2. Pleurodesis is a procedure that obliterates the pleural space in order to prevent recurrent pleural effusion or recurrent
pneumothorax.
It is most commonly performed by draining the effusion or intrapleural air and then instilling a chemical irritant into the
pleural space, which induces inflammation and fibrosis. This is known as chemical pleurodesis. As an alternative to
chemical pleurodesis, the pleural space can be mechanically abraded during thoracoscopy or thoracotomy. This is known
as dry abrasion pleurodesis.
INDICATIONS
1 Malignant pleural effusions
2 Refractory nonmalignant pleural effusions
Hepatic hydrothorax
Congestive heart failure
Lupus pleuritis
Nephrotic syndrome
Chylothorax
Yellow nail syndrome
Chronic ambulatory peritoneal dialysis
4. CHOICE OF THE SCLEROSING AGENT
Tetracycline hydrochloride: Tetracycline has a wide range of efficacy (45-77%). It causes severe pain during the procedure, so
heavy analgesia may required.
Doxycycline: The average effectiveness of doxycyline is about 72%.Minocycline: Like doxycycline, minocycline has been proposed
as a replacement for tetracycline: An overall success rate of 86% has been reported in some short series.
Bleomycin: Bleomycin pleuredesis appears to be more effective but main drawbacks are cost and systemic absorption, with risk
of significant toxicity.
Corynebacterium parvum pleurodesis: The average effectiveness is about 75%.
Quinacrine: quinacrine can provoke serious toxicity of the central nervous system when higher doses are used.
Silver nitrate : it is an effective sclerosant, inducing a caustic injury to the mesothelium that results in an effective pleurodesis.
Success rate of silver nitrate pleuredesis is 75 to 90%
5. Talc:
Talc used for pleurodesis is United States Pharmacopea (USP) asbestos free and must meet minimal criteria with
regard to loss on ignition, acid-soluble substances, water- soluble substances, arsenic, lead and heavy metals.
Particle size of tale should be in between 10 to 50 mm.
Most commonly used dose of tale is 2 to 10 gm. The average effectiveness of tale is about 92%
lodopovidone:
lodopovidone is a topical antiseptic that has been used for pleurodesis too. It is an effective, safe, cheap and easily
available agent that may be an alternative to talc, which is the most commonly used agent. A solution containing a
mixture of 20 mL. 10% iodopovidone and 30 mL. normal saline was used to create pleurodesis. An overall success
rate is about 88 to 90%
6. Characteristics of the ideal
sclerosant agent
Low cost
Ample worldwide distribution
Easy to handle and administer
Easy to sterilize
Low indices of pleural infection
No cavity drainage required
No intense pain or discomfort
Minimal, easily controlled morbidity
Near 100% efficacy
7. Pleurodesis is less effective if following factors are present.
Acid pH (< 7.3)
Low glucose level (< 60 mg/dl)
Presence of chylothorax
Presence of lymphangitis
Performance status < 70
Lung entrapment
8. The cellular mechanisms involved in pleurodesis are not yet fully known, but it seems that, besides mesothelial
cells, inflammatory cells recruited from the blood stream (namely neutrophils and mononuclear phagocytes)
play an essential role.
There is also some evidence that the superior effectiveness of talc as sclerosing agent may be related to
phagocytosis of its particles following Instillation into the pleural space.
The recruitment and proliferation of fibroblasts in the pleural space is obviously essential for the process of
pleurodesis
9. PROCEDURE
The patient's medications should be reviewed prior to performing pleurodesis.
use of glucocorticoids and NSAID may decrease the success of chemical pleurodesis, because
pleurodesis requires pleural inflammation and glucocorticoids are potent antiinflammatory
agents.
A chest drain is inserted in all cases with a large bore intercostals tube (24F to 28F) with
underwater seal beg , placed in the fifth intercostal space at the mid axillary line In case of
pleural effusion,
once the daily drain output is reduced to less than 150 ml the patient undergoes pleurodesis.
In cases of pneumothorax complete expansion and the absence of any air is ensured before
instillation of chemicals for pleurodesis.
The chest X-ray is used to confirm complete re-expansion.Pulse, BP and temperature are
measured before the procedure.
Before the procedure pre-medication with IV Tramadol 50 mg is given to all patients.
10. 10 ml of 2% lignocaine in 50 ml of normal saline is administered into the pleural space through the chest tube
and wait for few minutes.
If iodopovidone is used for pleurodesis, take 20 ml of 10% iodopovidone in 30 ml of normal saline and is
administered in the pleural space through the chest tube, followed by clamping of the tube for four hours.
If talc is used for pleurodesis, take 5 gm tale and make a slurry mixed with 50 ml saline and administered in the
pleural space through the chest tube, followed by clamping of the tube for four hours.
Tale slurry distributes poorly; therefore, ask the patient to change his position from supine to prone to right and
left lateral position every 15 minutes.
There is no evidence that such rotation improves the probability of successful pleurodesis
The tube is removed when drainage became less than 150 ml per day, and the chest radiograph continues to
shows re-expansion.
Repeat pleurodesis should be considered if after 48 to 72 hours, drainage remains >150 mL per 24 hours.
11. COMPLICATIONS
. Most common:
Fever
Chest pain,
Gl symptoms
Less common:
Respiratory failure (ARDS)
Cardiac arrhythmias
cardiac arrest
hypotension
Mild systemic inflammatory
reactionEmpyema
Dissemination of talc into extrapulmonary organs
