Can chest tubes (chest drainage tubes) cause pleurodesis?

Chest Tubes and Pleurodesis: Evidence for Causation

Chest tubes can cause pleurodesis in certain circumstances, particularly when used for drainage of malignant pleural effusions, with success rates ranging from 77% to 98% when combined with sclerosing agents. 1

Mechanism and Evidence

Chest tubes alone rarely cause spontaneous pleurodesis, but they serve as the primary delivery method for chemical pleurodesis agents. The process involves:

1. Drainage of pleural fluid: Complete drainage is essential for successful pleurodesis
2. Instillation of sclerosing agent: Typically talc slurry through the chest tube
3. Inflammatory response: The sclerosant creates aseptic inflammation leading to pleural adhesions

Chest Tube Size and Pleurodesis Success

The ERS/EACTS guidelines highlight important findings regarding chest tube size:

• Large-bore tubes (≥24F) were traditionally used in studies showing high pleurodesis rates 1
• Small-bore catheters (10-12F) have also been used successfully for talc slurry pleurodesis 1
• The RAHMAN study (n=320) demonstrated that small-bore tubes (12F) had lower pleurodesis success rates compared to large-bore tubes (24F), with 30% vs 24% failure rates respectively 1

Technique for Talc Slurry Pleurodesis via Chest Tube

1. Preparation: Mix 4-5g talc with 50ml normal saline 1
2. Administration:
   • Drain pleural space completely
   • Instill talc slurry when radiograph shows minimal fluid and complete lung expansion
   • Clamp chest tube for 1 hour after instillation
   • Consider patient rotation to ensure distribution 1
3. Post-procedure management:
   • Apply 20cm H₂O suction after unclamping
   • Remove chest tube when 24-hour drainage is 100-150ml
   • If drainage remains excessive (≥250ml/24h) after 48-72 hours, repeat talc instillation 1

Success Rates and Factors Affecting Pleurodesis

The literature reports variable success rates:

• Talc poudrage: 77-98% success 1
• Talc slurry: 81% success in one retrospective study of 58 patients 2

Factors affecting success include:

• Complete lung expansion: Essential for successful pleurodesis
• pH of pleural fluid: Lower success rates with pleural pH <7.2 1
• Adequate distribution of sclerosing agent throughout pleural space
• Inflammatory response: Higher inflammatory responses correlate with successful pleurodesis 1

Complications

Common complications include:

• Fever (63% in one study) 2
• Pain during and after the procedure
• Respiratory complications (6-14%)
• Respiratory failure (4-8%)
• Empyema (5%) 2

Small vs. Large Bore Catheters

Studies comparing small and large bore catheters show:

• A retrospective study of 102 patients found no significant difference in recurrence rates between small-bore (12F) and large-bore chest tubes for malignant pleural effusions 3
• However, the RAHMAN randomized trial showed better pleurodesis success with larger tubes 1

Pitfalls and Caveats

1. Trapped lung: Pleurodesis will fail if the lung cannot fully expand to contact the chest wall
2. Incomplete drainage: Residual fluid prevents contact between pleural surfaces
3. Patient selection: Inappropriate patient selection (e.g., patients with trapped lung) leads to pleurodesis failure
4. Tube size: Consider larger tubes (≥24F) when pleurodesis is the primary goal, based on the RAHMAN study findings 1
5. Tube position: Proper positioning is critical for complete drainage and effective pleurodesis

For patients with recurrent or difficult pneumothoraces, chemical pleurodesis should only be attempted if the patient is either unwilling or unable to undergo surgery, as surgical approaches have lower recurrence rates 1.