What is the recommended procedure for pleurodesis?

Recommended Procedure for Pleurodesis

Talc is the most effective sclerosing agent for pleurodesis, with a success rate of 93%, and should be administered either as talc slurry through a chest tube or as talc poudrage via thoracoscopy. 1

Patient Selection and Preparation

• Patients selected for pleurodesis should have significant symptoms that are relieved when pleural fluid is evacuated 1
• Complete re-expansion of the lung without evidence of bronchial obstruction or fibrotic trapped lung is essential for successful pleurodesis 1, 2
• Absolute contraindications include trapped lung and mainstem bronchial obstruction, as these prevent the necessary apposition of pleural surfaces 2
• Relative contraindications include massive pleural effusion with rapid re-accumulation, short life expectancy, active pleural infection, and concurrent corticosteroid therapy 2

Procedure for Talc Slurry Pleurodesis

1. Insert a small-bore intercostal tube (10-14 F), which is the recommended initial choice for effusion drainage and pleurodesis 1
2. Drain the pleural space completely to ensure full lung re-expansion 1
3. Confirm complete lung re-expansion and proper tube position with chest radiograph 1
4. Administer premedication with intravenous narcotic and anxiolytic-amnestic agents before the procedure 1
5. Instill lignocaine solution (3 mg/kg; maximum 250 mg) into the pleural space 1
6. Prepare talc slurry by mixing 4-5 g of talc with 50 ml of normal saline 1
7. Instill the talc slurry through the chest tube when minimal or no pleural fluid remains and complete lung expansion is confirmed 1
8. Clamp the chest tube for 1 hour after talc instillation 1
9. Patient rotation is recommended during the clamping period to ensure even distribution of the talc 1
10. After unclamping, maintain the patient on -20 cm H₂O suction 1
11. Remove the chest tube when 24-hour drainage is less than 100-150 ml 1
12. If drainage remains excessive (≥250 ml/24 h) after 48-72 hours, repeat talc instillation at the same dose 1

Procedure for Talc Poudrage via Thoracoscopy

1. Perform thoracoscopy under local anesthesia with conscious sedation or by video-assisted thoracoscopic surgery (VATS) 1
2. Remove all pleural fluid during thoracoscopy 1
3. Ensure complete collapse of the lung for optimal visualization and distribution of talc 1
4. Administer approximately 5 g (8-12 ml) of talc as a powder spray over the pleural surface 1
5. Inspect the pleural cavity after insufflation to ensure even distribution of talc 1
6. Insert a 24-32F chest tube 1
7. Apply graded and progressive suction until daily fluid drainage is less than 100 ml 1

Alternative Sclerosing Agents

If talc is unavailable, alternative agents can be used, though with lower success rates:

• Doxycycline: 500 mg mixed with 50-100 ml of sterile saline, with success rates of 72-80% 1
• Bleomycin: 60 units mixed with 50-100 ml of sterile saline, with success rates of 54% 1, 3

Management of Pleurodesis Failure

• Initial failure may result from suboptimal technique or inappropriate patient selection 1
• Options for management of failed pleurodesis include:
  • Repeat pleurodesis with the same or different agent 1
  • Thoracoscopy with talc poudrage if initial slurry method was used 1
  • Pleuroperitoneal shunting or pleurectomy for patients with good clinical condition 1
  • Repeated thoracentesis for patients with limited life expectancy 1

Common Complications and Management

• Pain and fever are the most common adverse effects of pleurodesis 1
• Chest pain occurs in 14-40% of patients undergoing talc pleurodesis 2, 4
• Fever occurs in approximately 10-24% of patients 2, 4
• Adequate analgesia and antipyretics should be provided to manage these symptoms 2
• Serious complications such as respiratory failure and ARDS are rare but more common with small-particle talc; therefore, large-particle talc is recommended 2, 5

Efficacy Considerations

• Talc pleurodesis has a success rate of approximately 90% at 30 days and 76-80% at 180 days 4
• Thoracoscopic talc poudrage appears to be more effective than bedside talc slurry, with a relative risk of non-recurrence of 1.19 in favor of thoracoscopic approach 6
• Pleural fluid pH and adenosine deaminase levels are independent predictors of talc pleurodesis outcome 7