Is Betadine (povidone-iodine) used for pleurodesis?

Betadine (Povidone-Iodine) for Pleurodesis

Direct Answer

Yes, povidone-iodine (Betadine) is an effective and safe agent for pleurodesis with success rates of 88-98% that are comparable to talc (90-93%), though it is not included in major Western guidelines despite extensive use in other regions. 1

Guideline Position and Evidence Quality

• Major Western guidelines from the British Thoracic Society and American Thoracic Society list talc, bleomycin, and doxycycline as established options but do not include povidone-iodine, despite its comparable efficacy 1
• Povidone-iodine use is limited in the UK and US but extensive in other regions, particularly in resource-constrained settings 1, 2
• The absence from guidelines does not reflect inferior efficacy but rather limited adoption in Western practice patterns 1

Efficacy Profile

Povidone-iodine achieves pleurodesis success rates of 88-98%, which matches or exceeds talc (90-93%), bleomycin (61%), and doxycycline (76-85%). 1

• Meta-analysis of 265 patients showed an overall success rate of 90.6% (95% CI: 86.4-93.8%) 3
• Success rates are independent of administration method—tube thoracostomy (87.5%) versus thoracoscopy (94.2%) 3
• Efficacy is consistent across indications: pleural effusion (88.5%) and pneumothorax (93.5%) 3
• Individual studies report success rates ranging from 89.5% to 98.4% 2, 4

Administration Protocol

Instill 20 mL of 10% povidone-iodine mixed with 80 mL normal saline and 2 mg/kg lidocaine through the chest tube after confirming complete lung re-expansion. 4

• Ensure complete pleural fluid drainage and lung re-expansion before instillation, as trapped lung is an absolute contraindication 1, 5
• Clamp the chest tube for 1-2 hours after instillation 3, 4
• Patient rotation during clamping is not definitively established for povidone-iodine, though rotation is not necessary for tetracycline-class agents 1
• Reconnect to suction after the clamping period 1
• Remove chest tube when daily drainage is <150-200 mL 1, 4

Safety and Tolerability

Povidone-iodine demonstrates excellent tolerability with no risk of acute respiratory failure, unlike talc which carries a small (<1%) risk of ARDS. 1

• Chest pain is the most common adverse effect, occurring in 7.9-18% of patients, typically mild and manageable with immediate symptomatic treatment 2, 3, 4
• Fever occurs in approximately 10-16% of patients 6, 3
• No procedure-related mortality has been reported in any study 2, 3, 4
• Systemic hypotension was reported in only three patients across all studies 3
• One case of pleural empyema (1.6%) was reported and successfully treated with drainage and antibiotics 4

Clinical Advantages Over Alternative Agents

Povidone-iodine offers significant cost advantages over bleomycin while achieving superior success rates (90.6% vs 61%). 1, 7

• Readily available and inexpensive compared to talc and bleomycin 1, 2, 6
• Can be easily administered at bedside through small-bore catheters without requiring operating room or thoracoscopy 8, 3
• Does not require trained personnel for handling cytotoxic drugs, unlike bleomycin 7
• Superior to doxycycline, which often requires multiple administrations 1

When to Consider Povidone-Iodine

Use povidone-iodine as first-line when talc is unavailable, in resource-constrained settings, or when bedside administration through small-bore catheters is preferred for patient comfort. 1, 2, 8

• Particularly appropriate in developing countries where cost and availability are primary concerns 2, 6
• Suitable for malignant pleural effusions, recurrent pneumothorax, and refractory tubercular effusions 2, 3
• Can be administered through tube thoracostomy or thoracoscopy with equal efficacy 3

Critical Contraindications (Same as All Pleurodesis)

• Absolute contraindications: Trapped lung or inability to achieve complete lung re-expansion, and mainstem bronchial obstruction 5
• Relative contraindications: Massive effusion with rapid re-accumulation, short life expectancy, active pleural infection, and concurrent corticosteroid therapy 5
• Confirm complete lung re-expansion with chest radiograph before proceeding 1, 5

Common Pitfalls to Avoid

• Never attempt pleurodesis without confirming complete lung re-expansion on chest radiograph, as this will result in treatment failure 1, 5
• Do not omit adequate analgesia—administer intravenous narcotic and anxiolytic agents before the procedure, plus intrapleural lidocaine (2 mg/kg) with the sclerosant 1, 4
• Avoid rapid drainage of large effusions (>1-1.5L at once) to prevent re-expansion pulmonary edema 5