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PLEURODESIS

Pleurodesis is a medical procedure aimed at inducing adhesion between the visceral and parietal pleura to prevent fluid or air accumulation in the pleural space, commonly used for recurrent malignant pleural effusions and pneumothorax. Various agents such as talc, tetracycline derivatives, and bleomycin are employed, with talc being the most widely used due to its efficacy. The procedure can be performed chemically or mechanically, and while it has high success rates, outcomes can vary based on the underlying disease and type of pleural effusion.

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133 views28 pages

PLEURODESIS

Pleurodesis is a medical procedure aimed at inducing adhesion between the visceral and parietal pleura to prevent fluid or air accumulation in the pleural space, commonly used for recurrent malignant pleural effusions and pneumothorax. Various agents such as talc, tetracycline derivatives, and bleomycin are employed, with talc being the most widely used due to its efficacy. The procedure can be performed chemically or mechanically, and while it has high success rates, outcomes can vary based on the underlying disease and type of pleural effusion.

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mbk bst
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© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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PLEURODESIS

INTRODUCTION

 Induction of symphysis of visceral and parietal pleura

 Agent – exuberant inflammatory response

 Objective – prevent accumulation of air/fluid

 Tube/Thoracoscopy/Intrapleural catheter
MECHANISM

 Inflammatory response
 Imbalance – pleural coagulation and fibrinolysis
 Favoring adhesion formation
 Mesothelial cells lining pleurae
 Exposure ot TFG-β – produce collagen = adhesion
 Successful pleurodesis: high VEGF and Bfgf

TFG-β: Transforming Growth Factor


VEGF: Vascular Endothelial Growth Factor
bFGF: basic Fibroblast Growth Factor
INDICATIONS & CONTRAINDICATIONS

 INDICATIONS:
 Recurrent symptomatic malignant pleural effusion (MPE)
 Recurrent pneumothorax
 Refractory benign effusions

 CONTRAINDICATIONS:
 No absolute C.I.
 Critically ill with high oxygen need
TYPES

 CHEMICAL:
 Sclerosant via thoracoscope or chest tube
 Powder – sprayed with atomizer
 Slurry – liquid preparation
 IPC (intrapleural catheter)
 Drainage + pleurodesis
 Mechanical friction
 Chemical impregnated: silver nitrate
TYPES

 MECHANICAL:
 Pleural abrasion
 Pleurectomy
 Apical
 Total (recurrence: 0.4% v 2.3%)

 Open or VATS
 Open: if unable to tolerate moderate sedation
CHEMICAL PLEURODESIS
CHEMICAL PLEURODESIS

 When?
 More than half visceral pleura apposed to parietal
 Without need to wait until drain output <150ml

 Successful:
 No significant recurrence
 Complete: no accumulation in 30 days
 Partial: some accumulation; symptoms palliated

 Failure:
 Effusion and symptoms persist
Choice of agent

 More than 30 agents proposed (since 1935)


 None ideal
 Efficacy, safety, availability and cost
 Talc poudrage used in 1935 (after lobectomy)
 Best studied: talc, tetracycline derivatives and bleomycin
TALC

 Most commonly used worldwide


 Poudrage since 1935
 Slurry since 1958
 Asbestos-free magnesium trisilicate
 Sterilization: dry heat/ethylene oxide/gamma irradiation
 Sifted through mesh
 Varying pore size: (11-20 microns, US; 34 in France)
 More ARDS in US
TALC
TALC..

 TTP (thoracoscopic talc poudrage) superior to TS (talc slurry)


 TTP superior to tetracycline, bleomycin, doxycycline (Cochrane)
 TAPPS trial (<14F tubes) awaited

 British Thoracic Society, European Respiratory Society, American


Thoracic Society:
 Talc = agent of choice
 Use graded talc (<50% particles under 20µm)
 TTP superior in MPE (lung, breast) 16 and mesothelioma
TETRACYCLINE DERIVATIVES

 Tetracycline derivatives: parenteral doxycycline


 Oral doxycycline in saline also used
 Thoracoscopic insufflation
CYTOTOXIC DRUGS

 Bleomycin best studied


 Irritant
 Better in efficacy to tetracycline
 Inferior to talc
IODOPOVIDONE

 Widespread availability
 Low cost
 89% success
 Varying degrees of pain
 Visual loss (>200 ml of 10% solution)
 Shorter hospital stay (v. talc)
SILVER NITRATE

 Randomised trial:
 96% success (v. TS 84%)
 ‘Rescue’:
 Failed talc poudrage
 89% efficacy
 Minimal side effects even with high dose (1g)
 Incremental doses – increasing SIRS but equal success
 Decline in use due to pain
 Resurgence with use in IPCs
BACTERIAL AGENTS

 OK-432:
 Strep pyogenes (penicillin-treated)
 Initially immunotherapy for malignancy
 Japan – widespread use (lack of talc)
 Success 70% (upto 85% with minocycline)
 Major side effect: Intersitial lung disease (esp with EGFR-TKI); 25% mortality
 Corynebacterium parvum:
 1978, malignant effusions and ascites
 Pleural fluid pH or glucose not an issue (v. other sclerosants)
 Comparable to doxycycline
OTHER AGENTS

 Mistletoe (Viscum album): Korea (talc and tetracycline not available)


 Autologous blood pleurodesis (ABP):
 Persistent air leaks
 MPE
 100-150 ml
 Lower rates of pain and hospital stay
 Pneumothroaces: promising
MODES OF DELIVERY

 Chest tubes:
 28-32F: Pain
 TIME1 trial: 12 v 24; less pain but higher failure
 Meta-analysis: <14 v >14 = similar efficacy
 Rotation myth: no difference with q20min rotations v no rotation
 Analgesia: intrapleural lidocaine (2-3mg/kg)
 Medical thoracoscopy:
 Rigid or flexi-rigid thoracoscope
 GA not required (conscious sedation, well tolerated)
 Talc most commonly used
 Advantage: pleural drainage and biopsy
SPECIFIC DISEASE STATES

 MALIGNANT PLEURAL EFFUSIONS:


 Poor prognosis
 Lung cancer MPE: survival 5.5 months
 Paramalignant effusions:
 Solid tumor + effusion (cytology negative)
 Lower survival v cancer without effusion
MPE….

 Success rates affected by tumor types


 Mesothelioma and lung cancer MPE: higher failure
 Breast cancer MPE: more successful (75% v 58% for lung)
 Mesothelioma MPE:
 Antitumor effect of pleurodesis by inducing inflammation
 Increased survival rate
NONMALIGNANT EFFUSIONS

 Last resort
 Address underlying etiology
 Role of IPC:
 Refractory heart failure
 Refractory hepatic hydrothorax
 Longer time to pleurodesis
 Higher recurrence
 Chylothorax: after conservative and surgical options have failed
PLEURODESIS FOR PNEUMOTHORAX

 Secondary pneumothorax (COPD, ILD, cystic fibrosis)


 Recurrent primary spontaneous pneumothorax (PSP)
 Persistent air leaks (>5 days)
OUT PATIENT PLEURODESIS

 IPC: minimized hospitalization


 Topical anesthesia
 TIME2 trial: reduces dyspnea at 6 months
 Disadvantage: cost
 ASAP trial:
 Aggressive regimen upto 1L/day
 Autopleurodesis: 54 days (median)
IPC
ONGOING STUDIES

 OMPTIMUM trial:
 IPC with TS pleurodesis v TS
 REDUCE trial:
 IPC in nonmalignant effusion

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