Key Definitions

  • Malignant pleural effusion: accumulation of fluid in the pleural space with malignant cells within it; may cause severe dyspnea, chest tightness, pleuritic pain, and cough
  • Parietal pleura: membrane that lines the inner chest wall Pleural space: space between the two pleura; normally contains 5–20 ml of fluid that acts as a lubricant to allow the membranes to move without resistance during respiration
  • Visceral pleura: membrane that covers the lung

Malignant pleural effusion is a frequent and often morbid side effect of advanced metastatic disease, and its symptoms may cause anxiety and emotional distress for patients as well as their families. By the time a pleural effusion develops, patients often are near the end of life, so the goal of treatment is usually to ease symptoms and maintain quality of life. Treatment options include thoracentesis, chemical sclerosis/talc pleurodesis, chemotherapy, radiation, and placement of a long-term indwelling catheter such as Tenckhoff or Pleurx®. In their article in the February 2010 issue of the Clinical Journal of Oncology Nursing, Walker and Bryden discussed the nursing care of patients with Tenckhoff catheters.

Catheters for Drainage

A Tenckhoff catheter is a translucent silicone rubber tube with multiple drainage holes, a radiopaque stripe down its length, and a Dacron cuff. The catheter is implanted in the pleural space, tunneled through the subcutaneous tissue, and brought out through a skin exit wound. Fibrin will grow onto the cuff, securing the catheter in place while creating a barrier between the outside of the chest cavity and the pleural space. A MaxPlus adapter is luer locked on the end of the catheter to facilitate the drainage access process. A similar system is the Pleurx catheter, but it is not used in the authors’ institution. Although the Tenckhoff and Pleurx catheters have equally positive patient outcomes, in the authors’ experience the Tenckhoff system is about one-fourth the cost of the Pleurx catheter. Tenckhoff catheters can often be placed on an outpatient basis under local or general anesthesia. All patients with Tenckhoff catheters require community nursing care when discharged; if this cannot be arranged in advance, patients may need to be admitted after the procedure.

Side Effects of Catheters

Lung reexpansion (either partial or complete) after the catheter is inserted may cause coughing and pain. Pulmonary edema and oxygen desaturation are less common but will develop shortly after the procedure while the patient is still in the hospital. Removing too much fluid too quickly may cause side effects such as hypotension or circulatory collapse. Healthcare providers should monitor vital signs and respiratory status closely. Because this is a closed, sterile system, if the lung has an air leak the drainage bag may fill with air. The air must be released manually because it can cause temporary subcutaneous emphysema, which is uncomfortable for the patient but not life threatening. Patients and caregivers should be instructed on how to release the air should the condition occur after discharge.

Catheter Care and Maintenance

Tenckhoff catheters must be cared for using aseptic techniques. The authors recommend using a needleless system when possible. At the authors’ institution, daily community nursing visits begin immediately following placement of a catheter. During the visits, nurses instruct patients and their families in catheter care procedures. The visits will continue until the nurses find that the patients and/or caregivers are able to manage the care on their own. If patients do not have family caregiver support or cannot care for the catheter on their own, a community nurse will continue to provide all necessary care. The drainage schedule may vary depending on how much fluid the patient produces. For drainage guidelines and additional information on drainage procedures, refer to the full article by Walker and Bryden. At the authors’ institution, MaxPlus adapters are changed every seven days or more frequently as needed (e.g., if blocked). If an alternate adapter is being used, follow the manufacturer’s guidelines for changing. The incisions from the catheter insertion will require as-needed dressing changes. The posterior incision has dissolvable sutures, but the visiting nurse may need to remove a suture from the anterior incision 7–10 days after the procedure. The incisions should be monitored for signs of infection and inflammation. Patients should keep the site dry for the first two weeks after insertion. Patients will require a follow-up visit with the surgeon two to four weeks after the catheter is placed. If the pleural effusion resolves and no drainage occurs for at least three consecutive weeks, the catheter may be removed. This is an outpatient procedure done under local anesthesia. For more information on Tenckhoff catheters for malignant pleural effusions, including a quick reference for troubleshooting complications, refer to the full article by Walker and Bryden.

Five-Minute In-Service offers readers a concise recap of full-length articles published in the Clinical Journal of Oncology Nursing (CJON) or Oncology Nursing Forum. This edition summarizes “Managing Pleural Effusions: Nursing Care of Patients With a Tenckhoff Catheter” by Susan J. Walker, RN(EC), MN, and Gina Bryden, RN, BA, MAEd, which was featured in the February 2010 issue of CJON. Questions regarding the information presented in this Five-Minute In-Service should be directed to the CJON editor at CJONEditor@ons.org.

Receive free continuing nursing education credit for reading the full version of this Clinical Journal of Oncology Nursing article. To access the test, visit http://evaluationcenter.ons.org.