Introduction

• Chemical pleurodesis is a procedure designed to obliterate the pleural space by creating adhesions between the parietal and visceral pleura
• Prevents recurrence of pneumothorax or pleural effusion through inflammation-induced pleural surface adhesion
• Successfully eliminates the potential space within the pleural cavity, preventing further fluid or air accumulation
• Represents the most effective intervention for preventing recurrent pleural disease with success rates ranging from 80-95% depending on agent and technique

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Indications

Pediatric-Specific Indications

• Recurrent spontaneous pneumothorax - Particularly secondary pneumothorax in conditions such as cystic fibrosis
• Malignant pleural effusion in pediatric cancers including:
  • Non-Hodgkin lymphoma (80-85% of primary malignant tumors in children)
  • Rhabdomyosarcoma
  • Askin tumor (Ewing sarcoma variant)
  • Wilms tumor with pleural extension
• Persistent air leak after failed medical management (>5-7 days)
• Complicated parapneumonic effusion/empyema when survival >2-3 months expected
• Chylothorax refractory to conservative management

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Contraindications

General Contraindications

• Trapped lung - Inability of the lung to fully expand to the chest wall 
• Interstitial pulmonary fibrosis with significant lung restriction
• Endobronchial obstruction preventing lung expansion
• Severe comorbidities making the procedure risks outweigh the benefits

Pediatric-Specific Considerations

• Age <2 years - Limited evidence and increased procedural risks
• Active respiratory infection - Should be treated prior to pleurodesis in non-malignant conditions
• Congenital heart disease with significant hemodynamic instability
• Severe underlying lung disease where pleurodesis may compromise already limited respiratory reserve
• Coagulopathy that cannot be corrected (more critical in pediatric patients due to smaller blood volumes)

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Pre-Procedure

​Medication Management

• Corticosteroids: Reduce or discontinue 24-48 hours prior to procedure if clinically safe (may decrease pleurodesis success by counteracting inflammatory response)
• NSAIDs: May be continued - not contraindicated for chemical pleurodesis and may help with pain management
• Anticoagulation: If possible, consider holding for placement of chest tube. It can be resumed once the chest tube is in place.

Imaging Requirements

• Recent chest imaging: CT scan or chest radiograph within appropriate timeframe
• Thoracic ultrasound: Strongly recommended per 2023 BTS guidelines to guide pleural interventions, assess lung expansion potential, and reduce complications
• Lung expansion assessment: Essential to confirm expandable lung before pleurodesis
• Large-volume thoracentesis: Consider if uncertain whether symptoms are related to effusion or if lung expandability is questionable

Pain Management Strategy

• Pre-procedure consultation: Regional anesthesia team for epidural catheter placement (evidence shows superiority over paravertebral blocks)
• Neuropathic medications: Consider gabapentin (starting dose 300mg TID) or pregabalin starting 2 weeks before and continuing up to 1 month post-procedure
• Post-procedure pain service: Consultation for epidural management and breakthrough pain control
• Multimodal analgesia:
  • IV ketorolac (Toradol) prior to sclerosant injection
  • IV acetaminophen 1g every 6 hours
  • H2 blockers (famotidine 20mg BID) or proton pump inhibitors (omeprazole 20mg daily) as gastroprotection
  • Opioids are superior to NSAIDs for pleurodesis-related pain management

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Labs

• Routine labs: Generally not required unless clinically indicated, or evidence of coagulopathy
• Pulmonary function testing: Consider in patients with advanced lung disease
• Specialty consultation: Pulmonology consultation may be beneficial for complex cases

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Technique

Sclerosing agent

• Sonography and fluoroscopy to document existing effusion and/or pneumothorax

16 yo male with recurrent right pneumothorax despite blebectomy

• Chest tube selection: 12-14F tube preferred. Tubes smaller than 16 French are strongly recommended - associated with less pain, fewer complications, shorter hospital stays, and equivalent efficacy to large-bore tubes
• Complete evacuation: Ensure complete drainage of pleural space before sclerosant administration (target <100mL drainage in 24 hours)

Doxycycline opacified with contrast is instilled via a pigtail catheter.

Doxycycline

• Efficacy: 72-84% success rate (requires multiple doses in some cases)
• Adult dosing: 500-1000 mg based on patient size and clinical factors
• Pediatric dosing: 10-20 mg/kg (maximum 500mg) - preferred in children due to extensive safety data
• Preparation protocol:
  • Mix calculated dose with appropriate volume sterile solution (combination of sterile water and 1% lidocaine)
  • Add contrast agent for fluoroscopic visualization if needed
• Lidocaine safety:
  • Adults: Maximum 0.3 mL/kg of 1% lidocaine (3 mg/kg; maximum 25 mL or 250 mg)
  • Pediatric: Maximum 3-5 mg/kg of 1% lidocaine (reduce dose in neonates and infants)
• Considerations: Associated with more severe chest pain (40% incidence) compared to talc (7% incidence)

Pediatric-Specific Considerations for Agent Selection

• Doxycycline preferred in children due to:
  • Extensive pediatric safety data
  • Lower risk of ARDS compared to talc in smaller patients
  • Easier weight-based dosing calculations
• Talc use in pediatrics:
  • Limited data in children <5 years
  • Should only be graded, sterilized talc
  • Consider reduced doses (50-100 mg/kg) compared to adult dosing

Bleomycin

• Efficacy: 54% success rate - inferior to both talc and doxycycline
• Dosing: 15 units maximum (1.0 unit/kg per procedure, maximum 15 units)
• Cost: Significantly more expensive than talc or doxycycline
• Use: Reserved for cases where talc and doxycycline are contraindicated

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Technique

​Initial Injection Protocol

• Image Guided injection: Administer under ultrasound or fluoroscopic guidance
• Distribution verification: Confirm adequate distribution of sclerosant throughout pleural space
• Post-injection management: Clamp chest tube for 4 hours, then connect to -20 cm H2O suction
• Patient monitoring: Observe for uncontrolled coughing and respiratory distress during procedure
• Patient positioning: Rolling patient after instillation provides no substantial advantage

Subsequent Injection Protocol

• Timing: Repeat injection 24-48 hours after initial treatment if indicated
• Location: May be performed at bedside or in interventional radiology
• Pain service notification: Alert pain management team prior to second injection
• Protocol consistency: Follow same clamping and post-procedure care procedures

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Complications

• Common (>10%): Chest pain, fever, tachycardia, dyspnea
• Serious (1-15%): ARDS, respiratory failure, pneumothorax

Management of complications

• Acute respiratory distress: Monitor closely during procedure and early post-procedural period
• Uncontrolled pain: Consider drainage of sclerosant for immediate relief
• Infection: Risk of empyema approaches zero with sterile technique and asbestos-free talc
• Incomplete pleurodesis: Consider repeat procedure, alternative agents, or IPC placement

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Post-Procedure

Immediate Care

• Oxygen support: Maintain SaO2 >95% to reduce respiratory effort and minimize pain
• Pain management: Collaborative approach with pain service for optimal control
• Emergency pain relief: If severe uncontrolled pain occurs, chest tube may be opened to drain residual sclerosant

​Monitoring Protocol
Daily chest radiographs: Monitor lung expansion and pleural space

• Drainage assessment:
  • For effusions: Remove chest tube when 24-hour drainage <100 mL with satisfactory evacuation and full lung expansion
  • For pneumothorax: Perform clamping trial (12-24 hours) when pleural surfaces are opposed; remove if no pneumothorax on imaging

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Follow-up

• Imaging schedule: Chest radiographs at 2, 6, and 12 months post-procedure
• Symptom assessment: Monitor for recurrence of effusion or pneumothorax
• Long-term outcomes: Assess effectiveness and patient quality of life measures
• Survival considerations: Successful pleurodesis associated with improved survival outcomes

Follow-up CXR demonstrates resolution of pneumothorax and mild pleural thickening.

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References

1. Roberts ME, Rahman NM, Maskell NA, et al. British Thoracic Society Guideline for pleural disease. Thorax. 2023;78(Suppl 3):s1-s42.
2. Light RW. Pleural diseases. 6th ed. Philadelphia: Lippincott Williams & Wilkins; 2013.
3. Dipper A, Jones HE, Bhatnagar R, et al. Interventions for the management of malignant pleural effusions: a network meta-analysis. Cochrane Database Syst Rev. 2020;4:CD010529.
4. Davies HE, Mishra EK, Kahan BC, et al. Effect of an indwelling pleural catheter vs chest tube and talc pleurodesis for relieving dyspnea in patients with malignant pleural effusion: the TIME2 randomized controlled trial. JAMA. 2012;307:2383-2389.
5. Castaldo N, Fantin A, Palou-Schwartzbaum M, et al. Exploring the efficacy and advancements of medical pleurodesis: a comprehensive review of current research. Breathe. 2024;20:240002.
6. Gilbert CR, Lee HJ, Skalski JH, et al. The American Thoracic Society 2018 Clinical Practice Guideline: Management of pleural effusions that are refractory to medical management. Am J Respir Crit Care Med. 2018;198:839-851.
7. Clive AO, Jones HE, Bhatnagar R, et al. Interventions for the management of malignant pleural effusions: a network meta-analysis. Cochrane Database Syst Rev. 2016;5:CD010529.
8. Bhagat M, Adusumilli AK, Ghimire A, Cho RJ. Comparative efficacy of doxycycline and its analogues with autologous blood patch pleurodesis for persistent air leak following secondary spontaneous pneumothorax in adults—a systematic review. J Thorac Dis. 2024;16:7155-7164.
9. Rahman NM, Pepperell J, Rehal S, et al. Effect of opioids vs NSAIDs and larger vs smaller chest tube size on pain control and pleurodesis efficacy among patients with malignant pleural effusion: the TIME1 randomized clinical trial. JAMA. 2015;314:2641-2653.
10. Putnam JB Jr, Light RW, Rodriguez RM, et al. A randomized comparison of indwelling pleural catheter and doxycycline pleurodesis in the management of malignant pleural effusions. Cancer. 1999;86:1992-1999.
11. Subedi A, Banjade P, Joshi S, et al. Updates on British Thoracic Society Statement on Pleural Disease and Procedures 2023. Open Respir Med J. 2023;17:e18743064286775.
12. Ali MA, Sharma S, Surani S. Pleurodesis. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan.
13. Balfour-Lynn IM, Abrahamson E, Cohen G, et al. BTS guidelines for the management of pleural infection in children. Thorax. 2005;60(Suppl 1):i1-i21.