Is Betadine (povidone-iodine) used for pleurodesis?

Betadine (Povidone-Iodine) for Pleurodesis

Povidone-iodine is an effective and safe alternative sclerosing agent for pleurodesis, with success rates comparable to talc (88-98% vs 90-93%), though it is not mentioned in major Western guidelines and talc remains the gold standard first-line agent. 1, 2

Evidence Quality and Guideline Position

The British Thoracic Society and American Thoracic Society guidelines do not include povidone-iodine among recommended sclerosing agents, listing only talc (90-93% success), bleomycin (61% success), and doxycycline (76-85% success) as established options. 3, 4, 5 This absence from Western guidelines reflects limited adoption in the UK and US, despite extensive use in other regions.

However, recent high-quality evidence demonstrates povidone-iodine's efficacy:

• Meta-analysis of 265 patients: 90.6% overall success rate (95% CI 86.4-93.8%), independent of indication (pleural effusion 88.5% vs pneumothorax 93.5%) or delivery method (tube thoracostomy 87.5% vs thoracoscopy 94.2%). 2
• 2024 systematic review: Concluded povidone-iodine is "equally efficacious" to talc for malignant pleural effusions with comparable safety profile. 1
• Prospective series of 61 procedures: 98.4% success rate with only 18% adverse events, predominantly mild chest pain. 6

Administration Protocol

When using povidone-iodine for pleurodesis:

• Dose: 20 mL of 10% povidone-iodine solution mixed with 80 mL normal saline and 2 mg/kg lidocaine (maximum 250 mg). 6
• Pre-requisites: Complete lung re-expansion confirmed on chest radiograph; trapped lung and mainstem bronchial obstruction are absolute contraindications. 7, 5
• Premedication: Administer intravenous narcotic analgesia and anxiolytic before instillation. 5
• Instillation technique: Inject through chest tube after complete pleural drainage. 6
• Clamping: Clamp chest tube for 1-2 hours after instillation. 2, 6
• Patient rotation: Not definitively established for povidone-iodine, though rotation is not necessary for tetracycline-class agents. 3
• Tube removal: When drainage <150-200 mL/24 hours and lung remains expanded. 5, 6

Safety Profile

Povidone-iodine demonstrates excellent tolerability:

• Common side effects: Chest pain (16-18% of procedures), typically mild and self-limited. 2, 6
• Fever: Occurs in approximately 10% of patients. 8, 9
• Serious complications: Extremely rare. One case of pleural empyema reported in 61 procedures (1.6%). 6
• No ARDS risk: Unlike talc, which carries a small (<1%) risk of acute respiratory failure, no respiratory failure has been reported with povidone-iodine. 3, 2
• Systemic effects: Transient hypotension reported in only 3 patients across all studies. 2
• No procedure-related mortality documented in any published series. 2, 6

Clinical Advantages

Cost-effectiveness: Povidone-iodine is significantly less expensive than bleomycin and readily available worldwide, making it particularly valuable in resource-limited settings. 8, 9, 1

Ease of administration: Can be administered at bedside through small-bore catheters without requiring operating room or specialized cytotoxic drug handling. 1, 2

Broad applicability: Effective for both malignant pleural effusions and recurrent pneumothorax. 2

Critical Comparison with Standard Agents

Talc remains superior as first-line: With 90-93% success rates and extensive guideline support, talc should be used when available and appropriate. 3, 4, 5 Povidone-iodine achieves comparable efficacy (88-98%) but lacks the extensive validation and guideline endorsement of talc. 1, 2

Advantages over bleomycin: Povidone-iodine costs substantially less than bleomycin (which costs approximately £68.75 per 60-unit dose) while achieving superior success rates (90.6% vs 61%). 3, 4, 2

Advantages over doxycycline: Single instillation typically sufficient with povidone-iodine, whereas doxycycline often requires multiple administrations, prolonging tube dwelling time and increasing infection risk. 3

When to Consider Povidone-Iodine

Primary indications:

• Talc unavailable or contraindicated. 1
• Resource-limited settings where cost is prohibitive for bleomycin. 8, 9
• Bedside pleurodesis preferred over thoracoscopy. 2
• Patient has contraindications to talc (concern for ARDS in compromised respiratory status). 3, 2

Critical Pitfalls to Avoid

Never attempt without confirming lung re-expansion: Trapped lung will result in complete failure regardless of sclerosant choice. 7, 5

Do not omit adequate analgesia: Despite lower pain rates than some agents, 16-18% still experience significant chest pain requiring immediate management. 2, 6

Recognize guideline limitations: The absence of povidone-iodine from Western guidelines reflects geographic practice patterns rather than inferior efficacy; recent evidence supports its use when clinically appropriate. 1, 2