What are the steps of a pleurodesis?

Steps of Pleurodesis Procedure

The pleurodesis procedure involves a series of specific steps aimed at creating adhesions between the visceral and parietal pleural surfaces to obliterate the pleural space, with talc being the most effective agent with a success rate of approximately 90%. 1, 2

Pre-Procedure Preparation

• Administer small doses of intravenous narcotic and anxiolytic-amnestic agent before the procedure 1
• Ensure complete drainage of pleural fluid/air and confirm complete lung re-expansion radiographically 1, 2
• Verify that 24-hour chest tube drainage is minimal (ideally <100 ml) 3

Chemical Pleurodesis Technique (Talc Slurry Method)

1. Insert a small bore intercostal tube (10-14 F) - Small bore tubes cause less discomfort while maintaining comparable success rates to large bore tubes 1

2. Drain the pleural space completely - Ensure controlled evacuation to avoid re-expansion pulmonary edema:

   • Limit drainage to 1-1.5 L at one time or slow to 500 ml/hour
   • Stop if patient develops chest discomfort, persistent cough, or vasovagal symptoms 1

3. Confirm lung re-expansion - Verify with chest radiograph that the lung is fully expanded and the intercostal tube is properly positioned 1

4. Administer analgesia - Instill lignocaine (3 mg/kg; maximum 250 mg) intrapleurally 1

5. Prepare and instill sclerosant - For talc slurry:

   • Mix 4-5 g of talc with 50 ml of normal saline
   • Gently agitate the mixture
   • Instill through the chest tube 1, 2

6. Clamp the chest tube - Keep clamped for 1 hour after instillation 1

7. Rotate patient - Move patient to different positions (left and right lateral) to ensure even distribution of the sclerosant 1, 3

8. Unclamp and apply suction - After unclamping, maintain the patient on -20 cm H₂O suction 1

9. Monitor drainage and remove tube - Remove the chest tube when 24-hour drainage is 100-150 ml 1

10. Assess for failure - If after 48-72 hours chest tube drainage remains excessive (≥250 ml/24 h), repeat talc instillation at the same dose 1

Thoracoscopic Pleurodesis (Talc Poudrage) Alternative

1. Perform thoracoscopy - Examine the pleural cavity and evacuate fluid completely 2

2. Apply talc directly - Insufflate approximately 5 g (8-12 ml) of talc evenly over pleural surfaces 1, 2

3. Insert chest tube - Place a 24-32 F chest tube 1

4. Apply graded suction - Maintain until fluid drainage is less than 100 ml/day 1

Factors Affecting Success

• Complete lung re-expansion is essential for successful pleurodesis 2
• Pleural pH <7.2 is associated with lower success rates 2
• High tumor burden and few normal mesothelial cells decrease response 2
• Trapped lung or mainstem bronchial occlusion may lead to failure 1

Management of Failed Pleurodesis

• Consider repeat pleurodesis with the same agent 1, 2
• Alternative options include thoracoscopy with talc poudrage, pleuroperitoneal shunting, or long-term indwelling pleural catheter 1, 2
• For terminal patients with short expected survival, repeat thoracentesis may be appropriate 1

Common Complications

• Pain and fever 2
• Respiratory failure (rare) 2
• Systemic inflammation 2
• Re-expansion pulmonary edema from rapid evacuation of large effusions 1

By following these systematic steps, pleurodesis can effectively prevent recurrence of pleural effusions or pneumothorax, with talc providing the highest success rates among available sclerosing agents.