INTRODUCTION — Pleurodesis is a procedure that obliterates the pleural space to prevent recurrent pleural effusion or recurrent pneumothorax. It is most commonly performed by draining the effusion or intrapleural air and then inducing intrapleural inflammation and fibrosis by either instilling a chemical irritant or performing mechanical abrasion. The use of a chemical irritant is known as chemical pleurodesis.
Alternatives to chemical pleurodesis include mechanical abrasion (also termed dry abrasion) of the parietal pleura during thoracoscopy or thoracotomy or placement of a tunneled pleural catheter, which drains pleural fluid and may induce pleurodesis without instillation of a sclerosing agent. The indications, contraindications, choice of sclerosant, procedure, and complications of chemical pleurodesis will be reviewed here. The techniques of tube thoracostomy and pleural abrasion during thoracoscopy are discussed separately (see "Thoracostomy tubes and catheters: Indications and tube selection in adults and children" and "Pneumothorax: Definitive management and prevention of recurrence"). The role of tunneled pleural catheters is discussed elsewhere. (See "Management of malignant pleural effusions".)
INDICATIONS — Chemical pleurodesis has been used to manage malignant pleural effusions, refractory nonmalignant pleural effusions, and pneumothorax [1,2].
Malignant effusion — Malignant pleural effusion is the most widely accepted indication for chemical pleurodesis [2,3]. Identifying patients with malignant pleural effusions who should be considered for chemical pleurodesis and alternative options for managing malignant pleural effusions are discussed in detail elsewhere. (See "Management of malignant pleural effusions".)
Nonmalignant effusion — The primary therapy for nonmalignant pleural effusions is treatment of the underlying cause. Refractory nonmalignant pleural effusions sometimes require chemical pleurodesis [4] although management with a tunneled pleural catheter has become an alternative approach [5,6] and may result in spontaneous pleurodesis [7].
Successful chemical pleurodesis has been reported in case reports of patients with pleural effusions caused by chronic ambulatory peritoneal dialysis [8], yellow nail syndrome [9], chylothorax [10,11], lupus pleuritis [10,12], chronic kidney disease [13], and heart failure [14-16]. Although there are reports of success in hepatic hydrothorax [5,10,14,17,18], the rate of complications in pooled data from a systematic review was 82 percent [18]. Tunneled pleural catheters without chemical sclerosant for patients with hepatic hydrothorax have been reported to cause spontaneous pleurodesis in 33 percent of patients after a mean time of insertion of 132 days [19].
The management of patients with refractory nonmalignant pleural effusion is discussed in detail separately. (See "Management of nonmalignant pleural effusions in adults".)
Pneumothorax — Thoracoscopic pleurodesis and bedside methods of chemical pleurodesis (ie, non-thoracoscopic methods) successfully prevent the recurrence of primary and secondary spontaneous pneumothorax [1,20-23]. However, thoracoscopy with mechanical pleurodesis has benefits over chemical pleurodesis without thoracoscopy because thoracoscopy allows for simultaneous inspection and resection of subpleural blebs and bullae. In addition, thoracoscopic mechanical pleurodesis, although requiring longer hospital stays, does not expose the patient to possible risks related to talc. The rate of complications from the intrapleural installation of large particle talc, however, is low (see 'Complications' below). Comparatively, evidence suggests a similar reduction in recurrence from thoracoscopy as compared with chemical pleurodesis [21,23,24]. Thus, chemical pleurodesis is a reasonable option in those who prefer to avoid thoracoscopic surgery. Patients can undergo thoracoscopy with talc poudrage with reported recurrence rates for primary and secondary spontaneous pneumothoraces of 1.7 to 9.5 percent and 25 percent respectively [25-27].
The management of spontaneous pneumothorax is discussed in detail elsewhere. (See "Pneumothorax in adults: Epidemiology and etiology" and "Treatment of secondary spontaneous pneumothorax in adults".)
CONTRAINDICATIONS — Pleurodesis will fail if the lung cannot fully expand to the chest wall (eg, trapped lung, interstitial pulmonary fibrosis, endobronchial obstruction) because successful pleurodesis requires contact of the visceral and parietal pleura. Chemical pleurodesis should therefore not be attempted when the lung does not fully expand after therapeutic thoracentesis. Patients whose lungs cannot fully expand usually have radiographic evidence of a pneumothorax after thoracentesis or experience chest discomfort during thoracentesis before all pleural fluid is drained [28]. No clear-cut definition exists of an unexpandable lung or the ideal imaging study to confirm its existence to a degree that would prevent successful thoracentesis [29]. It is important to note that patients with unexpandable lungs due to malignant pleural disease still benefit symptomatically from pleural fluid drainage [29]. (See "Diagnosis and management of pleural causes of nonexpandable lung".)
For patients with malignant pleural effusions, 30 percent of patients referred for pleurodesis are found to have unexpandable lung [30,31]. Before attempting pleural drainage, the clinician should evaluate the position of the mediastinum on the chest radiograph. Normally, the mediastinum will shift away from a large effusion. If the mediastinum is shifted toward the effusion, it likely indicates that the pleural pressure on the side with the effusion is more negative than that on the contralateral side. Trapped lung (with fibrotic inelastic visceral pleura), entrapped lung (with an ongoing inflammatory or malignant process restricting expansion), endobronchial obstruction, or malignant encasement of the lung should be suspected. Of note, these same conditions can also result in a midline mediastinum despite the presence of a large effusion [32].
An additional way to assess whether a unexpandable lung is contributing to a pleural effusion is to perform pleural manometry at the time of therapeutic thoracentesis [33,34]. Manometry measures pleural pressure changes as pleural fluid is withdrawn and allows the calculation of pleural elastance at the end of the procedure. A final value for pleural elastance ≥19 cm H2O per liter of fluid removed indicates a high likelihood of a unexpandable lung and predicts pleurodesis failure. In centers that can standardize the technique and produce reliable results, pleural manometry provides helpful information to identify a unexpandable lung [34]. (See "Diagnosis and management of pleural causes of nonexpandable lung", section on 'Diagnosis'.)
A series of 155 patients with malignant pleural effusions undergoing talc pleurodesis through medical thoracoscopy (pleuroscopy with local anesthesia and moderate sedation) found that chest ultrasound performed before pleurodesis had a sensitivity of 91 percent and specificity of 88 percent in predicting successful pleurodesis [35]. Ultrasound findings of pleural adhesions and assessment of images for the potential for lung expansion were used to predict failure. This study also noted that longer times from detection of the effusions to the performance of pleurodesis had an independent association with pleurodesis failure. It is not known, however, whether this finding represents lead time bias. Guidelines for managing patients with malignant pleural effusions do not recommend early pleurodesis in asymptomatic patients in an effort to increase success rates [36].
No specific chemical characteristics of pleural fluid alone have sufficient predictive properties to be used to exclude individual patients with malignant effusions from consideration for pleurodesis [37]. In patients with malignant pleural effusions, certain chemical characteristics of pleural fluid make successful pleurodesis less likely, including pleural pH less than 7.20 or 7.30, pleural glucose less than 60 mg/dL, and lactate dehydrogenase greater than 600 U/L [38-41]. A meta-analysis found that these criteria predicted pleurodesis failure with a sensitivity of only 55 to 59 percent and a specificity of 65 to 78 percent [42]. An international study of patients diagnosed with malignant pleural effusions by video-assisted thoracoscopic surgery derived and validated a scoring system (the LENT prognostic score) to predict survival at one month, three months, and six months after diagnosis [43]. Elements used in the scoring system included pleural fluid lactate dehydrogenase (LDH), Eastern Cooperative Oncology Group (ECOG) performance score, blood neutrophil-to-lymphocyte ratio, and tumor type. Whether the LENT prognostic score can be used to assist decision making in selecting patients for chemical pleurodesis remains to be established. Lower pleural fluid LDH concentrations (<1500 International Units/L) correlated with better survival in a case series of 74 patients with adenocarcinoma of the lung [44]. Another study of 91 patients with malignant pleural effusions demonstrated that an ECOG score of 3 or 4 and previous chemotherapy or radiotherapy were independent predictors of a poor overall survival after video-assisted thoracoscopic surgery (VATS)-mediated talc pleurodesis [45]. Among patients with malignant effusions due to non-small cell lung cancer, presence of epidermal growth factor receptor mutations predicted a high success rate for pleurodesis (>90 percent) and median survival of 39 months when patients were treated sequentially with gefitinib followed by VATS talc pleurodesis when disease progression was noted [46,47].
The PROMISE Study [48] examined five patient cohorts to identify and validate biomarkers to develop a scoring system to predict survival >3 months and pleurodesis success. The study analyzed thousands of pleural proteins along with clinical, radiologic, and biologic variables and found a panel of factors that discriminated between high- and low-risk groups. High-risk patients had greater than a 75 percent chance of death within three months, and low-risk patients had less than a 25 percent chance of death. The study failed to predict pleurodesis success. The PROMISE score, however, is relatively complex and challenging to implement in daily practice [49].
For patients with pneumothorax referred for treatment, few robust data exist to predict which patients will benefit the most from any one of the multiple pleurodesis methods available [50].
CHOICE OF AGENT — Numerous chemical irritants have been used to induce pleurodesis. These include talc, tetracycline, minocycline, doxycycline, silver nitrate, iodopovidone, bleomycin, Corynebacterium parvum with parenteral methylprednisolone acetate, erythromycin, fluorouracil, interferon beta, autologous blood, mitomycin (also known as Mitomycin-C), cisplatin, cytarabine, doxorubicin, etoposide, bevacizumab (intravenous or intrapleural) and Streptococcus pyogenes A3 (OK-432) [1,51-58].
The characteristics of the agents most commonly used for chemical pleurodesis are described in the following sections. The choice among these agents is determined by several factors, including local expertise, availability of individual agents, and the underlying process for which chemical pleurodesis is needed. Unfortunately, a network meta-analysis of different comparative studies of pleurodesis agents noted considerable risk of bias, a paucity of patient-reported outcomes, and high heterogeneity between trials, which makes definitive recommendations difficult for selecting an ideal agent [59,60]. These issues are discussed further on the individual topic reviews. (See "Management of malignant pleural effusions" and "Management of nonmalignant pleural effusions in adults" and "Pneumothorax in adults: Epidemiology and etiology" and "Treatment of secondary spontaneous pneumothorax in adults".)
●Talc – Talc, a trilayered, magnesium sheet silicate, is the most effective and most commonly used agent. In two systematic reviews, talc was the chemical agent that most frequently resulted in successful pleurodesis (no recurrence of pleural fluid) [51,59]. Numerous additional studies have confirmed that talc is the most effective agent for pleurodesis [61], including three meta-analyses [62-64]. Taken together, these studies indicate that successful pleurodesis occurs in greater than 90 percent of patients treated with talc. However, such results have not been universal. One clinical trial of talc pleurodesis reported a lower success rate of 78 percent, 30 days after pleurodesis [30] and a phase II study in Japan demonstrated an efficacy of 83 percent of talc in 30 patients with malignant pleural effusions [58]. Accumulated experiences from meta-analyses and large prospective studies have supported talc as the optimum agent for chemical pleurodesis with an acceptable safety profile [59,65-67]. (See "Talc pleurodesis", section on 'What is talc'.)
●Tetracycline derivatives – Minocycline and doxycycline are used for pleurodesis. Success rates with these agents in most reports are lower than those with talc, with recurrence rates of 13 to 35 percent [68,69]. However, some clinicians prefer tetracycline derivatives for chemical pleurodesis in patients being treated for pneumothorax. (See "Pneumothorax: Definitive management and prevention of recurrence".)
●Silver nitrate and iodopovidone – Silver nitrate and iodopovidone have also been used for chemical pleurodesis. However, larger studies of these agents are necessary before their use can be recommended.
A randomized trial that compared silver nitrate to talc enrolled 60 patients with a symptomatic malignant pleural effusion who were randomly assigned to receive 5 g of talc slurry or a 0.5 percent solution of silver nitrate [70]. Both groups had similar efficacy at 30, 60, and 90 days, with no recurrence being observed in nearly all patients. Another randomized trial compared silver nitrate and tetracycline for 50 patients with malignant pleural effusions [71]. Both agents had similar rates of early and late recurrences of pleural effusions, and patients treated with silver nitrate had a lower incidence of chest pain and fever. A systematic review of silver nitrate pleurodesis by chest catheter or thoracoscopy reported that silver nitrate had a good side-effect profile and equal efficacy to talc pleurodesis in those studies that compared to two agents [72]. Silver nitrate has been shown in a small case series of 17 patients to produce pleurodesis in 89 percent of patients for whom prior talc pleurodesis had failed [73].
The efficacy of iodopovidone for pleurodesis was examined in two separate case series; iodopovidone induced successful pleurodesis in 86 to 96 percent of patients [74,75]. A randomized trial that enrolled 39 patients with malignant pleural effusions compared talc slurry (21 patients) and iodopovidone (18 patients) instilled through a chest tube [76]. No differences were noted in the number of patients who failed pleurodesis in the talc (four patients) as compared with the iodopovidone (five patients) group. Another randomized trial compared two concentrations of iodopovidone (1 versus 2 percent) in 60 patients with malignant pleural effusions mainly due to breast cancer with the purpose of systematically identifying adverse effects [77]. All but two patients had a successful pleurodesis. Pleuritic chest pain attributable to the pleurodesis was the most common adverse event occurring in 55 percent with 11 of the 60 patients having severe pain. The pain resolved within several hours after pleurodesis. Forty-one patients developed hypertensive spikes with 10 serious events, but none required therapy and were attributed to anxiety. Four patients developed hypotension with one serious event. Five patients experienced subclinical hypothyroidism 30 days after pleurodesis that resolved without treatment. Transient mild changes in blood tests of liver enzymes, electrolytes, and C-reactive protein were not considered clinically important.
●Bleomycin – Bleomycin is used less commonly for pleurodesis because of systemic toxicity and cost.
PATIENT PREPARATION — Each patient's medications should be reviewed prior to performing pleurodesis. Concomitant use of glucocorticoids may decrease the success of chemical pleurodesis, because pleurodesis requires pleural inflammation and glucocorticoids are potent antiinflammatory agents [35,78-80]. Previously, concern existed that nonsteroidal anti-inflammatory agents decreased the likelihood of a successful pleurodesis, but a study demonstrated no negative effects [81]. In our practice, we reduce or hold a patient's glucocorticoids 24 to 48 hours prior to pleurodesis if possible.
Systemic anticoagulation is generally reversed for placement of a chest tube; it is not necessary to hold anticoagulation for chemical pleurodesis once the chest tube is in place.
PROCEDURE VIA CHEST TUBE OR CATHETER
Pleural drainage — In preparation for pleurodesis for pleural effusion, the pleural space is drained by tube thoracostomy, using a small bore (12 to 14 Fr) catheter or tunneled pleural catheter (15.5 Fr) if one is already in place [82]. The relative advantages and disadvantages of small bore versus large bore (24 to 32 Fr) chest tubes remain controversial [83-86]. A randomized trial, however, that compared 12 Fr versus 24 Fr chest tubes found only a modest decrease in pain with the smaller tube but a higher pleurodesis failure rate with the smaller (30 percent) as compared with the larger (24 percent) tubes [81]. We use small bore catheters or tunneled pleural catheters because differences in outcomes relative to large bore tubes are modest, and we find small bore catheters better tolerated during insertion. There appears to be no effect on success rates for pleurodesis when small-bore catheters are placed into the ideal position by ultrasound guidance [87]. (See "Thoracostomy tubes and catheters: Placement techniques and complications", section on 'Patient preparation' and "Thoracostomy tubes and catheters: Indications and tube selection in adults and children".)
Previously, it was common practice to delay pleurodesis until daily chest tube drainage was less than 150 mL. However, this delay appears to be unnecessary as noted in two small randomized trials and a case series [88-90]. In one study, for example, 25 patients with malignant pleural effusions were randomly assigned to standard (15 patients) or short-term (10 patients) protocols [88]. In the standard protocol, tetracycline was instilled only after the lung had completely expanded and the chest tube drainage was less than 150 mL per day. In the short-term protocol, the same dose of tetracycline was instilled as soon as there was complete lung expansion, which was usually within 24 hours. Pleurodesis was successful in 80 percent of patients in both groups.
Case series support the feasibility of performing chemical pleurodesis via tunneled pleural catheters. One study reported successful pleurodesis in 92 percent of patients undergoing the instillation of talc slurry through a tunneled pleural catheter [91]. A prospective randomized trial comparing talc pleurodesis via a tunneled pleural catheter versus drainage of fluid via a tunneled pleural catheter alone reported pleurodesis success rates with talc of only 43 percent, which was higher than the spontaneous pleurodesis with drainage alone of 23 percent [92]. This low success rate of talc pleurodesis by tunneled pleural catheter is especially notable because of the large number of patient exclusions before randomization. Another study reported that successful pleurodesis rates with pleurodesis via tunneled pleural catheters may vary between 24 to 47 percent depending on frequency of fluid drainage, with daily drainage having a higher success rate as compared with alternate-day drainage [93]. This approach is now undergoing investigation in a multicenter randomized trial [94].
When pleurodesis is performed for pneumothorax, pleural air is drained until the lung is fully re-expanded.
Analgesia — Chemical pleurodesis via chest tubes can be painful; patients are usually pretreated with parenteral doses of an opiate (eg, morphine) or nonsteroidal anti-inflammatory drugs and an anxiolytic/amnestic agent (eg, midazolam). Additionally, the British Thoracic Society guidelines for managing malignant pleural effusions recommend that lidocaine (2 to 3 mg/kg; maximum 250 mg) should be instilled intrapleurally, just before administration of the sclerosant [95]. Postprocedure analgesia should be provided as necessary to maintain comfort. Patients undergoing pleurodesis by thoracoscopy require moderate sedation and local anesthesia for pleuroscopy and general anesthesia for video-assisted thoracoscopic surgery.
Sclerosant agents — We typically perform chemical pleurodesis using talc because of its demonstrated efficacy. As noted above, chemical pleurodesis can be performed using any of a number of different chemical agents, the most common of which are talc and the tetracycline derivative, doxycycline.
Talc — Chemical pleurodesis with talc can be accomplished with similar efficacy using insufflation (also called poudrage) during a thoracoscopy procedure or with slurry via an intercostal tube as described above [96]. Talc insufflation via medical thoracoscopy with local anesthesia and moderate sedation (also termed pleuroscopy) has been reported in randomized trials to have similar pleurodesis success rates at 90 days posttreatment as compared with instillation of talc slurry via intercostal chest tubes [97]. Generally, the dose of talc administered intrapleurally is 4 g for insufflation and 5 g for slurry. Size-calibrated talc that contains less than 10 percent of small particles (eg, 5 to 10 microns in diameter) should always be used. Commercially available United States talc has a median diameter of 26.57 microns with a range of particle sizes from 0.399 microns to 100.237 microns [98]. Further details about the two procedures, talc doses, and analgesia are provided separately. (See "Talc pleurodesis".)
Doxycycline — The typical dose of doxycycline used for intrapleural instillation is 500 mg dissolved in a total volume of 50 mL of normal saline [99,100].
Doxycycline pleurodesis is often painful, although not more painful than other pleural sclerosants [62]. Some practitioners add a local analgesic agent (eg, lidocaine, 25 mL [250 mg] of a 1 percent solution, or mepivacaine, 20 mL [400 mg] of 2 percent solution) to the doxycycline solution, although data supporting this are lacking [100,101]. Systemic absorption of the local anesthetic may be significant. In addition to local analgesia, systemic administration of an analgesic agent is usually necessary.
At least one case of acute hypoxic/hypercapnic respiratory failure has been reported after pleurodesis with doxycycline (300 mg) [102]. Chest radiograph showed no pulmonary opacities and the presence of high peak ventilator pressures suggested acute bronchospasm due to an anaphylactic reaction. The patient improved in a few hours with ventilatory support and bronchodilator therapy.
Others — Several other agents have been used including bleomycin, cisplatin, doxorubicin, etoposide, fluorouracil, interferon-beta, mitomycin, Corynebacterium parvum, and methylprednisolone [103].
Several agents are under investigation. In one retrospective study of an investigational agent, viscum, rates of successful pleurodesis were similar to those achieved with talc in patients with malignant pleural effusion [104]. Further studies are needed before it can be used routinely as an alternative to talc or tetracycline.
Technique — Chemical pleurodesis may be performed at the time of thoracoscopy, at the bedside in the hospital, or in an outpatient clinic. Talc insufflation, which is performed during thoracoscopy, is described in detail separately. (See "Talc pleurodesis", section on 'Talc insufflation'.)
When chemical pleurodesis is performed at the bedside via tube thoracostomy or a tunneled pleural catheter (eg, instillation of talc slurry or doxycycline), the usual protocol is as follows:
●Document good apposition of the pleural surfaces by chest radiograph.
●Ascertain adequate patient comfort and pain prevention, including intrapleural lidocaine.
●Administer the sclerosant agent (eg, talc, doxycycline) via the chest catheter. (See "Talc pleurodesis", section on 'Talc slurry' and 'Doxycycline' above.)
●Pleural fluid drainage through the chest catheter should be discontinued for one to two hours following instillation of the chemical irritant. Talc slurry distributes poorly; therefore, some clinicians rotate the patient. However, there is no evidence that such rotation improves the probability of successful pleurodesis [51]. Studies with tetracycline also show no need to rotate the patient [105,106].
●After the catheter has been reopened, the results of passive drainage are observed. Some clinicians apply chest catheter suction (-20 cm H2O) for at least 24 hours if drainage is sluggish and the lung is slow to re-expand to the chest wall.
●The traditional approach is to leave the chest tube in place until drainage is less than approximately 150 mL per 24 hours, although there are no scientific data to support this approach. The rationale is that ongoing pleural drainage helps to maintain apposition of the pleural surfaces and the chest tube is in place should repeat pleurodesis be needed. For example, if drainage is greater than 150 mL over 24 hours, repeat pleurodesis may be considered after 48 to 72 hours. Alternatively, some clinicians remove the chest tube within 24 hours after the instillation of talc or doxycycline, based on two small randomized trials showing no difference between the two approaches [88,107]. The largest trial randomly assigned 41 patients with a malignant pleural effusion to have their chest tube removed either 24 or 72 hours after talc pleurodesis; there was no difference in the success rate between the two groups [107]. Pending larger studies, we suggest leaving the chest tube in place until the rate of drainage of pleural fluid is <150 mL/day.
●If pleural fluid production persists despite chemical pleurodesis, use of a tunneled pleural catheter or thoracoscopic pleurodesis can be considered for secondary management. The options are discussed separately. Two studies have demonstrated pleurodesis success rates of 92 percent when pleurodesis is performed by thoracoscopic poudrage with intraoperative placement of a tunneled pleural catheter that is left in place for a median of six to eight days [108,109]. (See "Management of malignant pleural effusions" and "Management of nonmalignant pleural effusions in adults".)
COMPLICATIONS — The most common adverse sequelae of chemical pleurodesis are fever, pain, and GI symptoms [62]. Pain can be treated with opioids with the addition, if necessary, of nonsteroidal anti-inflammatory agents, which do not decrease the rate of success of pleurodesis [81]. Far less commonly, patients may experience respiratory failure, cardiovascular complications, a systemic inflammatory response, empyema, decreased lung volume, and dissemination of the chemical agent. Based on a meta-analysis (n = 1499), mortality is not increased among patients undergoing talc pleurodesis for a malignant pleural effusion compared with tube drainage alone or use of other sclerosants (eg, doxycycline, mitoxantrone) [62].
Most of the complications of pleurodesis appear to be related to the sclerosing process (eg, pain, cardiovascular side effects, systemic inflammation, empyema) and are likely to occur with all sclerosants, although some appear to be sclerosant- and dose-specific. As an example, increased systemic exposure to talc (eg, using more than 5 grams) appears to increase the risk of adverse sequelae, but does not increase the success rate. (See "Talc pleurodesis", section on 'Complications and safety'.)
Respiratory failure — The complication of acute respiratory failure, although rare, is more commonly seen after talc pleurodesis compared with other sclerosant agents. It is unlikely that the method of administration (insufflation versus slurry) plays a major role in the development of respiratory failure; however, the dose and mean particle size of talc may be important, because smaller particles can present an increased risk. This is discussed in detail separately. One case series of pleurodesis using graded-size talc noted no instances of respiratory failure in 558 patients [66]. (See "Talc pleurodesis", section on 'Complications and safety'.)
Cardiovascular — Cardiovascular complications, such as arrhythmias, cardiac arrest, chest pain, myocardial infarction, and hypotension, have been reported following pleurodesis [65]. However, it is unclear whether these complications are a result of the surgical procedure, co-morbid conditions, or the chemical irritant.
Inflammation — A mild systemic inflammatory reaction is common following chemical pleurodesis [65]. As an example, in a retrospective study of 35 patients, patients who received talc insufflation via thoracoscopy had an increased temperature, white blood cell count, and C-reactive protein level compared to patients that underwent thoracoscopy alone [110].
Empyema — Bacterial empyema has been reported following pleurodesis using talc slurry (0 to 11 percent), talc insufflation (0 to 3 percent), or rarely tetracycline [111,112]. Local site infection is uncommon. Pleurodesis via tunneled pleural catheters have a higher risk of cellulitis, catheter track, and intrapleural nosocomial infections as compared with pleurodesis via short-term intercostal chest tubes or thoracoscopy because of the longer times tunneled catheters are kept in place [96]. Risks of intrapleural infection from tunneled catheters among patients treated for malignant pleural effusions are especially high in patients with preprocedure evidence of trapped lung, multiloculated effusions, and febrile neutropenia [113].
Dissemination — Dissemination of talc into BAL fluid and multiple organs has been noted [114-116]. The dissemination of talc into extrapulmonary organs appears to be dose-related [117].
Cancer — A link between talc and cancer has been reported in individuals who mine and process talc [118]. This association has been attributed to asbestos within the talc. As a result, there is a theoretical concern that talc pleurodesis could place the patient at increased risk for mesothelioma or lung cancer [119]. However, the incidence of malignancy is not increased in patients who undergo talc pleurodesis and talc used for medical purposes is asbestos-free [120,121].
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Pleural effusion".)
SUMMARY AND RECOMMENDATIONS
●Malignant pleural effusion is the most common and widely accepted indication for chemical pleurodesis. In addition, chemical pleurodesis is sometimes used to manage refractory nonmalignant pleural effusions, recurrent primary spontaneous pneumothorax, and secondary spontaneous pneumothorax. (See 'Indications' above.)
●We suggest systemic glucocorticoid therapy be reduced or temporarily discontinued if possible prior to chemical pleurodesis (Grade 2C). We typically hold these medications for 24 to 48 hours prior to pleurodesis. (See 'Patient preparation' above.)
●The sclerosant agents used most commonly are talc and doxycycline. Talc slurry administered via chest tube appears equally effective compared with aerosolized talc administered via insufflation during thoracoscopy (also called poudrage). Doxycycline is a less effective alternative to talc. Chemical sclerosant can also be instilled through a tunneled pleural catheter. (See 'Sclerosant agents' above and "Talc pleurodesis".)
●After instillation of the sclerosant agent (eg, talc or doxycycline), the chest catheter drainage is discontinued for one to two hours, then drainage is resumed. We suggest leaving the chest catheter in place until fluid drainage is less than 150 mL per day rather than removal within the first 24 hours (Grade 2B). (See 'Technique' above.)
●The most common short term adverse effects of chemical pleurodesis include pain, fever, and gastrointestinal symptoms. More rare adverse effects include respiratory failure, cardiovascular complications, a mild systemic inflammatory reaction, and empyema. (See 'Complications' above.)
