Index
It is a medical procedure in which the pleural space is artificially erased. It involves the adhesion of the two pleurae.
The cough, chest pain, and shortness of breath associated with asbestos-related illnesses are often caused by an accumulation of excess fluid in the space between the inner and outer layers formed by the pleural lining around the lungs. .
This painful condition is called a pleural effusion, and it makes breathing difficult because it puts pressure on the lungs. If left untreated, it can lead to an infection or a collapsed lung.
The goal of a pleurodesis procedure is to drain excess fluid and then remove the pleural space so that fluid can no longer collect there.
Pleurodesis is a type of palliative treatment for pleural mesothelioma and many other cancers, which means that it is done by doctors to relieve symptoms rather than to kill or kill cancer cells.
Pleurodesis offers a more permanent solution than the other common procedures for treating pleural effusions.
A thoracentesis procedure drains excess fluid but does not seal the pleural space, whereas insertion of a pleural catheter requires regular maintenance at home, potentially for the rest of a patient’s life.
Pleurodesis is a procedure that is designed to join the two layers of the lining of the lung (the pleura).
This works to eliminate the space between the layers (the pleural cavity) so that fluid (water, blood, or pus) can no longer collect between the layers.
There are usually three to four teaspoons of fluid between the outer (parietal) and inner (visceral) pleural membranes.
When a pleural effusion occurs, due to both benign and malignant causes, this amount of fluid builds up and the pleural space can sometimes hold a few extra liters of fluid.
Before recommending pleurodesis, doctors first want to see that a pleural effusion (or pneumothorax) will recur in the future.
For a one-time event, a thoracentesis to remove the fluid is usually all that is needed.
Unfortunately, benign pleural effusion (and pneumothorax) and especially malignant pleural effusion often recur.
Applications
Pleurodesis is done to prevent recurrence of pneumothorax or recurrent pleural effusion. It can be done chemically or surgically.
It is generally avoided in patients with cystic fibrosis, if possible, because lung transplantation becomes more difficult after this procedure.
Previous pneumothorax with or without pleurodesis is not a contraindication for subsequent lung transplantation.
There are two methods of causing inflammation in the pleural lining: chemical and mechanical. Due to its low cost and the ease of the procedure, the most common method is talc chemical pleurodesis.
Chemical pleurisy
Talc is a type of clay mineral, and has historically been the main ingredient in baby powder. The talc used for pleurodesis is medical grade, sterile, and asbestos-free.
Chemicals such as bleomycin, tetracycline (eg, minocycline), povidone iodine, or a talc suspension can be introduced into the pleural space through a chest drain.
The instilled chemicals cause irritation between the parietal and visceral layers of the pleura that closes the space between them and prevents more fluid from accumulating.
Pharmacy ready-made chemicals for pleurodesis should be clearly labeled “NOT FOR IV ADMINISTRATION” to avoid potentially fatal errors in mis-site administration.
Povidone iodine is just as effective and safe as talc, and may be preferable because of its easy availability and low cost.
Chemical pleurodesis is a painful procedure, so patients are often premedicated with a sedative and pain relievers. A local anesthetic can be instilled into the pleural space, or an epidural catheter can be placed for anesthesia.
During chemical pleurodesis, talcum powder can be inserted into the pleura using thoracoscopy tools, or it can be mixed with liquid in a talc suspension and inserted through a chest tube. Once the talc is sufficiently distributed, the doctor removes it.
Substances such as bleomycin, tetracycline, nitrogen mustard, and povidone iodine can also be used for chemical pleurodesis, but talc is the most popular option because it is effective and less expensive to administer.
A 2013 Australian review of pleurodesis for mesothelioma patients confirmed talc pleurodesis as the most effective treatment, and a 2016 Cochrane review also found talc pleurodesis to be the most effective for malignant pleural effusions.
Pleurodesis rápida
One drawback of the common talc pleurodesis procedure is the week-long hospital stay that is often required for recovery. Many specialists recommend inserting a pleural catheter in its place because it can be done as an outpatient procedure.
To find the best compromise between these two options, specialists have developed a “rapid pleurodesis” procedure that uses a pleural catheter and chemical pleurodesis. This method allows most patients to be discharged from the hospital within 48 hours.
A randomized trial from 2014 and a retrospective analysis from 2016 determined that a rapid pleurodesis protocol can be as effective as the common chemical pleurodesis procedure that most clinicians currently follow.
Surgical
Surgical pleurodesis can be performed by thoracotomy or thoracoscopy. This involves mechanically irritating the parietal pleura, often with a rough pad. Additionally, surgical removal of the parietal pleura is an effective way to achieve stable pleurodesis.
Alternatively, tunnelled pleural catheters (TPCs) can be placed in an outpatient setting and often lead to self pleurodesis, thus portable vacuum flasks are used to evacuate pleural fluid.
Routine evacuation holds the pleura together, causing physical shaking of the catheter, causing the pleura to heal slowly.
This method, although the minimally invasive and least cost solution, takes an average of 30 days to achieve pleurodesis and is therefore the slowest means of achieving pleurodesis among other modalities.
Sterile talcum powder, administered intrapleurally through a chest tube, is indicated as a sclerosing agent to decrease the recurrence of malignant pleural effusions in symptomatic patients.
It is usually done at the time of a diagnostic thoracoscopy. Although this method may involve a more invasive surgical procedure, the results of a 2015 study suggest that mechanical pleurodesis may provide greater symptom relief than chemical pleurodesis.
Reasons why pleurodesis can be performed
There are several conditions for which pleurodesis can be performed, which in turn is the result of medical conditions such as lung cancer, mesothelioma, cystic fibrosis, and other diseases.
Malignant pleural effusion : People with lung cancer, breast cancer, or lung metastases from other cancers may develop a malignant pleural effusion, a pleural effusion that contains cancer cells.
When this is the case, there are 2 options. One is to do a thoracentesis and place a stent that continually drains fluid from the effusion to another part of the body (an indwelling pleural catheter or a tunnel pleural catheter). The other is pleurodesis.
Persistent pneumothorax: A pneumothorax is a term used to describe a collapsed lung. If a pneumothorax occurs and a chest tube is placed, the pneumothorax often resolves.
If the pneumothorax persists (a persistent air leak) or goes away and then comes back, more treatments are needed to resolve the pneumothorax or prevent a recurrence.
Preparation before a pleurodesis
Before performing pleurodesis, doctors consider several things. Most importantly, it is important that the removal of pleural fluid improves symptoms (shortness of breath) in people with cancer.
Usually only a pleural effusion is left that does not cause symptoms such as chest pain or shortness of breath in this setting. In addition to this, some doctors recommend the procedure only if the life expectancy is greater than one month.
On the other hand, spontaneous pneumothorax can occur in young, healthy people. In this case, the procedure can be done to prevent another pneumothorax from occurring in the future.
Pleurodesis procedure
A pleurodesis is a procedure done to treat recurrent collapsed lungs or the accumulation of fluid between the lung and the lining of the chest wall that does not go away.
It is sometimes done for people with pleural effusions (the accumulation of fluid between the membranes that surround the lungs) that recur as a result of lung cancer and other conditions.
A pleurodesis procedure generally involves a three to seven day hospital stay, although a newer method that is being tested by some specialists requires only a brief overnight stay.
Before the procedure, patients are usually given a narcotic for pain and a benzodiazepine, such as Xanax, for added comfort.
The first step in a pleurodesis procedure is to drain excess fluid from the pleural space. The next step is to irritate the two layers of the pleural lining, which causes inflammation and scarring.
The scar tissue fuses the two pleural layers, eliminating the space between them. This scarring clears the pleural space so that fluid can no longer accumulate in the space.
Medications (Doxycycline or talcum powder) are placed in the space between the lung and the chest wall.
This causes irritation or inflammation between the two layers, helping the lung to stick to the chest wall. The goal is to stop the accumulation of fluid and / or air in that space and to keep the lung inflated.
When you do it in your hospital room, doxycycline or talc is injected into a chest tube. The chest tube is then clamped or hung from a pole to make sure the medicine stays on your chest.
You will be asked to change your position every 30 minutes for about two hours to move the medicine into the chest cavity. You will have pain with this procedure.
You will be given a patient controlled analgesia (PCA) that allows you to give yourself your own dose of medicine to help relieve pain. Your nurse will check your breathing and heart rate often.
If you do it in the operating room, the medications can be placed directly into your lung. You will not need to change position.
In either case (done in the room or in the operating room), a chest tube will remain in place for at least 48 hours or until the lung tissues have coalesced. You will have a daily chest X-ray to check your progress.
The procedure is very effective overall, but it may be less effective if multiple areas of effusion are present (loculated effusions). In this case, other procedures may be necessary, such as removing the pleura.
With lung cancer, an alternative to late-stage pleurectomy is to place a stent between the pleural cavity and the outside of the body, allowing people to remove fluid that accumulates at home.
Recovery from pleurodesis
The chest tube will stay in place for 24 to 48 hours, or until your lung has attached itself to the chest cavity. If you had a surgical procedure, you may need to stay in the hospital for a few days. You will receive regular x-rays to check your progress.
After removing the chest tube, you will need to keep the wound clean. Wash it every day with a mild soap and pat it dry.
You may notice some drainage from the wound for a day or two. Keep a bandage over it until it stops draining. Change the bandage at least every day. Follow all instructions for the care and follow-up of wounds administered to you.
Here is what not to do after your procedure:
Incision care
You may have more than one small incision depending on whether you had lung surgery or just a chest tube placed for this procedure.
After removing the chest tube, leave the chest tube dressing in place for 48 hours, remove the dressing.
After removing the bandage from the chest tube (48 hours), you can shower or wash the wound (s) daily with mild soap. Pat them dry. Don’t rub them because this prevents healing.
Do not put lotions, powders, or ointments on the incision (s). Do not soak in a bathtub, hot tub, or go swimming until healed. Check wounds daily for:
Increased redness. Pus-like drainage. Excess swelling or bleeding. Temperature (by mouth) greater than 100.4 ° F. for two readings taken 4 hours apart.
There may be a small amount of drainage from the chest tube site for a day or two. Use a band-aid or small bandage until the drainage stops. Change the dressing daily as needed.
Pain relief
It is common to have pain. When you have pain, take your pain pills as directed. If the pain is sharp and constant or gets worse, call your doctor.
Avoid anti-inflammatory pain relievers, non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen and Motrin for at least 7 days. You will be informed if you can start taking them again after your follow-up visit.
Exercise
Do not strain, lower yourself, or hold your breath during activities, such as during a bowel movement. Don’t lift more than 10 pounds until your doctor says it’s okay.
Do not drive for 2 weeks and / or if you are taking narcotic pain relievers. Check with your doctor before returning to work.
Complications of pleurodesis and side effects
In general, a pleurodesis procedure is well tolerated. For a certain percentage of people, the procedure will be ineffective and treatment will continue with an indwelling catheter to drain the fluid, or a pleurectomy (removal of the pleural) will be needed.
Common side effects and complications of pleurodesis:
- Chest pain.
- Fever.
- Infection.
Chest pain and fever are the most common adverse effects of pleurodesis. Some patients report a burning or tight sensation around the lungs, but this is usually relieved with medication before the procedure.
Due to the inflammatory response that helps seal the pleural space, fever commonly develops about four to 12 hours after talc pleurodesis.
As with any surgical procedure, there is a risk of infection that may need treatment with antibiotics. In rare cases, pleurodesis can lead to cardiovascular complications or acute respiratory distress syndrome.
Another concern, for people who may have a lung transplant in the future, is that a prior pleurodesis can make this procedure more difficult.
For those who have a pleural effusion due to minor conditions, or who have recurrent pneumothorax (often related to a hereditary factor), pleurodesis can provide assurance that another effusion or pneumothorax will not occur when immediate medical help is not available.
Example : Frank’s lung cancer was causing recurrent pleural effusions, so his doctor recommended that he undergo a procedure called pleurodesis.
Who qualifies for a pleurodesis?
Not all patients with pleural mesothelioma are candidates for pleurodesis.
If the cancer has progressed to a late stage and the patient has a trapped lung, meaning there is extensive tumor coverage of the two layers of the pleural lining, a pleurodesis will not be effective in sealing the pleural space, according to a 2017 review. The procedure.
Also, patients with a life expectancy of a few months cannot undergo the procedure because they may wish to avoid hospitalizations and the discomfort associated with recovering from surgery.
In these cases, doctors will consider other palliative treatments for mesothelioma.
On the other hand, if the patient is in good general health and the cancer is still localized, they may be a candidate for more aggressive tumor removal surgery, such as pleurectomy / decortication.
Aggressive treatment of pleural mesothelioma generally involves removing the pleural lining rather than sealing it.
When to call the doctor
Signs of infection:
- Increased redness or warmth of the incision.
- Pus-like drainage.
- Excess swelling or bleeding.
- Temperature greater than 100.4 ° F (by mouth), for two readings, 4 hours apart.
- Pain not controlled with pain pills.
- Fatigue or tiredness
- Body pain.
Sudden onset of sharp chest pain with shortness of breath or shortness of breath: call 911.
Your outlook depends on what condition caused you to need pleurodesis. The long-term prognosis for people with pneumothorax who are treated with this procedure is good, with improvements in lung function.
In small studies, pleurodesis had success rates of about 75 to 80 percent in people with non-cancer pleural effusion.
We can conclude that pleurodesis may be indicated in benign pleural effusions, with restrictions. The main indication for pleurodesis is recurrent malignant pleural effusions with complete lung expansion in patients with good performance status indices.
Pleurodesis through a chemical stimulus, especially talc pleurodesis, remains the first option for the treatment of recurrent malignant pleural effusion. Silver nitrate appears to be a reasonable option for use in Brazil, although more studies are needed on its safety.
The most effective route is video-assisted surgery. However, the use of small-gauge chest drains (catheters) provides good cost-effectiveness / comfort, especially for patients in advanced stages of neoplastic disease.
The most important aspect to consider is that pleurodesis has become a procedure that physicians can perform in outpatient clinics.
This greatly simplifies its execution while maintaining efficiency rates. Therefore, there is no need for hospitalization, which would deprive patients, during this difficult phase of their lives, of contact with their families.
