Pleurodesis is a procedure to induce adhesion of the pleural layers to treat recurrent pneumothorax or malignant pleural effusion. It involves using sclerosing agents or surgical abrasion. Talc, tetracycline derivatives like doxycycline, and minocycline are common sclerosing agents used. The procedure involves draining the pleural fluid then injecting the sclerosing agent through a chest tube while the lung is expanded to cause an inflammatory response and formation of fibrous adhesions between the pleural layers.
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. Prognostic factors for successful
chemical pleurodesis
• Pleural fluid pH
- pH > 7.2
• Glucose level
- glucose > 60mg/dl
• Changes in pleural pressure during
thoracentesis
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. • 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. • 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. • 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. • 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.
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. 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. • 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. • 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. 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
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. - disadv.
i. Shunt becomes obstructed
ii.Insertion requires gen. anaesthesia
iii.Must be inserted by a surgeon
iv.Must use the pump daily
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. • Thoracentesis
- For symptomatic relief
- Req. frequent visit to physician
- Can lead to loculation of the pleural fluid
