What are the contraindications for pleurodesis?

Contraindications for Pleurodesis

The primary contraindications for pleurodesis are trapped lung, inability to achieve complete lung re-expansion, and mainstem bronchial obstruction, as these conditions prevent the necessary apposition of pleural surfaces required for successful pleurodesis. 1

Absolute Contraindications

• Trapped lung/incomplete lung re-expansion: When the lung cannot fully expand to contact the chest wall after fluid drainage, pleurodesis will likely fail 1
• Mainstem bronchial obstruction: Prevents adequate lung re-expansion, making pleurodesis ineffective 1
• Failure of tube thoracostomy to re-expand the lung: If the lung doesn't re-expand after chest tube placement, pleurodesis should not be attempted 2

Relative Contraindications

• Massive pleural effusion with rapid re-accumulation: High risk of re-expansion pulmonary edema if drained too quickly 1
• Short life expectancy: Patients with very limited survival may benefit more from repeated thoracentesis rather than pleurodesis 1, 3
• Poor performance status: Patients may not tolerate the inflammatory response associated with pleurodesis 4
• Active pleural infection: May interfere with successful pleurodesis and increase risk of complications 1
• Corticosteroid therapy: May decrease the efficacy of pleurodesis; should be stopped or dose reduced if possible before the procedure 1

Physiological Contraindications

• Pleural fluid pH < 7.20: Indicates trapped lung and predicts poor pleurodesis success 5
• Pleural pressure drop > 20 cmH₂O per liter of fluid removed: Suggests trapped lung or central bronchial obstruction 5
• Ipsilateral mediastinal shift: Indicates either mainstem bronchial obstruction or trapped lung, making pleurodesis unlikely to succeed 1

Specific Patient Considerations

• Potential lung transplant candidates: Pleurodesis may complicate future lung transplantation procedures 2
• Congestive heart failure: May be a contraindication as the underlying cause of effusion should be treated medically 2

Complications to Consider When Evaluating Contraindications

• Re-expansion pulmonary edema: Risk increases with rapid evacuation of large effusions (>1-1.5L at once) 1
• Respiratory failure and ARDS: Particularly with small particle talc 4
• Pain and fever: Common side effects that may be poorly tolerated in frail patients 1, 4

Clinical Decision Algorithm

1. Assess lung expandability:

   • If chest radiograph shows incomplete lung expansion after drainage, avoid pleurodesis 1
   • If pleural pressure drops >20 cmH₂O/L during drainage, consider trapped lung 5

2. Evaluate airway patency:

   • If bronchoscopy or imaging suggests mainstem bronchial obstruction, pleurodesis is contraindicated 1

3. Consider patient factors:

   • If life expectancy is very short, consider less invasive alternatives 1, 3
   • If on corticosteroids, weigh risks of reducing dose versus pleurodesis failure 1

4. Assess pleural fluid characteristics:

   • If pH <7.20, success rates are lower and alternative approaches may be preferred 5

When pleurodesis is contraindicated, alternative management options include repeated thoracentesis, indwelling pleural catheter placement, or pleuroperitoneal shunting in selected cases 1, 3.