follow-up appointments [52]. At least one in-­ person visit for suture removal is typically required with a healthcare provider within 2 to 4 weeks after initial placement.

Drainage protocols and algorithms for IPC removal will vary between providers and institutions. The most commonly prescribed IPC drainage regimens include daily, every other day, and symptom-guided drainage. Evaluating patient symptoms and priorities is important when determining an IPC drainage regimen. Based on available information, IPC drainage regimen does not seem to affect patient breathlessness but there is con icting data regarding its impact on quality of life [33, 34]. Daily IPC drainage is associated with shorter catheter-days in many patients, so if IPC removal is a priority, then an aggressive drainage strategy should be used [33, 34, 52].

General recommendations are to decrease drainage frequency when output decreases below a certain volume, often 50–100 mL [53]. If drainage is less than 50-100 mL for at least three consecutive drainage sessions, the next step is to decrease drainage frequency and assess readiness for catheter removal [53]. Review of patient symptoms and chest imaging are recommended prior to IPC removal to differentiate a non-­ draining catheter from successful pleurodesis, especially if an abrupt decrease in pleural uid drainage occurred. Symptomatic pleural effusions may recur in up to 10% of patients after IPC removal requiring future pleural interventions, so this should be discussed with patients prior to removal [32, 54].

IPC-Related Complications and Management

IPC-related complications are rare but can occur as long as the catheter is in situ. A thorough discussion regarding potential complications should be performed with each patient prior to placement so any issues can be promptly identifed in order to minimize associated morbidity and mortality. The most common long-term complications include a non-draining catheter, tract

metastasis and infection [52, 53]. Other complications include catheter fracture, migration out of the pleural space, chest pain, and development of pleural loculations. Contrary to previous beliefs, IPC removal is not always necessary in the setting of a complication and is typically required in less than 10% of patients [54]. Expert-panel recommendations and guidelines for the management of IPCs and associated complications are now available and will be highlighted in the following discussion [52, 53].

When a non-draining catheter is encountered, further investigation should be performed to distinguish between successful pleurodesis and catheter malfunction. A review of drainage trends, patient symptoms, and chest imaging (typically thoracic ultrasound or chest radiography) should be obtained. Chest radiography is easy to obtain, but thoracic ultrasound may be more sensitive at identifying a persistent pleural effusion. Catheter malfunction is the most likely culprit in the setting of abrupt cessation of drainage and persistent respiratory symptoms, especially if chest imaging reveals a persistent pleural effusion. Catheter malfunction has been reported to occur in 5–14% of patients and is typically the result of IPC occlusion with a fbrin clot or the development of pleural loculations [52]. The frst step for the treatment of catheter malfunction is to ush the IPC with sterile saline. If pleural uid drainage does not improve after ushing with saline, then administration of intra-pleural fbrinolytics may be considered, barring any contraindications. Several studies have evaluated the use of various intra-pleural fbrinolytics for the treatment of symptomatic pleural loculations, but alteplase at a dose of 2 to 10 mg is the most reported medication. Most studies show fbrinolytic administration may be successful after a dwell time of 60–120 min, but many patients will require repeat administration. Bleeding is the most common complication of intra-pleural fbrinolysis, albeit rarely (<3%), but individual bleeding risk should be evaluated prior to use [52, 55, 56].

Tunnel tract metastasis is thought to occur from migration of tumor cells from the pleural