Respiratory - Preparing for an Indwelling Pleural Catheter (IPC)

What is an IPC?

An indwelling pleural catheter (IPC) is a small tube that is designed to drain fluid from around your lungs, easily and painlessly, whenever it is needed.

It can stay permanently in place so that you do not need to come to hospital for repeated drainage procedures.

It is a soft flexible tube, which remains inside the chest and passes out through the skin. There is a valve on the end of the tube to prevent fluid leaking out and air passing into the chest. (see figure 1)

Figure 1 – Picture of an IPC when fully dressed and when about to used. Taken from British Medical Journal (BMJ)

Why do I need an indwelling pleural catheter?

The space between the chest wall and the lung is called the pleural space.

It has two thin membranes, one covering the outside of the lung and one lining the chest wall. Normally this space is dry. However, your pleural space has filled up with fluid, so that the lung cannot work properly, and hence the reason for your shortness of breath.

When we drain the fluid from the pleural space, it gives your lung more room to expand, and you will feel less short of breath.

In your case, we feel that the fluid will likely reaccumulate in that space. To save you repeated hospital attendances for further uncomfortable chest drainage, the indwelling pleural catheter will allow us to repeatedly drain the fluid as needed in your home/community.

What does the procedure involve?

This is a day case procedure. We will ask you to lie in a comfortable position. Using an ultrasound machine, we will pick a safe space to insert the drain. We then thoroughly clean the area and inject some local anaesthetic to numb the skin.

We then make two small cuts to make a path for the drain tubing under your skin. We then pass the tubing under your skin and into the pleural space (See figure 2). We will drain some of the fluid immediately and then two stitches will be applied.

You will be able to go home after the procedure. We recommend that someone picks you up and drives you home from hospital.

Figure 1 Diagram showing where an IPC is situated into the chest and how it drains fluid from the space around the lung (pleural space). Image taken from the Cleveland clinic

Who will drain the fluid from my IPC?

It is a very simple procedure to drain the fluid from your pleural space. We attach a specially designed bottle to the end of the tubing, and this will then drain the fluid.

We can either train you and/or family member to drain the fluid, or we can ask the district nurses to come to your house to drain the fluid. If district nurses are required for drainage of the IPC, then your medical team will arrange for this referral on discharge from hospital.

How long can the IPC stay in?

IPCs are designed to stay in permanently (though they can be removed if no longer required). We secure them in place initially with two stitches, which we will ask the district nurses to remove 14 days after the procedure.

In addition, there is a little cuff that sits around the part of the drainage tubing, which sits under the skin. The skin attaches to this cuff as it heals, securing it in place.

Are there any risks to having an IPC?

As with any procedure there are some associated risks, however this is a commonly performed procedure and is considered safe.

In terms of risks associated with the IPC being inserted, the most common risks are:

• Pain on insertion – however it is placed using local anaesthetic to numb the skin and muscles and any pain after the procedure should settle with simple painkillers
• Infection. This is uncommon, affecting 1 in 50 patients. We limit this risk by cleaning the area thoroughly and teaching you good IPC hygiene. However, if you notice redness, oozing or pain around the drain site or feel feverish, please seek medical attention
• Very rarely we can cause bleeding into the pleural space (1 in 500 patients). If this happens, you may need an operation to fix this

The longer terms risks are:

• The main risk is infection. Again, we will show you how to keep the drain clean and teach you how to spot any signs of infection that indicate you may require antibiotic treatment
• Sometimes cancer tissue can affect the area around the indwelling catheter. Please let your doctor know if you develop a lump or pain around the drain site in the weeks following insertion

Can I wash normally afterwards?

You will have a dressing on top of your drain whilst we wait for your stitches to heal. We recommend that you do not get the area wet until the stitches have been removed (14 days) but then you can wash as normal. After a month you will be able to go swimming.

Are there any alternatives to an IPC?

In addition to an IPC, there maybe other options to drain pleural fluid to reduce troublesome symptoms and these can be discussed with your doctor. Other options that maybe suitable could be:

• Repeated pleural aspirations: these have the advantages of avoiding a semi-permanent drain but the disadvantage of likely multiple visits to hospitals and putting you at risk of multiple procedures that can be complicated by pain, bleeding and infection
• Organising an elective admission for something called “pleurodesis”. This means admitting you to a respiratory ward, where a doctor will insert a short-term small drain into the pleural fluid and drain it all out. Then when the lung has re- expanded and all the fluid has gone, we can use sterile talcum powder to stick the lung to the chest wall and prevent fluid from building up again when the drain is removed. This is not suitable for all patients and success rates vary between 60-90%

How do I prepare for my IPC insertion?

As the procedure only requires local anaesthetic, you are safe to eat and drink beforehand.

We need details of all your medications (please bring them with you), allergies and any medical conditions. It is important to let us know in advance if you take blood-thinning medications as we temporarily stop these before your procedure.

Below is a guide on the typical timeframes needed to stop blood thinning medications, but it is vital that these are discussed with your doctor in case any additional treatment, such as temporary injectable medications are needed at the time you stop your tablet blood thinners.

Instructions for blood thinning medications

Warfarin - usually stopped 5 full days before the procedure. You will need an ‘INR’ blood test 1-2 days before the procedure to ensure your ‘INR’ is below 1.5. Please let us know if you are on warfarin and why, as in some situations, we may give you an alternative shorter-acting agent to take instead, in the lead-up to your procedure.

Aspirin – do not take on the day of the procedure.

Clopidogrel/diyridamole/ticagrelor - usually stopped 7 full days before the procedure.

Rivaroxaban/apixaban/dabigatran/edoxaban - usually stopped 2 full days before the procedure.

Low molecular weight heparin injections e.g. Tinzaparin, Enoxaparin, Dalteparin – usually stopped 1 full day before the procedure.

Can the IPC be removed?

An IPC usually stays in place permanently or until all the fluid has dried up. If there has been little or no fluid draining for a few weeks, we will usually ask to see you in clinic and perform an ultrasound scan. If the IPC is no longer needed, we can remove it under local anaesthetic.

Who should I contact if something happens to the tubing?

During working hours, please contact the relevant team at your local hospital:

Salford Royal Hospital - 0161 206 3187

Royal Oldham Hospital - 0161 627 8524

Fairfield General Hospital - 0161 778 3016

Outside of working hours, please attend your nearest Accident and Emergency department.

Any further questions?

You will have the opportunity to discuss these with your doctor or specialist nurse.

Alternatively, you may find the following website helpful: https://mypleuraleffusionjourney.com/