What are the techniques for pleurodesis using Betadin (povidone-iodine)?

Pleurodesis with Povidone-Iodine (Betadine): Technique and Protocol

Povidone-iodine pleurodesis is a safe, effective, and low-cost alternative to talc for managing recurrent malignant pleural effusions and pneumothorax, with success rates of 88-98% comparable to talc's 90-93%, though it lacks formal inclusion in major Western guidelines. 1

Patient Selection Criteria

Before attempting povidone-iodine pleurodesis, confirm the following:

• Complete lung re-expansion is mandatory - verify with chest radiograph after fluid drainage, as trapped lung or bronchial obstruction will cause treatment failure 1, 2
• Symptomatic dyspnea that improves with therapeutic thoracentesis 1
• Life expectancy sufficient to benefit from the procedure (generally >1 month) 1
• Absence of active pleural infection 1

Critical contraindications include trapped lung and mainstem bronchial obstruction, as these prevent necessary pleural surface apposition. 1

Step-by-Step Procedure Protocol

1. Chest Tube Insertion

• Insert a small-bore intercostal catheter (10-14 F) under ultrasound guidance 3, 1
• Small-bore tubes are associated with less discomfort than large-bore tubes while maintaining equivalent success rates 3

2. Pleural Fluid Drainage

• Drain pleural fluid in a controlled fashion, limiting removal to 1-1.5 L at a time to prevent re-expansion pulmonary edema 1, 2
• Continue drainage until minimal or no pleural fluid remains 1
• Confirm complete lung re-expansion with chest radiograph before proceeding 3, 1

3. Premedication

• Administer intravenous narcotic and anxiolytic-amnestic agents before the procedure 1
• Instill lignocaine solution (3 mg/kg; maximum 250 mg) into the pleural space for local analgesia 3, 1

4. Povidone-Iodine Instillation

The standard protocol involves:

• Mix 20 mL of 10% povidone-iodine with 80 mL of normal saline (total volume 100 mL) 4
• Add 2 mg/kg of lidocaine to the mixture for additional analgesia 4
• Instill the solution through the chest tube when complete lung expansion is confirmed 4

5. Post-Instillation Management

• Clamp the chest tube for 1-2 hours after instillation 1, 4
• Patient rotation during the clamping period is not definitively established for povidone-iodine, though rotation is recommended for talc slurry 1
• After unclamping, maintain the patient on -20 cm H₂O suction 1

6. Chest Tube Removal

• Remove the chest tube when 24-hour drainage is less than 150-200 mL 1, 4
• If drainage remains excessive (≥250 mL/24 h) after 48-72 hours, consider repeat instillation 1

Expected Outcomes and Success Rates

• Complete response (no recurrence) occurs in 88-98% of patients 1, 5, 4
• Success rates are comparable to talc (90-93%) and superior to bleomycin (61%) and doxycycline (76-85%) 1
• Mean follow-up data shows sustained efficacy at 5.6-10.2 months 5, 4

Complications and Management

Common Adverse Events

• Chest pain occurs in 16-27% of patients during or immediately after instillation 4, 6, 7
  • Manage with immediate analgesics; pain is typically mild and self-limited 5, 6
• Fever occurs in approximately 11% of patients 6
  • Treat with antipyretics; typically resolves within 24-48 hours 1

Serious Complications

• No procedure-related mortality has been reported in multiple studies 5, 4, 6
• Pleural empyema is rare (<2%) and responds to drainage and antibiotics 4
• No risk of acute respiratory failure or ARDS, unlike talc which carries a small (<1%) risk with small-particle preparations 1
• Thyroid and renal function changes are not clinically significant 7

Critical Pitfalls to Avoid

• Never attempt pleurodesis without confirming complete lung re-expansion - check post-drainage chest radiograph for mediastinal shift and full lung expansion 1, 2
• Avoid corticosteroids at the time of pleurodesis, as they reduce pleural inflammatory reaction and increase failure rates 3, 2
• Do not remove more than 1.5 L during initial drainage to prevent re-expansion pulmonary edema 1, 2
• Do not perform intercostal tube drainage without pleurodesis, as this has nearly 100% recurrence rate at 1 month 2

Comparison with Standard Agents

Povidone-iodine offers several advantages:

• Lower cost than bleomycin with superior success rates (90.6% vs 61%) 1
• Easier administration than talc poudrage - can be performed at bedside without thoracoscopy 4, 8
• Excellent safety profile - no respiratory failure risk unlike talc 1
• Readily available in most healthcare settings, particularly valuable in resource-constrained environments 5, 6

However, talc remains the guideline-recommended first-line agent when maximum success rate is critical and thoracoscopy is planned for diagnostic purposes 1. Povidone-iodine is not mentioned in major British Thoracic Society or American Thoracic Society guidelines despite comparable efficacy 1.

Management of Failed Pleurodesis

If povidone-iodine pleurodesis fails:

• Repeat pleurodesis with the same agent or consider switching to talc 1
• Thoracoscopy with talc poudrage if initial slurry method was used 1
• Indwelling pleural catheter for patients with nonexpandable lung or multiple failed attempts 1, 2
• Repeated thoracentesis for patients with very limited life expectancy 1, 2