Tips and tricks in management of pleural effusions by medical pleurodesis: when, why, and how.

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?