This document discusses the management of a 52-year-old man with stage IV lung cancer and a malignant pleural effusion. It provides guidelines for pleurodesis using sclerosing agents like tetracycline or talc to prevent further fluid accumulation. Complications, techniques, and management of failure are reviewed. Indications for different chest tube sizes and drainage systems are presented.

1. Brian Lee, MD
Internal Medicine Resident
Advisor: Supparerk Disayabutr, MD
Division of Respiratory Disease andTuberculosis,
Department of Medicine,Siriraj Hospital

2.  A 52 year-old man
 NSCLC stage IV S/P palliative chemotherapy
 Progressive dyspnea 1 week PTA
 Physical examination
 RS: trachea in midline; decreased breath sound
and vocal resonance, with dullness on
percussion at entire Rt. hemithorax

3.  Serosanguinous
 Lymphocytic exudate
 Cytology: positive for
malignancy

4.  Observation
 Repeat pleural aspiration
 Chest tube insertion, intrapleural sclerosant
 Thoracoscopy with talc poudrage

5. BTS guidelines for the management of malignant pleural effusions
Thorax 2003;58(Suppl II):ii29–ii38

9.  Indications / contraindications
 Size of chest tube
 Drainage systems
 When?
 Which agent?
 Technique: amount of fluid drainage, rotation?
 Failure: what should we do next?

10.  Malignant pleural effusions
 Benign recurrent pleural effusion
 Chylothorax, pleural effusion associated with connective
tissue diseases, nephrotic syndrome, cardiac failure,
cirrhosis, etc.
 Pleuroperitoneal communication during
long-term peritoneal dialysis

11.  Candidate for lung transplantation
LAM, cystic fibrosis
 Hypersensitivity to sclerosing agent
 Trapped lung
Due to extrinsic or intrinsic tumor, or
encapsulated visceral pleura

12. SMALL (10–14 F)
 Less discomfort
 Radiographical
guidance
LARGE (24–32 F)
 More discomfort
 Less obstruction by
clots
 Optional: 20-24 F
Comparable success rates

13. Patient
Patient
PatientSuction
Thoracic
suction
Thoracic
suction
1st - Reservoir
2nd -
Subaqueous
3rd – Pressure
regulator

14.  Thoracic suction or wall suction: pressure
regulator (3rd) bottle not needed
 Usual suction: check for bubbles in 3rd bottle
 Check drainage system regularly

15.  Release < 1-1.5 L at one time
 Instill agent when CXR shows complete lung
re-expansion
 Suction
 Usually unnecessary
 May be required for incomplete lung expansion,
persistent air leak
 Gradual increase to -20 cmH2O

16.  Risk
- Associated with pleural pressure (Ppl)
- Not necessarily with volume of fluid
removed
- Ppl dropped to < -20 cmH2O
 In common practice : 1,000-1,500 ml *
* Light RW, et al. Am Rev Respir Dis 1980; 121: 799-804.

17.  Instill lidocaine (3 mg/kg; maximum 250 mg)
 Oxytetracycline 10 ml / amp contains
lidocaine 200 mg
 Premedication for anxiety and pain

19.  Most widely used
 Fever (10%) and pleuritic chest pain (30%)
 Dose 1.0–1.5 g or 20 mg/kg
 Oxytetracycline 10 ml / amp = 500 mg +
lidocaine 200 mg
Cancer 1987;59:1973–7.

20.  Magnesium silicate
 Dose 2-5 g
 ARDS, acute pneumonitis with respiratory
failure (<1%)
 Talc poudrage: spray during thoracoscopy
 Talc slurry: suspension form via ICD
No significant difference in success rate

22.  Clamping of ICD 1-2 h
 Rotation of patient
 Not necessary after instilling tetracyclines
 Required when using talc slurry
 Remove ICD when drain < 150-250 ml/day

23.  Medical thoracoscopy with talc poudrage
 Findings
 Thickening of parietal and visceral pleura
 Plaque at medial & lateral part of parietal pleura
 Adhesion at diaphragmatic & upper parietal pleura

25.  Mostly due to incomplete lung expansion
 Causes of failure
 Trapped lung, lung entrapment
 Endobronchial obstruction
 Persistent air leak
 Suboptimal technique, drainage system

27.  Physical examination and CXR: no tracheal or
mediastinal shift, even with large effusions
 During thoracentesis
Symptom (cough, chest pain, -ve pressure)
 Pleural pressure measurement
- Initial pleural pressure
- Pleural elastance

28. Lan RS, et al. Ann Intern Med 1997; 126: 768-74.Light RW, et al. Am Rev Respir Dis 1980; 121: 799-804.

29. Bedside manometry, Peter Doelken MD.
Pleural manometry

31.  Repeat pleurodesis
 Repeat thoracentesis
 Long term indwelling pleural catheter
 Intrapleural fibrinolytic drugs: loculations
 Pleuroperitoneal shunting
 Pleurectomy
What should we do?

34.  A 69 y/o male
 Old pulmonaryTB last 20 years with chronic
productive cough for 4 years
 Dyspnea and right pleuritic chest pain for 3
hours, no fever

35.  V/S:T 37oc, PR 100/min, RR 26/min, BP 110/70
mmHg
 GA: AThai elderly age male, good
consciousness, not pale, no edema, mild
respiratory distress
 RS: trachea shift to the left, decreased breath
sound and vocal resonance at right lung,
hyperresonance on percussion at right lung
 Others : unremarkable

37.  Primary spontaneous pneumothorax
 Secondary spontaneous pneumothorax
 Traumatic pneumothorax
 Iatrogenic pneumothorax

38.  Oxygen and observation
 Simple aspiration
 Intercostal drainage
 Intercostal drainage and medical
pleurodesis
 Surgical pleurodesis

40.  Follow up chest x-ray  lung w as fully
expanded with no air leak
 ICD was removed and pt was discharged
 2 days later, he had sudden dyspnea and
right pleuritic chest pain

42.  Recurrent secondary spontaneous
pneumothorax
 Rx : medical thoracoscopy with talc
poudrage

44.  Primary spontaneous pneumothorax
- Recurrence
- First episode of contralateral pneumothorax
- First episode in risk groups : aircrew, diver, single lung
- Bilateral simultaneous
 Secondary spontaneous pneumothorax*
- Underlying lung diseases eg. COPD, LAM, bullous
disease
- Catamenial pneumothorax
* Controversial issue

45.  Secondary spontaneous pneumothorax
- High recurrent rate (40-50%) if pleurodesis is not
performed
- ACCP consensus : recommendation of chest tube and
pleurodesis for all patients with 1st episode of secondary
spontaneous pneumothorax
- BTS guideline : recommend manual aspiration for small
pneumothorax (but submit that most patients will require
chest tube drainage)
Baumann MH, Strange C, Heffner JE, et al. Chest 2001; 119: 590-602.
Henry M, Arnold T, Harvey J. Thorax 2003; 58 (Suppl 2): ii39-ii52.

46.  Medical pleurodesis
- Indications / contraindications
- Size of chest tube : small or large bore?
- Drainage system
- Appropriate time and sclerosing agent
-Technique
- Success or failure : what should we do next?