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Ovid: Oxford Handbook of Respiratory Medicine

Authors: Chapman, Stephen; Robinson, Grace; Stradling, John; West, Sophie Title: Oxford Handbook of Respiratory Medicine, 1st Edition Copyright ©2005 Oxford University Press > Table of Contents > Part 4 – Practical procedures > Chapter 68 – Pleurodesis Chapter 68 Pleurodesis P.692
Background The aim of pleurodesis is to seal the visceral pleura to the parietal pleura with adhesions to prevent pleural fluid or air accumulating. Successful pleurodesis is dependent upon two factors:

  • 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, which is required to produce pleural fibrosis and adhesions. This may be induced by a chemical sclerosing agent or by pleural abrasion at thoracoscopy.

Indications

  • Recurrent and symptomatic pleural effusion (most commonly as a result of malignancy, although pleurodesis is also rarely used in benign recurrent effusions)
  • Recurrent pneumothorax (due to concerns regarding the long-term safety of intrapleural talc, surgical abrasion pleurodesis is usually the 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, tetracycline, and bleomycin.

  • Talc is the most effective (success rate about 90%), and can be administered either as a slurry via a chest drain or as a poudrage at thoracoscopy, but it carries a risk of inducing ARDS (see later)
  • Tetracycline is successful in about 65% cases
  • Bleomycin has success rates of only 60%, and is expensive.

Other, rarely used agents include doxycycline, minocycline, interferon, interleukins, cisplatin, or the patient’s own blood. Corticosteroids may increase the failure rate of pleurodesis by inhibiting the pleural inflammatory response and development of adhesions, and should be discontinued beforehand. The effect of NSAIDs on the success of pleurodesis is unclear. Technique Most centres will have a written pleurodesis protocol, usually involving pre-medication and intrapleural local anaesthesia. A typical protocol is set out below:

  • Discuss procedure with patient and obtain written consent.
  • Insert chest drain (page 688): small bore (10–14F) chest tubes are sufficient for fluid drainage and pleurodesis, and are more comfortable than larger drains. Flush drain with 20 ml normal saline 6 hourly.
  • Commence heparin 5000 IU bd as prophylaxis against thromboembolism (increased risk following pleurodesis, especially in patients with malignancy).
  • P.693

  • Drain fluid in a controlled manner. There is a small risk of re-expansion pulmonary oedema if large effusions are drained too quickly; control output by clamping drain; aim to drain a maximum of 1 litre/hour.
  • CXR when drain output slows (<150 ml/day):
    • Consider pleurodesis if fluid removed and lung fully or partially expanded on CXR (although success rates are much lower in the setting of an incompletely expanded lung)
    • Consider trial of suction if lung only partially re-expanded. Aim to gradually increase pressure to -20 cm H2O. Use of suction may be limited by pain.

For pleurodesis:

  • 6. Insert IV cannula and attach pulse oximeter.
  • 7. Pleurodesis is often extremely painful. Consider pre-medication with opioid (diamorphine 2.5 mg IV), anti-emetic (metoclopramide 10 mg), and benzodiazepine (midazolam 1–2 mg IV, titrate to conscious level, care in elderly and in patients with respiratory failure). The patient should be comfortable but co-operative.
  • 8. Administer intrapleural local anaesthetic (e.g. lidocaine 3 mg/kg, maximum 250 mg) via the chest drain, as intrapleural administration of sclerosants is frequently painful. Clamp drain and wait several minutes.
  • 9. Administer sterile talc slurry (4 grams talc in 30 ml normal saline).
  • 10. Flush drain with 20 ml saline.
  • 11. Further analgesia if required.
  • 12. Clamp drain for one hour after administration of sclerosant. Then unclamp drain and consider applying suction, -20 cm H2O. Restart drain flushes.
  • 13. Monitor pulse, blood pressure, temperature, respiratory rate, and oxygen saturations half-hourly for two hours and then six hourly.
  • 14. Analgesia and antipyretics as required.
  • 15. Optimal duration of drainage following pleurodesis is unknown; consider drain removal within 12–72 hours if there is adequate drainage of fluid and lung expansion on CXR. Can usually remove tube at 48 hours.
  • 16. In cases of mesothelioma arrange prophylactic radiotherapy for the drain site (total of 21 Gy in 3 fractions over one week). Malignant seeding at drain sites in non-mesothelioma malignant effusions is uncommon and prophylactic radiotherapy is not required.

Complications All sclerosants may cause chest pain and fever as side-effects. Use of sterile talc may rarely (<1%) result in respiratory failure due to adult respiratory distress syndrome, manifest as hypoxia and diffuse pulmonary infiltrates within 48 hours of pleurodesis. The risk appears to be reduced with lower talc doses (<5 grams). Future developments are likely to focus on more effective and safer sclerosing agents for pleurodesis, for example, transforming growth factor-β, which has been demonstrated to produce an effective pleurodesis in rabbits.

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