What are the types of pleurodesis?

Types of Pleurodesis

Pleurodesis can be broadly categorized into chemical and surgical methods, with surgical pleurodesis being the preferred approach for most clinical scenarios requiring pleural symphysis.

Chemical Pleurodesis

Chemical pleurodesis involves introducing sclerosing agents into the pleural space to create inflammation and adhesion between visceral and parietal pleura:

• Talc pleurodesis - The most effective chemical agent with success rates of 85-92%, available in two forms:

  • Talc slurry: Administered through a chest tube (5g sterile talc in 50-100ml normal saline) 1, 2
  • Talc poudrage: Applied during thoracoscopy, generally preferred over slurry 1, 2

• Tetracycline/Doxycycline - Less effective than talc with higher recurrence rates (16% in surgical pleurodesis), but causes similar levels of pain 1, 3

• Bleomycin - Used primarily for malignant pleural effusions at a dose of 60 units as a single intrapleural injection 4

• Other agents - Povidone iodine, silver nitrate, and autologous blood have been used but with less supporting evidence 5, 6

Surgical Pleurodesis

Surgical approaches create mechanical irritation or remove pleural tissue:

• Mechanical pleural abrasion - Performed during thoracoscopy or thoracotomy, with recurrence rates of approximately 2.3% 1

• Pleurectomy - Removal of parietal pleura, with lower recurrence rates (0.4%) compared to abrasion but potentially higher morbidity 1

• Surgical approaches:

  • Video-assisted thoracoscopic surgery (VATS) - Minimally invasive approach with shorter operating time (33 vs 44 minutes), shorter drainage time (3 vs 5 days), fewer complications (2% vs 7%), and shorter hospital stay compared to thoracotomy 1, 7
  • Open thoracotomy - "Gold standard" with lowest recurrence rates (<0.5%) but higher morbidity (3.7%) 1
  • Transaxillary minithoracotomy - Less invasive than full thoracotomy 1

Indications for Pleurodesis

• Pneumothorax indications:

  • Second ipsilateral pneumothorax
  • First contralateral pneumothorax
  • Bilateral spontaneous pneumothorax
  • Persistent air leak (>5-7 days)
  • Spontaneous hemothorax
  • High-risk professions (pilots, divers) 1

• Malignant pleural effusion - Primary indication for chemical pleurodesis, especially talc 2, 6

Contraindications

• Absolute contraindications:

  • Trapped lung or inability to achieve complete lung re-expansion
  • Mainstem bronchial obstruction 3

• Relative contraindications:

  • Massive pleural effusion with rapid re-accumulation
  • Short life expectancy
  • Active pleural infection
  • Corticosteroid therapy 3

Mechanism of Action

Pleurodesis works through:

• Diffuse inflammation of pleural surfaces
• Coagulation-fibrinolysis imbalance favoring fibrin adhesion formation
• Recruitment and proliferation of fibroblasts
• Collagen production creating permanent adhesions 8

Complications

• Common side effects:

  • Chest pain (27-40%)
  • Fever (24%)
  • Dyspnea (12%) 3, 2

• Serious complications:

  • Acute respiratory distress syndrome (ARDS) - rare but reported with talc
  • Respiratory failure - particularly with small-particle talc
  • Empyema 1, 3

Clinical Recommendations

• For pneumothorax: Surgical pleurodesis is strongly preferred over chemical pleurodesis 1

• For malignant pleural effusion: Talc is the agent of choice with success rates of 60-90% 2

• Technique considerations:

  • Complete lung re-expansion is essential before performing pleurodesis
  • Chest tube drainage should be minimal (<100mL/24h) before chemical pleurodesis
  • Premedication and intrapleural lidocaine (3mg/kg; max 250mg) should be administered before chemical agents 2, 4

• Post-procedure care:

  • BiPAP should be withheld as long as pneumothorax is present 1
  • Avoid non-steroidal anti-inflammatory drugs as they may interfere with pleurodesis effectiveness 6
  • Remove chest tube when 24-hour drainage is minimal (100-150ml) 2