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Pleurodesis 

Pleurodesis
Chapter:
Pleurodesis
Author(s):

Stephen Chapman

, Grace Robinson

, John Stradling

, Sophie West

, and John Wrightson

DOI:
10.1093/med/9780198703860.003.0068
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date: 30 November 2021

General points

Aim of pleurodesis is to seal visceral to parietal pleura with adhesions to prevent pleural fluid or air accumulating. Pleurodesis dependent upon:

  • Lung re-expansion following removal of pleural fluid or air, which allows the apposition of visceral and parietal pleura. This may be encouraged by applying suction to an intercostal drain

  • Inflammation of the pleural surfaces and local activation of coagulation, required to produce pleural fibrosis and adhesions. May be induced by chemical sclerosing agent or by mechanical pleural abrasion at VATS.

Indications

  • Recurrent symptomatic pleural effusion (usually malignant, although pleurodesis also rarely used in benign recurrent effusions)

  • Recurrent pneumothorax (due to concerns regarding the long-term safety of intrapleural talc, surgical abrasion pleurodesis usually procedure of choice in younger patients; chemical pleurodesis may be used as a last resort in older patients who are unfit for surgery).

Chemical pleurodesis

Types of sclerosant

Choice of sclerosing agents varies. The most commonly used agents are sterile talc and bleomycin.

  • Talc most effective (success rate ~90%) and usually well tolerated, although risk of ARDS (see later). Administered either as slurry via chest drain or as poudrage at thoracoscopy, with comparable efficacy

  • Bleomycin has success rates of only 60%

  • Tetracycline successful in 65% cases, but lack of drug manufacture.

Other rarely used agents include doxycycline, minocycline, interferon, interleukins, cisplatin, or patient’s own blood.

Corticosteroids

may increase failure rate of pleurodesis, by inhibiting inflammatory response and development of adhesions, and should be discontinued. Effect of NSAIDs on pleurodesis efficacy unclear.

Technique

Most centres will have written pleurodesis protocol, usually involving premedication and intrapleural local anaesthesia. A typical protocol is set out as follows:

  • Discuss procedure with patient, and obtain written consent

  • Insert chest drain (see Pleurodesis pp. [link][link]): small bore (10–14F) chest tubes sufficient for fluid drainage and pleurodesis and are more comfortable than larger drains. Flush drain with 20mL normal saline 6-hourly

  • Commence LMWH thromboembolism prophylaxis (increased risk following pleurodesis, especially in patients with malignancy)

  • Drain fluid in a controlled manner. Small risk of re-expansion pulmonary oedema if large effusions drained too quickly; control output by clamping drain; drain a maximum of 1.5L per 2h

  • CXR when drain output slows (<150mL/day):

    • Consider pleurodesis if fluid removed and lung fully or partially expanded on CXR (although success rates much lower in the setting of an incompletely expanded lung)

    • Consider trial of suction if lung only partially re-expanded, if pain allows. Aim to increase pressure to –20cmH2O over 2h.

For pleurodesis

  • Insert IV cannula, and attach pulse oximeter

  • Pleurodesis may be extremely painful. Consider premedication with opioid (morphine sulfate solution 2.5–5mg or IV opioid) and anti-emetic (e.g. metoclopramide 10mg). For significant anxiety, consider a benzodiazepine (e.g. midazolam 1–2mg IV, titrate to conscious level; care in elderly and in patients with respiratory failure). The patient should be comfortable but cooperative

  • Administer intrapleural local anaesthetic (e.g. lidocaine 3mg/kg, max 250mg) via chest drain, as intrapleural administration of sclerosants frequently painful. Clamp drain, and wait several minutes

  • Prepare talc slurry. Using sterile technique, aspirate 50mL normal saline into a syringe, and carefully remove plunger while keeping gloved finger over end of syringe. Tip 4–5g sterile talc into syringe, and replace plunger gently. Shake syringe for 2–3min to ensure homogeneous slurry. Administer slurry via chest drain over 1–2min

  • Flush drain with 20mL saline, and restart 6-hourly flushes

  • Further analgesia, if required

  • Clamp drain for 1h after administration of sclerosant. Then unclamp, and consider applying suction, increasing to –20cmH2O over 2h

  • Monitor pulse, BP, temperature, RR, and O2 saturations half-hourly for 2h and then 6-hourly

  • Analgesia and antipyretics, as required

  • Optimal duration of drainage following pleurodesis unknown; consider drain removal within 24–72h if adequate drainage of fluid and lung expansion on CXR. Can usually remove tube at 48h

  • For mesothelioma, arrange drain site prophylactic radiotherapy if large-bore chest drain was used (give total of 21Gy in three fractions over 1 week). Malignant seeding in non-mesothelioma malignant effusions uncommon and prophylactic radiotherapy not required.

Complications

All sclerosants may cause chest pain and fever. Sterile talc may rarely (<1%) result in respiratory failure due to ARDS, manifest as hypoxia and diffuse pulmonary infiltrates within 48h of pleurodesis. ‘Mixed’ talc (containing small particles) appears to be associated with greater systemic inflammation and greater deterioration in gas exchange than ‘graded’ talc (which has small particles removed), so routine use of graded talc is recommended.

Further information

Maskell NA et al. Randomized trials describing lung inflammation after pleurodesis with talc of varying particle size. Am J Respir Crit Care Med 2004;170:377–82.Find this resource:

Roberts ME et al. Management of a malignant pleural effusion: British Thoracic Society pleural disease guideline 2010. Thorax 2010;65(Suppl 2):ii32–ii40.Find this resource: