Pleurodesis

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patient selection

indications for pleurodesis

  • [1] Pleural effusion management:
    • Malignant pleural effusion or nonmalignant pleural effusion (including heart failure, hepatic hydrothorax, nephrotic syndrome, peritoneal dialysis, chylothorax, and lupus). (Folch 2023)
    • General criteria for use of pleurodesis for pleural effusions: (Folch 2023)
      • (1) Symptomatic pleural effusion.
      • (2) Therapeutic drainage causes clinical improvement.
      • (3) Recurrence despite maximal treatment of the underlying condition.
      • (4) Lung re-expansion following drainage.
  • [2] Pneumothorax or persistent air leak: discussed further here 📖

contraindications to pleurodesis

  • ⚠️ Inability to achieve complete lung inflation. Chemical pleurodesis requires that the lung can be fully reinflated and opposed to the chest wall. If it is impossible to completely reinflate the lung (e.g., despite placing the chest tube to suction), then pleurodesis is contraindicated.
    • Pleurodesis can be performed despite an ongoing air leak, provided that complete lung inflation is achievable. (Fishman 2023)
    • Pleurodesis isn't an option for trapped lung (where it's impossible to achieve complete apposition of the visceral and parietal pleura).
  • ⚠️ Poorly functioning chest tube: It is essential that the chest tube is functioning properly.
  • ⚠️ Plans for future thoracic surgery. Pleurodesis may make subsequent thoracic surgery more challenging. This predominantly is relevant for patients who may be lung transplant candidates. Doxycycline could have a slight advantage here, as the degree of pleural symphysis and density of adhesions may be less than with talc. (Fishman 2023)
  • ⚠️ Unresolved pleural space infection.
  • ⚠️ Low pH: pH below 7.15-7.3 predicts failure of pleurodesis (relative contraindication). (Folch 2023)

potential complications

  • Common complications:
    • Chest pain.
    • Fever
      • Usually low-grade.
      • Usually begins 4-12 hours post-procedure and may last up to 3 days.
      • Reported in up to 69% of patients. (Folch 2023)
    • Gastrointestinal symptoms. (Folch 2023)
  • Rare complications:
    • Empyema.
    • Acute lung injury (following talc pleurodesis).
choice & dose of sclerosant administration 

High-quality evidence is lacking to compare various agents. (9432409, 8205870) 

talc

  • Talc is generally believed to be more effective. For malignant pleural effusions, a Cochrane Database network meta-analysis suggested that doxycycline was associated with a higher failure rate than talc, but this was statistically nonsignificant (odds ratio for failure of 2.51, 95% confidence interval 0.81-8.40). (32315458)
  • Talc carries a very low risk of precipitating hypoxemic respiratory failure (including ARDS), due to migration of talc particles out of the pleura. Modern talc preparations that contain a larger particle size have reduced this risk. (Fishman 2023) Risk of respiratory failure may be minimized by:
    • (1) Not exceeding a dose of 5 grams.
    • (2) Avoiding bilateral talc pleurodesis.
    • (3) Avoiding talc administration following significant pleural injury or numerous pleural biopsies. (Folch 2023)
  • Dose of talc:
    • The dose is typically 3-5 grams in 50-200 ml of normal saline, usually 4 grams. (32525474) Four grams may be reasonable for a pleural effusion (to balance efficacy versus the risk of hypoxemic respiratory failure). (23374395)
    • Two grams may be sufficient to treat spontaneous pneumothorax. (Folch 2023)

doxycycline

  • Advantages of doxycycline:
    • (1) Doxycycline might be preferred among patients with a substantial ongoing air leak, due to the theoretical risk that talc could enter the lung parenchyma and cause pneumonitis. However, one study did demonstrate successful utilization of talc in this context. (20172150)
    • (2) Doxycycline may be preferred if the patient is a potential candidate for future lung transplantation (see discussion above).
    • (3) Doxycycline carries no risk of causing hypoxemic respiratory failure.
  • Disadvantages of doxycycline: efficacy may be lower than talc.
  • Dose of doxycycline: Dose may typically be 500-1,000 mg doxycycline in 50-100 ml of normal saline.
protocol for bedside pleurodesis

[1] pretreatment to reduce pain

  • [a] Systemic analgesia:
    • Start acetaminophen prior to the procedure (e.g., 1 gram Q6hr scheduled).
    • Premedicate with opioid analgesia (either PO or IV).
  • [b] Lidocaine should be administered into the pleura ~10 minutes before pleurodesis.
    • Use 3 mg/kg (up to 250 mg maximum dose).
    • 1% lidocaine contains 10 mg of lidocaine per ml. Thus, the dosing of 1% lidocaine is 0.3 ml/kg (up to 25 ml maximum volume).

[2] administration of sclerosant agent

  • Instill the scleosant agent (talc or doxycycline; dose discussed above).
  • Then flush 20 ml of normal saline into the pleural catheter. (32525474)

[3] the next two hours 

  • Clamp the chest tube for two hours.
  • There is no need to rotate the patient in bed.
  • If the patient cannot tolerate chest tube clamping (e.g., due to pneumothorax with air leak), the tube may be hung over an IV pole (to prevent tension pneumothorax, without preventing the sclerosant from immediately draining out of the chest).

[4] suction for 24 hours

  • Open the chest tube and place it on -20 cm suction for at least 24 hours.
  • Suction is essential to achieve maximal apposition of the pleural and the chest wall.
  • Chest radiograph should be performed ~18-24 hours after talc instillation. (32525474)

[5] chest tube removal

  • The chest tube may be removed after >24 hours, after the fluid drainage has decreased to <150-250 ml/day. (Folch 2023, 32525474)
  • For doxycycline: If chest tube output continues to be high (>300 ml/day), consider repeating pleurodesis.
discussion of some additional technical details

pleurodesis via chest tube vs. thoracoscopic surgery

  • There is little evidence that pleurodesis is more effective if performed via surgery, as compared to performed via a chest tube.
    • Pleurodesis may be achieved by applying talc through a chest tube, or via thoracoscopy. A multicenter RCT of malignant pleural effusion found that the success rate was identical regardless of whether talc was introduced via chest tube or thoracoscopy. (31804680) Thoracoscopy had been touted for its ability to distribute talc more widely, but this doesn't seem to matter. Pleurodesis results from a generalized inflammatory reaction in the pleura, rather than from using talc to serve as localized “glue” that holds the visceral and parietal pleura together. (Murray 2022)
  • If a patient requires VATS surgery for some other indication (e.g., bleb resection for pneumothorax, or pleural biopsy), then pleurodesis may be performed at the end of the surgical procedure.

choice of chest tube for pleurodesis

  • Use of a larger bore chest tube (24 French vs. 12 French) was not shown to affect the rate of successful pleurodesis among patients with a malignant pleural effusion. (26720026) 

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