, Browne J Swift S Treasure T (2006) The evidence on the effectiveness of management for malignant pleural effusion: a systematic review. Eur J Cardiothorac Surg 29(5): 829–38 Van Meter ME, McKee KY, Kohlwes RJ (2010) Efficacy and safety of tunneled pleural catheters in adults with malignant pleural effusions: a systematic review. J Gen Intern Med 26(1): 70–6
❛For patients approaching the last days of life ... the goals of care are to keep the patient comfortable ... and to provide emotional support for the patient and their family ...❜
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Malignant pleural effusion in the palliative care setting Anne Arber, Catherine Clackson, Susan Dargan
P Anne Arber is Senior Lecturer in Cancer and Palliative Care, University of Surrey, Guildford, Surrey, GU2 7TE, England; Catherine Clackson is Macmillan Nurse Specialist, Ashford and St Peter’s Hospital NHS Foundation Trust; Susan Dargan is Macmillan Senior Specialist Nurse, Ashford and St Peter’s Hospital NHS Foundation Trust Correspondence to: Anne Arber [email protected]
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leural effusion is a distressing condition that leads to poor quality of life for the patient and their family, causing pain and discomfort; severe breathlessness, especially when lying flat; emotional distress and anxiety; and tachycardia. Malignant pleural effusion (MPE) is present in 15% of patients with advanced cancer (Antony et al, 2001). It is one of the indicators of advanced disease and short life expectancy, with a median prognosis of 3–12 months depending on the stage of the disease and the underlying malignancy. Treatment for MPE is always palliative. The shortest survival is in those with MPE secondary to lung cancer and the longest survival is in those with ovarian cancer (Chan et al, 2010). The most common sources of metastatic tumours to the pleura are lung and breast cancer, which together account for 50–65% of all malignant effusions (Chan et al, 2010). Lymphomas and tumours of the genitourinary tract and gastrointestinal tract account for 25% of MPEs (Chan et al, 2010). Approximately 95% of patients with malignant mesothelioma
Formation of pleural effusion Pleural effusion is an abnormal collection of fluid in the pleural space. Pleural fluid collects in the space between the visceral pleural layer covering the lungs and the parietal pleural layer on the outer side covering the chest wall (Allibone, 2008). Usually there is 20 ml of fluid in the pleural space. This fluid provides lubrication when breathing and the volume is kept balanced by secretion from the parietal pleura and absorption by the visceral pleura via the lymphatic system. Normally up to 10 litres of low-protein fluid flows through the pleural space each day (Light, 2007); fluid only accumulates when there is decreased oncotic pressure, for example caused by reduced serum albumin, or when there is increased pressure in the lymphatic system. The latter occurs when there is direct infiltration by a cancer into the pleural space or metastases in the pleural space causing disruption of the pleural surfaces and inflammation. MPE accounts for 50–75% of all pleural effusions (Antunes et al, 2003).
Presenting symptoms and diagnosis The most common symptoms of MPE are shortness of breath, cough, sometimes a dry cough, an uncomfortable feeling in the chest, and pleuritic pain (Allibone, 2008). Patients may feel short of breath during activity or at rest depending on the size of the effusion. They may also
© 2013 MA Healthcare Ltd
Abstract
Malignant pleural effusion (MPE) is a distressing condition for the patient, causing many symptoms such as shortness of breath, dry cough, an uncomfortable feeling of heaviness in the chest, and pleuritic pain. MPE reduces quality of life and functional status. It indicates that the disease is now advanced and life expectancy is generally short, with a median prognosis of 3–12 months depending on the stage of the disease and the underlying malignancy. This paper discusses the palliative treatment options for MPE, which include thoracentesis, medical pleurodesis, and indwelling pleural catheter. It is important that decisions about treatment are made within the multidisciplinary team and alongside the patient and family. Treatment goals are concerned with the relief or elimination of dyspnoea, restoration of near-normal activity and function, and avoidance of inpatient care. Key words: Breathlessness l Malignant pleural effusion l Pleurodesis l Palliative care l Treatment
will develop a pleural effusion (Parker and Neville, 2003). This paper discusses the palliative treatment options for MPE, which include thoracentesis, medical pleurodesis, and indwelling pleural catheter. It is important that decisions about treatment are made within the multidisciplinary team and alongside the patient and family. Treatment goals are concerned with the relief or elimination of dyspnoea, restoration of nearnormal activity and function, and avoidance of inpatient care.
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Clinical
Table 1. Advantages and disadvantages of different drainage procedures* Drainage procedure
Advantages
Disadvantages
Technically straightforward. Can be performed at home or in outpatient setting.
Temporary measure, impractical if fluid quickly accumulates. Patient finds the procedure distressing. Avoid removal of >1500 ml
Thoracoscopy with talc
High success rate (>90%)
Inpatient procedure requiring surgery. Some potential complications, e.g. post-surgical pain, empyema, respiratory failure. Patients need to have good performance status
Permanent or semi-permanent catheter
Family can help manage catheter at home, achieving more time at home for patient. Can be continuous or intermittent drainage. Placed by interventional radiology or surgery
Local cellulitis most common problem
Chest tube insertion with intrapleural sclerosant
Success rate >60%
Requires hospitalisation. Side effects of sclerosant, e.g. severe pain
Pleuroperitoneal shunt
No external catheter
Occlusion, infection risk, tumour seeding. Patient or carergiver needs to press pump to be effective
Thoracentesis (therapeutic thoracentesis)
suffer with fatigue and chest heaviness. Some patients with a small pleural effusion may be asymptomatic, with the effusion only picked up on routine chest X-ray. Symptoms may arise gradually or with sudden onset. For patients with malignant mesothelioma, pleural effusion occurs in most cases. Therefore, pleural effusion management is a key patient management issue in malignant mesothelioma. A history of worsening dyspnoea, cough, and pleuritic chest pain is suggestive. On physical examination there will be decreased breath sounds, fremitus, and dullness to percussion. Chest X-rays establish the diagnosis of an effusion and identify its extent. Computed tomography may be used when radiography is inconclusive. Effusions can be bilateral or unilateral. Once a diagnosis of pleural effusion is made, a thoracentesis (removal of a sample of the fluid from the pleural effusion) may be done to determine the cause of the fluid accumulation. The fluid may be examined for composition and cytology and a complete cell count culture and sensitivities will be performed if infection is suspected (Light, 2002). In 25% of patients with cancer and recurrent pleural effusion the malignant cells may not be discovered during cytology (Prakash and Reiman, 1985), therefore thoracoscopy with pleural biopsy is more likely to result in a definitive diagnosis.
Clinical management of pleural effusion Treatment options for MPE are palliative and are determined predominantly by the patient’s symptoms and performance status. Performance status is an attempt to quantify cancer patients’ general wellbeing and their ability to perform activities
322
of daily life. It is important to consider the management options that may be preferable for each individual patient. Discussions regarding a patient’s future clinical management usually occur along the patient’s pathway, and in the end-of-life situation this may be alongside an advance care plan. The context for discussions includes the tumour-specific multidisciplinary team meeting, where several qualified practitioners in different specialties including acute services and palliative care discuss a patient’s treatment options; the best or most appropriate route of treatment is then discussed with the patient in an outpatient clinic. The palliation of dyspnoea in MPE is managed by the removal of fluid from the pleural space by the least invasive procedure with minimal morbidity. Drainage of pleural effusion improves symptoms but does not affect survival (Putnam, 2002). The ideal treatment for MPE enables the patient to avoid hospital admission; relieves distressing symptoms, especially breathlessness, with minimal side effects; and results in an improved quality of life that enables the patient to remain at home (Olden et al, 2010). Treatment options to be considered for MPE are identified in Table 1. Therapeutic pleural aspiration (also known as therapeutic thoracentesis) is considered when MPE is symptomatic (Held-Warmkessel and Schiech, 2008). The aim is to relieve breathlessness, determine the contribution of the effusion to symptoms, and assess lung re-expandability. It is the most common procedure for the management of pleural effusion. The amount of fluid aspirated should be limited to 1–1.5 litres each time. The benefits to the patient are that it provides immediate symptom relief and it can be
© 2013 MA Healthcare Ltd
*Adapted from Allibone (2008)
International Journal of Palliative Nursing 2013, Vol 19, No 7
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Clinical
performed as an outpatient procedure or in the patient’s home. It is usually performed for those with a short life expectancy, but the recurrence rate at even just 1 month after pleural aspiration is close to 100%. Repeating pleural aspiration is recommended only for those with a very short life expectancy and a poor performance status. Patient education after a thoracentesis includes monitoring for acute shortness of breath and assessing for signs of pneumothorax and haemoptysis, including changes in heart rate. Other monitoring includes signs of hypoxia, cyanosis, and changes in breath sounds, which could mean that there is re-accumulation of the pleural effusion (Held-Warmkessel and Schiech, 2008). The current standard treatment for MPE is pleurodesis (Van Meter et al, 2010). Medical pleurodesis is recommended for palliation of breathlessness where life expectancy is longer than weeks (Chan et al, 2010). Medical/chemical pleurodesis by chest catheter is used for symptomatic effusions that respond to a therapeutic thoracentesis that allows expansion of the lung and chest wall. Its aim is to cause an irritation between the two layers covering the lung. The procedure involves the insertion of a chest drain and instillation of an intrapleural sclerosant, causing the mesothelial cells to bring about a pleural fibrosis (Sahn, 2000) resulting in the pleurodesis. The instillation of the sclerosant causes irritation and adhesion of the pleural linings and prevents further fluid accumulating. This intervention can be done at the bedside of the patient and involves a variety of agents, including talc and bleomycin. It is useful in managing pleural effusions in patients who are not candidates for video-assisted thoracoscopy. Chemical pleurodesis is effective in recurrent MPE if relief of dyspnoea is evident after thoracocentesis in those with a satisfactory performance status. The sclerosants commonly used are talc, tetracycline hydrochloride, doxycycline, minocycline, bleomycin and Corynebacterium parvum. The preferred sclerosant agent has been found to be talc followed by tetracycline and bleomycin (Lee et al, 2003). A key factor in the treatment of malignant mesothelioma is early intervention in the form of pleurodesis (British Thoracic Society Standards of Care Committee, 2007). This prevents the pleural space from constantly refilling and palliates the patient experience of breathlessness and anxiety. The most common strategy in malignant mesothelioma treatment is pleurodesis through the introduction of talc slurry. Long-term followup of patients having undergone talc pleurodesis has shown positive results (Cardillo et al, 2002).
International Journal of Palliative Nursing 2013, Vol 19, No 7
Box 1. Guidelines for safe practice and administration of a talc pleurodesis* Preparing the patient ●
Explain the procedure fully and offer reassurance
●
Position the patient comfortably in a sitting position with good access to the chest drain and the site
●
Give analgaesia in the form of morphine sulphate 10–20 mg or pethidine 50–100 mg, with an anti-emetic if required. Thereafter, continue with medication regularly as necessary
Draining the effusion ● Any
existing effusion should be completely drained before the procedure and this should be confirmed by X-ray
Preparing the slurry ● The
dose of large-particle talc should not exceed 4 g and will be mixed into a smooth slurry with up to 40 ml of sodium chloride 0.9% solution. Up to 30 ml of 1% lidocaine can be added to the slurry
Preparing the tube ●
Check the chest drain site to ensure correct positioning of the tube
●
Check the outer tube for excessive exudate and flush if necessary
●
Check for drainage levels (effusion should be completely drained)
Administering the slurry ● Administer
the preparation slowly and gently
●
Observe for excessive pain or breathlessness
●
Look for any leakage around the insertion site
●
Clamp the drain for a minimum of 1 hour and a maximum of 4 hours, according to local protocol
● After
this time the drain can be unclamped but should be left in until there is minimal drainage (less than 150 ml in 24 hours)
●
Following the procedure, the chest drain should be flushed with a further 20 ml of sodium chloride to ensure the slurry has been introduced into the cavity and the tube remains patent
Rotation ●
Patient rotation is possibly helpful to ensure good spread of the slurry and is recommended although not seen as essential. If the patient is physically able, encourage movement from side to side every 15–20 minutes while the drain is clamped
Side effects ●
Minor: fever, chest pain
●
Major: adult respiratory distress syndrome (ARDS), respiratory failure
*Adapted from Braithwaite (2008)
Box 1 provides details of nursing care for a patient receiving medical pleurodesis with talc slurry. The slurry is a mixture of sterile talc, sodium chloride, and a local anaesthetic such as lidocaine 1% (Stefani et al, 2006). The mixture is introduced via a chest drain and is useful in patients who wish to avoid surgery or for whom there would be an increased risk of complications. It is a relatively simple procedure and is successful in the treatment of recurrent effusions (Doddoli et al, 2004). It can be performed successfully by nurses as well as doctors, and
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suitably trained and experienced nurses carrying out the procedure is becoming common. Nurses who perform this procedure should have more than 6 months’ experience in respiratory care and should follow evidence-based protocols (Munday et al, 2007). Munday et al (2007) concluded that nurses are as safe and effective as doctors in performing the procedure, and patients are equally satisfied with nurses and doctors. It is very important that an experienced doctor or nurse performs the procedure—in some research patients have reported that having a junior doctor carry out the procedure added to their anxiety (Clayson, 2007). Video-assisted thoracoscopy has many advantages over other surgical procedures as it provides detailed visualisation of the hemithorax, allowing directed biopsies, therapeutic pleurectomies, mechanical and chemical pleuro desis, and improved distribution of the sclerosing agent and catheter placement for drainage (Antunes et al, 2003; Tan et al, 2006). It is an effective approach in patients with a good performance status who are able to undergo more interventional procedures, resulting in effective control of MPE and palliation of distressing symptoms (Arber and Spencer, 2013). Patients have to be fit enough to tolerate general anaesthesia and surgical intervention. They normally have to attend a specialist centre where video-assisted thoracoscopy is carried out, which involves travelling to the specialist centre and hospital admission. MPEs that require repeated thoracentesis or for which pleurodesis has failed can be managed with a tunnelled small-bore indwelling pleural catheter (IPC), such as Carefusion’s PleurX. Treatment goals concern the relief or elimination of dyspnoea, restoration of nearnormal activity and function, and avoidance of inpatient care. This is a new approach that allows management to be continued at home and is one of the least intrusive interventions for the palliative patient. The placement of the indwelling catheter is minimally invasive and can be performed as an inpatient or outpatient procedure (Lombardi et al, 2010). The system involves minimal physician intervention, reduces hospital stay, and improves quality of life for patients with a life expectancy of 2–3 months as it enables more control over their life and more time can be spent at home. However, there are implications for ongoing care, which involves training carers in device management. Every 1–2 days the IPC needs to be connected to a vacuum drainage bottle, which has a safety valve that prevents air entering when draining
the accumulated fluid (Olden and Holloway, 2010). There are also implications for the patient nearing the end of life regarding when to stop draining and knowing which symptoms are related to approaching death rather than to the accumulation of pleural fluid. The issues around discontinuing drainage from an IPC near the end of life are similar to those regarding stopping artificial hydration and nutrition. Patient and carer expectations need to be addressed at the planning stage when offering this approach—i.e. there needs to be an explanation that the approach is palliative, with time-limited benefits. Sensitive discussion with the patient and their carers is required when symptoms of breathlessness previously relieved by the drain are no longer being palliated by it.
Nursing management From the practitioner’s perspective it is important to work in partnership with the patient and their family so that they are actively involved in care and decision making. Caring for patients receiving treatment for MPE involves monitoring them for signs of bleeding, increased shortness of breath, and infection. Changes in breath signs can indicate that the effusion is re-accumulating, and the patient may be experiencing discomfort. It is important to prescribe opioid pain medications as there is some evidence that patients’ pain may not be well managed during these procedures. Patients have reported feeling frightened and unprepared for thoracentesis and experiencing pain as the lung expanded during the procedure (Fox et al, 1999; Hughes, 2006). According to Gray (2000), analgesia should be provided prior to thoracentesis, the procedure should be explained to the patient and their relatives, and use of an anxiolytic should be considered. Supplemental oxygen may help the patient’s symptoms by improving hypoxaemia and reducing the workload of the heart and lungs (HeldWarmkessel and Schiech, 2008). Fatigue can be a problem, so the care needs to be planned together with carers so that the patient does not need to expend too much energy until their lung function returns, for example after the lung has re-expanded. To meet nutritional needs small meals at regular intervals are best, comprising high-calorie foods that are easy to swallow (Held-Warmkessel and Schiech, 2008). Use of a fan on the side of the face may reduce feelings of breathlessness. Teaching appropriate positioning and maximal lung expansion is helpful (Bredin et al, 1999). Pursed lip breathing helps to reduce the feeling of breathlessness and helps with
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❛Treatment options for malignant pleural effusion are palliative and are determined predominantly by the patient’s symptoms and performance status.❜
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control of respiratory rate. These techniques can also be taught to carers. The patient needs to be helped to pace themselves so that their activity can be management and their shortness of breath reduced (Joyce et al, 2008). Referral to hospice and other supportive care services will help patients access breathlessness clinics and other resources to maintain a good quality of life and to manage associated symptoms such as dry cough, anorexia, pain, and psychosocial distress (O’Driscoll et al, 1999; Adlard et al, 2001; Department of Heath, 2007). For patients approaching the last days of life, for whom interventional management may not be appropriate, the goals of care are to keep the patient comfortable with drug therapy, including opioids and benzodiazepines, and to provide emotional support for the patient and their family to help them manage the totality of symptoms at the end of life.
Conclusion An MPE generally points to a poor prognosis and developing end-of-life situation requiring palliative care and optimum management of symptoms. Palliation of MPE results in relief of distressing symptoms. In addition to managing breathlessness and pain with opioids, drainage of the fluid will relieve symptoms quickly. Pleurodesis may prevent fluid re-accumulation. A semi-permanent catheter can be placed where pleurodesis is not possible. Adequate supportive care is also a key aspect of successful palliation JPN of symptoms for patients with MPE. I●
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follow-up of video-assisted talc pleurodesis in malignant recurrent pleural effusions. Eur J Cardiothorac Surg 21(2): 302–5 Chan K-S, Tse DMW, Sham MMK, Thorsen AB (2010) Palliative medicine in malignant respiratory diseases. In: Hanks G, Cherny NI, Christakis NA, Fallon M, Kaasa S, Portenoy RK (eds) Oxford Textbook of Palliative Medicine. 4th edn. Oxford University Press: 1107–44 Clayson H (2007) The experience of mesothelioma in northern England. MD thesis. Academic Unit of Supportive Care, University of Sheffield, UK Department of Health (2007) Mesothelioma Framework. DH, London Doddoli C, Barlesi F, Fraticelli A et al (2004) Video-assisted thoracoscopic management of recurrent primary spontaneous pneumothorax after prior talc pleurodesis: a feasible, safe and efficient treatment option. Eur J Cardiothorac Surg 26(5): 889–92 Fox V, Gould D, Davies N, Owen S (1999) Patients’ experiences of having an underwater seal chest drain: a replication study. J Clin Nurs 8(6): 684–92 Held-Warmkessel J, Schiech L (2008) Caring for a patient with a malignant pleural effusion. Nursing 38(11): 43–7 Hughes N (2006) The first time I told my story. A phenomenological study of the lived experience of mesothelioma. MSc thesis, University of Surrey, Guildford, UK Gray E (2000) Pain management for patients with chest drains. Nurs Stand 14(23): 40–4 Joyce M, Schwartz S, Huhmann M (2008) Supportive care in lung cancer. Semin Oncol Nurs 24(1): 57–67 Lee YC, Baumann MH, Maskell NA et al (2003) Pleurodesis practice for malignant pleural effusions in five Englishspeaking countries: survey of pulmonologists. Chest 124(6): 2229–38 Light RW (2002) Clinical practice. Pleural effusion. N Engl J Med 346(25): 1971–7 Light RW (2007) Pleural Diseases. 5th edn. Lippincott Williams & Wilkins, Philadelphia, PA Lombardi G, Zustovich F, Nicoletto MO, Donach M, Artioli G, Pastorelli D (2010) Diagnosis and treatment of malignant pleural effusion: a systematic literature review and new approaches. Am J Clin Oncol 33(4): 420–3 Munday H, Rintoul R, Laroche C, Buttery R, Hunter C, Lau-Walker M (2007) Talc pleurodesis: doctor versus nurse-led procedure. A prospective randomised non-inferiority, multi-centre pilot study. J Int Assoc Study Lung Cancer 51(1): 16 O’Driscoll M, Corner J, Bailey C (1999) The experience of breathlessness in lung cancer. Eur J Cancer Care 8(1): 37–43 Olden AM, Holloway R (2010) Treatment of malignant pleural effusion: PleuRx catheter or talc pleurodesis? A cost-effectiveness analysis. J Palliat Med 13(1): 59–65 Parker C, Neville E (2003) Lung cancer 8. Management of malignant mesothelioma. Thorax 58(9): 809–13 Prakash UB, Reiman H (1985) Comparison of needle biopsy with cytologic analysis for the evaluation of pleural effusion: analysis of 414 cases. Mayo Clin Proc 60(3): 158–64 Putnam JB (2002) Malignant pleural effusions. Surg Clin North Am 82(4): 867–83 Sahn SA (2000) Talc should be used for pleurodesis. Am J Respir Crit Care Med 162(6): 2023–4 Stefani A, Natali P, Casali C, Morandi U (2006) Talc poudrage versus talc slurry in the treatment of malignant pleural effusion. A prospective comparative study. Eur J Cardiothorac Surg 30(6): 827–32 Tan C, Sedrakyan A, Browne J Swift S Treasure T (2006) The evidence on the effectiveness of management for malignant pleural effusion: a systematic review. Eur J Cardiothorac Surg 29(5): 829–38 Van Meter ME, McKee KY, Kohlwes RJ (2010) Efficacy and safety of tunneled pleural catheters in adults with malignant pleural effusions: a systematic review. J Gen Intern Med 26(1): 70–6
❛For patients approaching the last days of life ... the goals of care are to keep the patient comfortable ... and to provide emotional support for the patient and their family ...❜
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