Pleurodesis

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Pleurodesis

  1. 1. Pleurodesis
  2. 2. • obliteration of the pleural space by inducing adherence of the visceral and parietal layers • by the use of sclerosing agents or surgical abrasion • to treat recurrent pneumothorax or malignant pleural effusion
  3. 3. Prognostic factors for successful chemical pleurodesis • Pleural fluid pH - pH > 7.2 • Glucose level - glucose > 60mg/dl • Changes in pleural pressure during thoracentesis
  4. 4. Mechanism of pleurodesis • A tight and complete apposition between the two pleural layers • Following intrapleural application of the sclerosing agent, - diffuse inflammation - pleural coagulation-fibrinolysis imbalance (favoring the formation of fibrin adhesions) - recruitment and subsequent proliferation of fibroblasts, and collagen production.
  5. 5. • The pleural mesothelial lining is the primary target for the sclerosant and causes the release of several mediators : - interleukin-8, - transforming growth factor-β (TGF-β) - basic fibroblast growth factor. • talc can induce apoptosis in tumor cells and inhibit angiogenesis, thus contributing to a better control of the malignant pleural effusion.
  6. 6. • Talc - Insufflated or slurry - Adv. - Widely available, inexpensive, effective - Ass. with development of ARDS (more common if smaller talc particles are used) • Tetracycline derivatives - Doxycycline, minocycline - Side effect – severe chest pain - Give lorazepam/midazolam and systemic pain medications before inj. Choice of sclerosing agent
  7. 7. • Antineoplastic agents - Bleomycin – less effective than talc or tetracycline derivatives , expensive - Nitrogen mustard –better than bleomycin , cheaper - Mitoxantrone – Adv- binds to cell membranes & remain in pleural space longer Side effect- cardiotoxicity
  8. 8. • Silver nitrate - Very effective - Recurrence of effusion is less - At high conc. – severe side effects. • Iodopovidone - 100ml of 2% iodopovidone - Side effects – intense pleuritic pain, systemic hypotension.
  9. 9. • Other agents - Dried killed Corynebacterium parvum - OK-432 - Quinacrine
  10. 10. Agent of choice: -Malignant pleural effusion treated with tube thoracostomy – doxycycline 500mg or tetracycline 1500mg or minocycline 300mg -Malignant pleural effusion diagnosed during thoracoscopy or at thoracotomy – pleural abrasion or parietal pleurectomy
  11. 11. Intrapleural injection of sclerosing agent • Performed by injecting sclerosant through a chest tube • Size of chest tube – no effect • Chest tube connected to a water-sealed drainage system • The effusion is allowed to drain • Sclerosant injected as soon as lung has expanded
  12. 12. • If lung not expand with tube thoracostomy, pleural fluid can be drained with: - PleurX catheter - Pleuroperitoneal shunt • Catheter then flushed with 50-100ml of saline • Chest tube is clamped for at least 1 hr. • Patient is rotated • Unclamp the chest tube and apply negative pressure
  13. 13. • Suction is maintained for 24hrs until pleural drainage <150ml/day. • Chest tube removed after 96 hrs • In outpatient basis - PleurX - Gravity drainage system of Patz • Facilitates home drainage for suitable ambulatory patients • Provides relief while avoiding hospitalization
  14. 14. Thoracoscopy for pleurodesis • If thoracoscopy is performed for an undiagnosed recurrent pleural effusion – induce a pleurodesis • Best method : mechanical abrasion of pleura • Alternatives- intrapleural instillation of 2% iodopovidone, intrapleural instillation of collagen. • Insufflation of talc- can cause resp. failure and death
  15. 15. Alternatives treatment • Symptomatic treatment - chest pain – analgesics - Dyspnea – opiates or oxygen
  16. 16. • Periperitoneal shunt - In pt. whom lung does not expand after tube thoracoscopy , pleurodesis has failed - Also if chylothorax is present - adv. i. Less hosp. time ii.Less pain iii.Can be performed on outpatient basis iv.Pt may benefit psychologically from using the pump when he is dyspneic
  17. 17. - disadv. i. Shunt becomes obstructed ii.Insertion requires gen. anaesthesia iii.Must be inserted by a surgeon iv.Must use the pump daily
  18. 18. • Pleurectomy 1.In pt who undergoes a diagnostic thoracotomy for an undiagnosed pleural effusion - If malignant disease is found – parietal pleurectomy 2.Symp. pt with a persistent pleural effusion and trapping of ipsilateral lung - Decortication of the trapped lung and parietal pleurectomy
  19. 19. • Thoracentesis - For symptomatic relief - Req. frequent visit to physician - Can lead to loculation of the pleural fluid

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