From the Guidelines
The most effective remedy for a failed pleurodesis with effusion is often the placement of an indwelling pleural catheter (IPC), which provides continuous drainage and symptom relief while potentially achieving spontaneous pleurodesis in patients. This approach is supported by recent guidelines, including the European Respiratory Journal's statement on benign pleural effusions in adults 1. The use of IPC has been shown to be effective in controlling recurrent and symptomatic malignant effusions, with a lower length of hospitalization and a modest improvement in quality of life and dyspnea scores 1.
When considering management options for a failed pleurodesis, several factors should be taken into account, including:
- The patient's performance status and life expectancy
- The underlying cause of the effusion
- Whether the lung can fully expand
- The presence of trapped lung or other complications
Alternative management options may include:
- Repeat pleurodesis attempt using a different sclerosing agent, such as talc, doxycycline, or bleomycin
- Surgical intervention with video-assisted thoracoscopic surgery (VATS) for decortication or pleurectomy
- Medical management with diuretics, such as furosemide, for effusions related to heart failure or hypoalbuminemia
- Thoracentesis, which can provide temporary relief but is not a long-term solution due to recurrence risk and complications with repeated procedures.
It is essential to address the factors that contributed to the initial pleurodesis failure, such as incomplete lung expansion, improper sclerosant distribution, or insufficient inflammatory response, to ensure the best possible outcome for the patient 1.
From the FDA Drug Label
Malignant Pleural Effusion—60 units administered as a single-dose bolus intrapleural injection Although there is no conclusive evidence to support this contention, it is generally accepted that chest tube drainage should be less than 100 mL in a 24-hour period prior to sclerosis However, Bleomycin instillation may be appropriate when drainage is between 100 to 300 mL under clinical conditions that necessitate sclerosis therapy.
If a pleurodesis with Bleomycin fails, the FDA drug label does not provide a specific remedy.
- The label only provides guidance on the administration of Bleomycin for malignant pleural effusion, including the dose and method of administration.
- It does not address the management of failed pleurodesis.
- Therefore, no conclusion can be drawn from the label regarding the remedy for failed pleurodesis with effusion 2.
From the Research
Remedy on Failed Pleurodesis with Effusion
- Failed pleurodesis with effusion can be a challenging condition to manage, and several options are available for treatment 3, 4, 5.
- In patients who are unfit for pleurodesis or have a recurrent malignant pleural effusion (MPE) after chemical pleurodesis, an outpatient intermittent drainage through a subcutaneous tunnelled indwelling pleural catheter (IPC) can be an effective treatment option 3.
- The IPC can provide symptom relief and improve quality of life in patients with end-stage cancers, with a low complication rate 3.
- Talc slurry is a commonly used sclerosing agent for pleurodesis, and its efficacy has been demonstrated in several studies 4, 6.
- However, talc slurry can cause complications such as fever and pain, and its use may be associated with a higher risk of recurrence in certain patient populations 6.
- Alternative sclerosing agents such as doxycycline and erythromycin have been studied, and erythromycin may be a promising option due to its ability to induce maximal fibrosis with minimal inflammation 7.
- The choice of sclerosing agent and treatment approach should be individualized based on patient factors and the specific clinical scenario 5, 6.
Treatment Options
- Indwelling pleural catheter (IPC) for outpatient intermittent drainage 3
- Talc slurry for chemical pleurodesis 4, 6
- Doxycycline solution for chemical pleurodesis 6
- Erythromycin as a potential sclerosing agent 7