Contraindications to Pleurodesis
Pleurodesis is absolutely contraindicated when the lung cannot fully re-expand after fluid drainage, which occurs with trapped lung, bronchial obstruction, or extensive pleural tumor encasement—attempting pleurodesis in these situations will fail and unnecessarily expose patients to procedural risks. 1, 2
Absolute Contraindications
Non-Expandable or Trapped Lung
- Complete lung re-expansion after fluid drainage is essential for pleurodesis success—this must be verified radiographically before proceeding. 1, 2
- Trapped lung occurs when visceral pleura is encased by tumor or fibrin, preventing apposition of pleural surfaces needed for symphysis. 3, 4
- A practical indicator: if pleural pressure falls more than 20 cmH₂O per liter of fluid removed, trapped lung is likely present and pleurodesis will fail. 3
- Pleural fluid pH <7.20 is a good predictor of trapped lung and correlates with pleurodesis failure. 3, 4
- Non-expandable lung occurs in approximately 30% of malignant pleural effusions—these patients should receive indwelling pleural catheters instead. 1, 5
Central Bronchial Obstruction
- Endobronchial tumor obstruction prevents lung expansion and makes pleurodesis futile. 1, 3
- Bronchoscopy may be needed to exclude this before attempting pleurodesis in patients with known lung cancer. 1
Active Pleural Infection with Multiple Loculations
- The presence of pleural infection with septations is a contraindication to pleurodesis. 1
- Multiple pleural loculations prevent adequate drainage and pleural apposition. 1, 6
Relative Contraindications
Very Short Life Expectancy
- Patients with extremely limited survival (<1 month expected) should undergo repeated therapeutic thoracentesis rather than pleurodesis, as they may not survive long enough to benefit from the procedure. 1, 2, 4
- Performance status and general health must be adequate to justify the intervention. 4
Lack of Symptomatic Benefit from Thoracentesis
- If drainage of pleural fluid does not relieve dyspnea, pleurodesis is unlikely to provide benefit and should not be performed. 4
- Always perform diagnostic/therapeutic thoracentesis first to assess symptomatic response before committing to pleurodesis. 4
Hemodynamic Instability
- Patients who cannot tolerate the procedure due to hemodynamic instability should not undergo pleurodesis. 6
Corticosteroid Therapy
- Active corticosteroid therapy should be stopped or dose reduced before pleurodesis, as steroids inhibit the pleural inflammatory response necessary for successful symphysis. 1, 2
- This is a modifiable contraindication—delay pleurodesis until steroids can be tapered if clinically feasible. 1
Special Considerations
Potential Lung Transplant Candidates
- Pleurodesis may complicate future lung transplantation surgery and should be avoided in potential transplant candidates. 7
Congestive Heart Failure
- Pleurodesis may be contraindicated in patients with heart failure, as the underlying condition should be treated medically rather than with pleurodesis. 2, 7
- Transudative effusions from heart failure should be managed by treating the underlying cardiac condition, not with pleurodesis. 2
Critical Pitfalls to Avoid
- Never attempt pleurodesis without radiographic confirmation of complete lung expansion—this is the most common cause of pleurodesis failure. 1, 2
- Do not use pleurodesis for patients with trapped lung; instead, offer indwelling pleural catheters or pleuroperitoneal shunts. 1
- Avoid removing more than 1.5L of fluid during initial drainage to prevent re-expansion pulmonary edema, which could complicate subsequent pleurodesis attempts. 2, 5, 6
- Do not proceed with pleurodesis if pleural fluid pH is <7.20 without careful consideration, as success rates are significantly lower. 3, 4