Clinical Crossroads 29.1.2010

Medical pleurodesis

When, Why and HowBrian Lee, MDInternal Medicine ResidentAdvisor: Supparerk Disayabutr, MDDivision of Respiratory Disease and

Tuberculosis, Department of Medicine, Siriraj Hospital

Case 1 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

Massive Rt. pleural effusion

Serosanguinous Lymphocytic

exudate Cytology: positive

for malignancy

What is your management?ObservationRepeat pleural aspirationChest tube insertion, intrapleural

sclerosantThoracoscopy with talc poudrage

Management of malignant pleural effusions

BTS guidelines for the management of malignant pleural effusionsThorax 2003;58(Suppl II):ii29–ii38

Malignant pleural effusions

Algorithm for the management of malignant pleural effusions.

Problems in medical pleurodesis

Indications / contraindications Size of chest tube Drainage systems When? Which agent? Technique: amount of fluid drainage,

rotation? Failure: what should we do next?

Indications for medical pleurodesis 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

ContraindicationsCandidate for lung transplantation

LAM, cystic fibrosisHypersensitivity to sclerosing agentTrapped lung

Due to extrinsic or intrinsic tumor, or encapsulated visceral pleura

Size of intercostal tube

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

Drainage systemsPatient

PatientPatientSuction

Thoracicsuction

Thoracicsuction

1st - Reservoir

2nd - Subaqueous

3rd – Pressure regulator

Thoracic suction or wall suction: pressure regulator (3rd) bottle not needed

Usual suction: check for bubbles in 3rd bottle

Check drainage system regularly

Lung re-expansion, fluid drainage, suction

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

Reexpansion pulmonary edemaRisk

- 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.

Analgesia and premedications Instill lidocaine (3 mg/kg; maximum

250 mg)Oxytetracycline 10 ml / amp

contains lidocaine 200 mgPremedication for anxiety and pain

Selecting a sclerosing agent

Tetracyclines

Most widely usedFever (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.

Sterile talcMagnesium silicate Dose 2-5 g ARDS, acute pneumonitis with

respiratory failure (<1%)Talc poudrage: spray during

thoracoscopyTalc slurry: suspension form via ICD

No significant difference in success rate

Talc poudrage

Clamping of ICD 1-2 hRotation of patient

Not necessary after instilling tetracyclines

Required when using talc slurryRemove ICD when drain < 150-250

ml/day

Case 1 (continued)Medical thoracoscopy with talc

poudrageFindings

Thickening of parietal and visceral pleura Plaque at medial & lateral part of parietal

pleura Adhesion at diaphragmatic & upper

parietal pleura

Failure of medical pleurodesisMostly due to incomplete lung

expansion

Causes of failure Trapped lung, lung entrapment Endobronchial obstruction Persistent air leak Suboptimal technique, drainage system

Incomplete lung expansion

Trapped Lung

Physical examination and CXR: no tracheal or mediastinal shift, even with large effusions

During thoracentesisSymptom (cough, chest pain, -ve

pressure)Pleural pressure measurement

- Initial pleural pressure- Pleural elastance

Pleural manometry

Lan RS, et al. Ann Intern Med 1997; 126: 768-74.

Light RW, et al. Am Rev Respir Dis 1980; 121: 799-804.

Bedside manometry, Peter Doelken MD.

Pleural manometry

Pleural manometry

Failed medical pleurodesis

Repeat pleurodesis Repeat thoracentesis Long term indwelling pleural

catheter Intrapleural fibrinolytic drugs:

loculations Pleuroperitoneal shunting Pleurectomy

What should we do?

Long term indwelling pleural catheter

Long term indwelling pleural catheter

Case 2 A 69 y/o maleOld pulmonary TB last 20 years with

chronic productive cough for 4 yearsDyspnea and right pleuritic chest pain

for 3 hours, no fever

Physical examinationV/S: T 37oc, PR 100/min, RR 26/min, BP

110/70 mmHgGA: A Thai 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

What is your diagnosis?

Primary spontaneous pneumothorax

Secondary spontaneous pneumothorax

Traumatic pneumothoraxIatrogenic pneumothorax

What is your management?

Oxygen and observationSimple aspirationIntercostal drainageIntercostal drainage and

medical pleurodesisSurgical pleurodesis

Case 2

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

Case 2

Recurrent secondary spontaneous pneumothorax

Rx : medical thoracoscopy with talc poudrage

Indications for medical pleurodesis

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

Indications for medical pleurodesis

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.

Conclusions 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?