Key Terms: Pleural effusion, Pleural space.
Definition
Pleurodesis is the adherence of the outer surface of a lung to the membrane surrounding that lung, which is performed to treat the buildup of fluid around the lung.
Purpose
The pleural space is the region between the outer surface of each lung (visceral pleurae) and the membrane that surrounds each lung (parietal pleurae). Under normal conditions, the pleurae are kept wet with pleural fluid to allow movement of the lungs within the chest. Pleural effusion, the accumulation of fluid in the pleural space, is most commonly caused by cancer. Pleurodesis causes the pleurae to stick together, thereby eliminating the pleural space and preventing fluid accumulation. Chemical pleurodesis is considered to be the standard of care for patients with malignant pleural effusion.
Description
Before pleurodesis is conducted, all pleural fluid must be removed. This is achieved by inserting a chest tube through the skin and into the pleural space (thoracostomy). Insertion of the chest tube is carried out in the hospital. The patient is awake during the procedure. The skin is sterilized and a local pain killer is injected into the skin and underlying tissue. A small cut is made into the skin and a tube is placed into the pleural space. Fluid is withdrawn and the tube remains in place until all pleural fluid is drained, which usually takes two to five days. After the chest tube is inserted, the patient may either remain in the hospital or be allowed to return home with instructions on how to care for the tube. A chest x ray may be taken to ensure that all the fluid has been drained.
Pleurodesis is achieved by putting one of any number of chemicals (sclerosing agents or sclerosants) into the pleural space. The sclerosant irritates the pleurae which results in inflammation (pleuritis) and causes the pleurae to stick together. The patient is given a narcotic pain reliever and lidocaine, a local pain killer, is added to the sclerosant. A variety of different chemicals are used as sclerosing agents. There is no one sclerosant that is more effective or safer than the others. Commonly used sclerosants and their success rates are:
- Talc: 90% to 96%
- Nitrogen mustard: 52%
- Doxycycline: 90%
- Bleomycin: 84%
- Quinacrine: 70% to 90%
After the sclerosant has been put through the chest tube, the tube is closed. The patient may be asked to change position every 15 minutes for a two-hour time period. This was believed to be necessary to achieve an even distribution of sclerosant in the pleural space. However, recent evidence suggests that the sclerosant spreads throughout the pleural space immediately. Afterward, the chest tube is reopened and the sclerosant is sucked out of the pleural space. The tube remains in place for several days to allow all fluid to drain. Once drainage slows down, the chest tube is removed and the wound edges stitched (sutured) back together.
Aftercare
The patient should keep the wound from the chest tube clean and dry until it heals. Also, the patient should watch for signs of wound infection such as redness, swelling, and/or drainage, and be alert to symptoms indicating that the effusion recurred.
Risks
Complications of pleurodesis are uncommon and include infection, bleeding, acute respiratory distress syndrome, collapsed lung (pneumothorax), and respiratory failure. In addition, other complications may be specific for each sclerosant. Talc and doxycycline can cause fever and pain. Quinacrine can cause low blood pressure, fever, and hallucination. Bleomycin can cause fever, pain, and nausea. Severe respiratory complications can be fatal.
Normal Results
Tube thoracostomy with pleurodesis is the most effective method to treat malignant pleural effusion. Successful pleurodesis prevents the recurrence of pleural effusion which relieves symptoms thereby improving quality of life.
Questions to Ask the Doctor
- Will I be hospitalized the entire time?
- How long will I be hospitalized?
- Is it possible to do this on an outpatient basis?
- How uncomfortable is the chest tube?
- Will I be given pain medication as needed?
- Will having a chest tube limit my movements in any way?
- Will I be confined to bed?
- Which sclerosant will you be using?
- Why are you using this sclerosant?
- What are the side effects of this sclerosant?
- What is the success rate associated with this sclerosant?
- How painful is the pleurodesis process?
Abnormal Results
If drainage of sclerosant from the chest tube exceeds approximately one cup, the pleurodesis was unsuccessful and needs to be repeated. Pleurodesis may fail because of:
- trapped lung, in which the lung is enclosed in scar or tumor tissue
- formation of isolated pockets (loculation) within the pleural space
- loss of lung flexibility (elasticity)
- production of large amounts of pleural fluid
- extensive spread (metastasis) of pleural cancer
- improper positioning of the tube
- blockage or kinking of the tube
Resources
Books
Baciewicz, Frank. "Malignant Pleural Effusion." In Lung Cancer: Principles and Practice, edited by Harvey Pass, James Mitchell, David Johnson, Andrew Turrisi, and John Mina. Philadelphia: Lippincott Williams & Wilkins, 2000, pp.1027–1037.
Schrump, David, and Dao Nguyen. "Malignant Pleural and Pericardial Effusions." In Cancer: Principles & Practice of Oncology, edited by DeVita, Vincent, Samuel Hellman, and Steven Rosenberg. Philadelphia: Lippincott Williams & Wilkins, 2001, pp.2729–44.
Works, Claire, and Mary Maxwell. "Malignant Effusions and Edemas." In Cancer Nursing: Principles and Practice, edited by Connie Yarbro, Michelle Goodman, Margaret Frogge, and Susan Groenwald. Boston: Jones and Bartlett Publishers, 2000, pp.813–830.
Periodicals
Colice, Gene, and Jeffrey Rubins. "Practical Management of Pleural Effusions: When and How Should Fluid Accumulations be Drained?" Postgraduate Medicine 105 (June 1999): 67–77.
Erasmus, Jeremy, Philip Goodman, and Edward Patz. "Management of Malignant Pleural Effusions and Pneumothorax." Radiologic Clinics of North America: Interventional Chest Radiology 38 (March 2000): 375–83.
—Belinda Rowland, Ph.D.
