Speaker's Highlight

• Don Sin University of British Columbia, St. Paul Hospital (Canada)
  Kenneth R. Chapman Toronto General Hospital Research Institute (Canada)
• Parameswaran Nair McMaster University (Canada)
  Carolyn Calfee UCSF (U.S.A.)
• Gregory P. Downey University of Colorado School of Medicine (U.S.A.)
  David A. Schwartz University of Colorado School of Medicine (U.S.A.)
• Neil Schluger Tuberculosis Control Branch, California Department of Public Health (U.S.A.)
  Nick Kim Critical Care & Sleep Medicine, University of California San Diego (U.S.A.)
• Nicola Hananiah Baylor College of Medicine (U.S.A.)
  Jae-Joon Yim Seoul National University College of Medicine (Republic of Korea)
• Koichiro Asano Tokai University School of Medicine (Japan)
  Diahn-Warng Perng Taipei Veterans General Hospital (Taiwan)
• Konstantinos Kostikas University of Ioannina (Greece)
  Karin Klooster University Medical Center Groningen (Kingdom of the Netherlands)

• Innovations in pleural catheter drainage for malignant effusions

  Malignant pleural effusions (MPE) are common complications of advanced thoracic and extrathoracic cancers, frequently presenting with dyspnoea, cough, and reduced exercise tolerance. In Australia, mesothelioma remains a particularly pressing concern because of the legacy of Wittenoom asbestos mining, and the country continues to record some of the highest mesothelioma incidence rates worldwide alongside lung cancer. Management of recurrent malignant effusions therefore occupies a meaningful share of respiratory and palliative care practice across the country.

  Recent advances in catheter design, drainage protocols, and combination intrapleural therapy have reshaped how clinicians approach symptomatic malignant effusions. This article reviews contemporary innovations for the audience of APSR 2022, with attention to Australian clinical realities, reimbursement pathways, and rural and remote care considerations.

  Evolution of tunneled indwelling pleural catheters

  Tunneled indwelling pleural catheters (IPCs) were developed to enable ambulatory drainage at home, thereby shortening or avoiding hospital admissions. Early devices such as the PleurX and Denver catheters established the design principles of a silicone tube with a polyester cuff that encourages tissue ingrowth and lowers dislodgement risk.

  Modern IPCs are now manufactured by several companies, with devices typically listed on the Australian Register of Therapeutic Goods (ARTG) following TGA assessment. Clinicians in metropolitan centres such as Sydney's Royal Prince Alfred Hospital or Brisbane's Princess Alexandra Hospital can usually obtain devices within standard procurement timelines, while rural centres may rely on coordinated ordering through state-wide pleural services.

  Symptomatic improvement has been reported in roughly 80 to 95 percent of recipients, with benefits particularly evident in patients with trapped lung or failed pleurodesis. For patients living in communities like Kalgoorlie, Broken Hill, or Mt Isa, an IPC can spare the fatigue of long road or commercial transfers for repeat drainage procedures.

  Smart drainage systems and digital monitoring

  The newest generation of pleural catheters incorporates pressure sensors, and wireless interfaces. Pressure sensors at the catheter tip enable pleural manometry during drainage, helping clinicians recognise early signs of trapped lung or impending re-expansion pulmonary oedema. Companion modules relay intrapleural pressure and drainage volume to a paired device or clinician dashboard.

  These platforms also support patient self-management. Drainage kits with prefilled evacuated bottles and disposable vacuum canisters are paired with a smartphone application that logs sessions and flags abnormal trends. Early adopters at Peter MacCallum Cancer Centre and Austin Health in Melbourne, together with Westmead and Royal Adelaide Hospital collaborators, are evaluating whether continuous monitoring can reduce unnecessary drainage frequency and detect complications sooner.

  Australian investigators have helped drive this evidence base through registries and prospective cohorts coordinated by the Thoracic Society of Australia and New Zealand (TSANZ). Studies combining digital drainage data with patient-reported outcomes are providing the granularity needed to refine ambulatory protocols and benchmark against international cohorts.

  Drug-eluting catheters and intrapleural therapy

  A growing area of interest is combining mechanical drainage with catheter-delivered intrapleural therapy. Drug-eluting coatings or dedicated infusion ports permit fibrinolytics, immunotherapies, or targeted agents to reach the pleural space at sustained high concentrations while limiting systemic exposure.

  For malignant mesothelioma, where Australian clinicians manage a comparatively large caseload, intrapleural chemotherapy and newer intrapleural immunotherapy approaches are under investigation. Catheter-based delivery avoids repeated pleural puncture and supports outpatient administration, which aligns with Australia's distributed care model and the reach of services like the Royal Flying Doctor Service for remote follow-up.

  Combination protocols pairing an IPC with talc slurry, intrapleural chemotherapy, or fibrinolytics for symptomatic relief in non-expandable lung have produced encouraging pilot data. Larger multicentre studies in the ANZ region are now testing whether catheter-based combination therapy can shorten the time to pleurodesis or extend the interval between drainage episodes.

  Ambulatory care pathways in the Australian context

  Ambulatory IPC management aligns naturally with the structure of Australian healthcare. Public hospital insertion attracts Medicare Benefits Schedule (MBS) rebates, and outpatient drainage consultations are covered when delivered by specialists or credentialed nurse practitioners under MBS arrangements. Private health funds typically cover device hardware for privately insured patients in private hospitals.

  Telehealth has become a routine adjunct since the COVID-19 era. Nurses from specialist pleural services in Melbourne, Sydney, Adelaide, and Perth coordinate virtual reviews with patients in regional and remote towns, including Katherine, Whyalla, and Warrnambool. Drainage diaries uploaded through patient portals allow clinicians to titrate drainage frequency without requiring travel.

  Outreach nursing, community palliative care teams, and linkages to general practitioners further support home drainage. Patients who identify as Aboriginal or Torres Strait Islander may benefit from culturally safe care delivered through Aboriginal Community Controlled Health Organisations, which can liaise with tertiary respiratory teams to ensure continuity across vast distances.

  Patient selection and outcome measurement

  Careful patient selection remains essential to good outcomes. Suitable candidates typically have a life expectancy measured in weeks to months, symptomatic recurrent effusions, and adequate social or clinical support for self-drainage. Trapped lung, heavily loculated effusions, or extensive pleural rind may favour alternative strategies such as indwelling pleural catheter with fibrinolytics or surgical decortication.

  Validated outcome tools are increasingly embedded in Australian services. Dyspnoea visual analogue scales, modified Borg dyspnoea score, and pleurodesis success rates are reported in many centres. Patient-reported measures such as the EORTC QLQ-LC13 lung cancer module and the more general EQ-5D-5L capture quality of life and symptom burden. Local registries coordinated through TSANZ are harmonising these outcomes for benchmarking across states.

  Shared decision-making conversations between patient, family, respiratory physician, oncologist, and palliative care clinician clarify expectations about drainage frequency, infection risk, signs of catheter dysfunction, and end-of-life planning. Documenting these discussions in the medical record supports continuity across the fragmented geography of Australian healthcare.

  Regulatory and reimbursement landscape

  The Therapeutic Goods Administration (TGA) regulates pleural drainage devices as medical devices, with most contemporary IPCs and digital drainage kits listed on the ARTG after conformity assessment. This pathway gives Australian clinicians early access to devices already established in North America, Europe, and parts of Asia.

  Reimbursement is split across several channels. The Pharmaceutical Benefits Scheme (PBS) does not generally fund catheter hardware, but inpatient insertion, image-guided insertion, and outpatient specialist review attract MBS items. Private health insurance funds may cover device costs in private hospital settings, while public patients receive devices under hospital cost centres without out-of-pocket expense.

  Australia's contribution to the global evidence base is notable. Investigator-led multicentre studies on tunneled IPCs, trapped lung management, and digital drainage platforms have shaped international guidelines. The combination of a strong clinical trials network, a universal public insurance scheme, and an engaged thoracic society means new technologies can be adopted, audited, and refined within a single coordinated system.

  The trajectory of malignant pleural effusion care is unmistakably toward integrated platforms that combine drainage, sensing, and targeted intrapleural therapy. For clinicians at APSR 2022, the practical takeaway is that catheter-based management has moved into a stage where technology, evidence, and Australian reimbursement structures together enable high-quality ambulatory care for almost any patient, regardless of postcode. The opportunity ahead lies in sustaining multicentre collaboration, ensuring equitable access in remote Australia, and continuing to pair novel devices with rigorous patient-centred outcome measurement.

  Richard Russell Nuffield Department of Clinical Medicine, University of Oxford (United Kingdom)
• Mona Bafadhel King’s College London (United Kingdom)
  David Jackson Guy’s and St Thomas’ Hospital, King’s College London (United Kingdom)
• James Chalmers University of Dundee (United Kingdom)
  David Price University of Aberdeen (United Kingdom)