Introduction
Chemical pleurodesis is performed to prevent recurrence of pneumothorax or pleural effusion in benign or malignant conditions. Instilled substances cause inflammation of the parietal and the visceral layers of the pleura and leads to adhesion of the pleural surfaces, preventing further fluid or air accumulation.

Indications
  • Malignant pleural effusions.
  • Refractory nonmalignant pleural effusions.
  • Recurrent Pneumothorax​.

Contraindication
Lung cannot fully expand to the chest wall (eg, trapped lung, interstitial pulmonary fibrosis, endobronchial obstruction).

Pre-Procedure
Medications
  • Steroids may decrease the success of chemical pleurodesis that counter act the inflammatory properties of chemical pleurodesis. Reduce or hold steroids 24 to 48 hours prior to pleurodesis if possible.
  • Nonsteroidal anti-inflammatory agents are not contraindicated and may be continued prior to and following the pleurodesis.
  • Systemic anticoagulation is generally reversed for placement of a chest tube if possible. It is not necessary to hold anticoagulation for chemical pleurodesis once the chest tube is in place.

Imaging
  • Recent chest radiograph, CT or MRI prior to the procedure.

Pain Management Plan
  • Pain secondary to the pleurodesis is typically universal, severe and may last for 1day or longer. Opiates are likely superior to NSAIDs in the management of pain.

Consults Prior to Procedure
  • Regional block team (pre op consult)for epidural catheter placement (literature better for epidurals than paravertebrals).
  • Medications (pre op consult) consideration for neuropathic medications including gabapentin/lyrica starting 2 weeks before and up to one month after the procedure.
  • Pain management service (post op consult)for management of epidural catheter meds and consideration of patient-controlled analgesia (PCA) or other method of treating breakthrough pain.
  • Ketorolac (Toradol) IV initiated prior to the doxycycline injection.
  • Acetaminophen IV Q 4 hours.
  • H2 blockers (eg Ranitidine) or proton-pump inhibitors (eg omeprazole) PO (optional).

Labs
No specific labs needed. Consider pulmonary consult and lung function test in patients with advanced lung disease.

Technique
  • Epidural catheter placement
  • Initial snapshot (DSA) images of the chest confirming the size of the effusion or pneumothorax
Picture
16 yo male with recurrent right pneumothorax despite blebectomy
  • Fluoroscopic confirmation of inflated lung.
  • "Trapped lung" may not expand and chemical pleurodesis may be less helpful: Place a large (12-14 Fr) pigtail catheter and drain the entire fluid or air volume.

Sclerosing Agents:
  • Doxycycline: 500 mg- 1000 mg for adult size 
Doxycycline opacified with contrast is instilled via a pigtail catheter.
  • Dose can be adjusted based on weight for smaller patients
  • Preparation: 500 mg of Doxycycline is mixed with 25 mL of fluid (combination of sterile water and 1%Lidocaine) and 25 mL of contrast
  • Maximum dose lidocaine (0.3 mL/kg of lidocaine 1% or 3 mg/kg; maximum 25 mL of 1% or 250 mg)
  • Solution injected intrapleurally under fluoroscopic or sonographic guidance demonstrating the distribution of the agent
  • Bleomycin (15 units) can be used as a second agent. The maximum dose 1.0 unit/kg per procedure (max 15 units)
  • Combination: Doxycycline followed by Bleomycin 
  • After injection of sclerosant, the chest tube is clamped for 4 hours then connected to -20 cm H2O suction
  • During the procedure in sedated patients, observe the patient for uncontrolled coughing and distress during the procedure
  • With severe pain not responding to medications during recovery, the chest tube can be opened to drain doxycycline; this may provide immediate reduction in pain
  • Rolling the patient after instillation of the sclerosing agent, protracted drainage of the effusion and use of larger chest tubes are unlikely to have any substantial advantages

Second Injection
  • Repeat injection 24-48 hours following initial injection.
  • May be done at bedside or in IR.
  • Notify pain service prior to injection.
  • Follow same steps of clamping, post-procedure care, etc.

Complications

Post-Procedure
  • Oxygen ​supply, keep SA02>95%, may reduce respiratory efforts and decrease pain.
  • Post-procedure pain management in consultation with pain service.
  • Daily chest radiograph .

For effusion
  • The chest tube is removed when the 24-hour drainage is < 100 mL and satisfactory evacuation of pleural fluid seen on the chest x-ray and the lung is fully expanded.
  • If the 24-hour drainage volume does not fall below 100 mL within 2 days of the second injection, then doxycycline is re-administered. 

For pneumothorax
  • When pleural surfaces are apposed, clamping trial of 12-24 hours is performed. If no pneumothorax on chest x-ray, remove tube.

Follow-up
  • Follow-up chest radiograph in 2, 6, and 12 months
Picture
Follow-up CXR demonstrates resolution of pneumothorax and mild pleural thickening.

References
  1. Iyer NP, Reddy CB, Wahidi MM, Lewis SZ, Diekemper RL, et al. Indwelling Pleural Catheter versusPleurodesis for Malignant Pleural Effusions. A Systematic Review and Meta-Analysis.Am Thorac Soc.2019;16(1):124-131
  2. Wahla AS, Uzbeck M, ElSameed YA, Zoumot Z. Managing malignant pleural effusion.Expert Rev RespirMed. 2018; 12(4):323-334
  3. Dugan KC, Laxmanan B, Murgu S, Hogarth DK. Management of Persistent Air Leaks.Chest.2017; 152(2):417–423
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