Pleurodesis - Procedure, Indications, Contraindications, and Complications

Introduction

Pleurodesis is the treatment procedure performed to prevent fluid collection in the pleural space. It prevents recurrent pleural effusions and pneumothorax, and it is done to treat persistent pneumothorax. This procedure is very effective in the treatment of pleural effusions.

What Is Pleural Effusion?

Pleural effusion refers to the collection of pleural fluid in the pleural space. Excess fluid buildup causes chest pain, cough, fever, and shortness of breath. It can be caused by various conditions like congestive heart failure, liver cirrhosis, pulmonary embolism, pneumonia, kidney diseases, radiation therapy, lupus, rheumatoid arthritis, esophagus rupture, lung cancer, and breast cancer.

What Is Pleurodesis?

Two pleural membranes cover the lungs. It consists of a parietal pleura (outer membrane) and visceral pleura (inner membrane), with a space between the two membranes called pleural space. 50 ml of pleural fluid is normally present in the pleural space. Excess pleural fluid or air can build up in the pleural space during pathological conditions. Thoracentesis is usually performed to drain the pleural fluid. Pleurodesis is indicated if the fluid accumulation is recurrent. The pleurodesis procedure can be chemical or mechanical. This procedure is done to stick the parietal and visceral pleura to obliterate the pleural space and prevent fluid accumulation.

How Is Pleurodesis Performed?

Pleurodesis can be a chemical or mechanical procedure.

1) Chemical Pleurodesis - Chemical pleurodesis involves using a sclerosing agent to obliterate the pleural space. It is performed under local anesthesia. It is a painful procedure, and the patients are premedicated with analgesics. A small incision is made on the chest, and a narrow chest tube is inserted. The fluid is then drained into a bag, and the sclerosing agent is administered via a small or large bore chest tube or a catheter.

The sclerosing agent coats the lungs and creates a sticky surface which induces pleural inflammation and fibrosis and obliterates the pleural space. In addition, it produces cytokines and adhesion molecules like interleukin - 8, vascular endothelial growth factor, and transforming growth factor-beta and induces inflammation and adhesion of the pleural membranes. Various sclerosing agents are used for chemical pleurodesis.

This includes talc, Tetracyclines, silver nitrate, Iodopovidone, Bleomycin, Corynebacterium parvum, Erythromycin, Fluorouracil, interferon beta, autologous blood, Mitomycin C, Cisplatin, Cytarabine, Doxorubicin, Etoposide, Bevacizumab, and Streptococcus pyogenes A3.

Talc is the commonly used sclerosing agent. It is a hydrated magnesium silicate that contains calcium, aluminum, iron, and lead. Tetracycline derivative Doxycycline is the second common sclerosing agent. Other sclerosing agents are commonly used. It is preferred in patients who cannot undergo thoracoscopy. Chest radiographs are taken after 24 hours to check for pneumothorax or fluid accumulation.

2) Mechanical Pleurodesis is a surgical procedure performed under general anesthesia during video-assisted thoracoscopy or thoracotomy. It involves mechanical abrasion of the parietal pleura using a scratch pad.

3) Pleurectomy involves radical total or subtotal resection of the parietal and visceral pleura and removal of the fibrous pleural rind (decortication). This is done to control malignant pleural effusions in those patients with failed chemical pleurodesis. It is a major surgical procedure with morbidity and mortality. It is done for patients who are fit for surgery. In advanced lung cancer patients, a catheter is placed between the pleural space and the outside of the body. This alternative to pleurectomy allows the patient to drain the fluid buildup at home.

What Are the Indications for Pleurodesis?

Indications for chemical pleurodesis and mechanical pleurodesis are similar, which include:

• Malignant pleural effusions.

• Recurrent pleural effusion.

• Recurrent primary and secondary pneumothorax.

• Chronic ambulatory peritoneal dialysis.

• Chylothorax.

• Nephrotic syndrome.

• Lupus.

• Hepatic hydrothorax.

• Heart failure.

• Pneumonia.

• Tuberculosis.

• Liver and kidney diseases.

• Inflammation of the pancreas.

What Are the Contraindications for Pleurodesis?

Pleurodesis is successful when physical contact is established between the visceral and the parietal pleura. Trapped lung or insufficient drainage interferes with complete lung expansion and fails pleurodesis. A device called pleural manometry is used to identify unexpandable lungs. Other contraindications are thoracic irritation, chest tube duration of more than ten days, more than 150 ml of fluid output, pleural infection, and patients with a life expectancy of less than three months. It is not indicated for patients with cystic fibrosis because lung transplantation becomes difficult after pleurodesis.

What Are the Complications of Pleurodesis?

The possible complications include:

• Infection.

• Fever.

• Pain.

• Empyema (collection of pus in the pleural space).

• Collapsed lung.

• Injury to the chest wall, the lungs, or blood vessels.

• Formation of blood clots (pulmonary embolism).

• Anaphylactic reactions to sclerosing agents.

• Displacement of the chest tube.

• Redness or swelling around the incision site.

• Bleeding.

• Shortness of breath.

• Systemic inflammation and acute respiratory distress syndrome due to the systemic absorption of talc.

• Atelectasis (collapse of lungs) due to anesthesia.

Mesothelial cells play an important role in an inflammatory response. It secretes inflammatory mediators essential for fibrosis. The presence of a tumor decreases the mesothelial cells and interferes with the inflammatory response. The type of tumor also plays a role. Diffuse mesothelioma and metastatic carcinomas produce an inadequate response.

What to Expect With Pleurodesis?

The chest tube is left in place 24 - 48 hours after the procedure. Routine X-rays are essential to check the progress. Once the chest tube is removed, it is essential to clean the wound. Drainage from the wound may be present for one or two days. It can be covered with a bandage. Instructions given by the doctor should be followed.

The doctor gives instructions like:

• Change the dressing daily.

• Do not rub the wound, as it slows down the healing process.

• Avoid taking a bath till the incision heals.

• Avoid taking medications for a longer time than that prescribed by the doctor.

• Avoid lifting heavy objects.

• Avoid holding your breath.

Consult the doctor for swelling or pain around the wound, pus drainage, bleeding, or fever.

Conclusion

Pleural effusions produce life-threatening complications. Pleurodesis is an effective treatment procedure in the management of recurrent pleural effusions. Patients perform well after pleurodesis with improvement in lung function. Pleurodesis is a complex procedure with a multidisciplinary approach, and the success of this procedure depends on various factors. Nevertheless, it offers a permanent solution compared to other procedures for treating pleural effusions.