Overview of Pleurodesis
Pleurodesis is a medical treatment used to stick the two layers of your lung’s outer covering together. This is done to stop air or fluid from filling up the space between these layers, which can cause difficulty in breathing or severe discomfort. Pleurodesis is commonly used to manage recurring collections of fluid in the lung space mainly caused by advanced cancers, such as those of the breast, ovaries, or lungs. It’s also used to treat a condition called pneumothorax – this is when air collects between the two layers causing the lung to collapse. By sticking the two layers together, pleurodesis can reduce breathing difficulty, lessen discomfort, shorten hospital stays, and lower treatment costs, especially for patients with a limited lifespan.
There are two ways to perform pleurodesis: chemical and mechanical methods. In chemical pleurodesis, a sclerosant (a substance causing hardening of a body part) such as talc, tetracycline derivatives, or iodopovidone is inserted into the space between the lung layers. This causes inflammation and scarring leading to the sticking of the two layers. This method is particularly effective for recurrent lung fluid collections due to cancer. Mechanical pleurodesis is often performed during video-assisted chest wall surgery or thoracotomy (surgery involving an incision into the chest). In this method, the outer covering of the lungs is physically scratched to achieve a similar sticking result and is usually recommended for patients at risk of a recurring pneumothorax. Advances in pleurodesis techniques and agents continue to improve patient results and enhance the effectiveness of the procedure.
Anatomy and Physiology of Pleurodesis
The pleural cavity is a small space between the two layers of tissue (the parietal and visceral pleura) that cover your lungs. In a healthy person, this space usually contains a small amount of fluid (around 10-20mL) which allows the lungs to move smoothly when you breathe. The covering of your chest wall, diaphragm and the space between the lungs is called the parietal pleura while the visceral covers directly your lungs themselves. These layers are made up of specific cells, located in a framework of special tissue containing blood vessels and nerves.
Normally, the amount of fluid that your body makes and gets rid of is balanced, so there’s no extra build-up. But certain diseases like malignant pleural effusions (fluid build-up due to cancer) or pneumothorax (air leaks into the space between chest wall and lung) can disrupt this balance. When this happens, you might find it hard to breathe, which means you’ll need medical treatment to remove the excess fluid or air.
Pleurodesis is a treatment that aims to remove the space between the two layers covering your lungs by causing them to stick together. Doctors achieve this by using chemicals (like talc) or by roughing up the tissues. This causes injury which starts an inflammation process. Various elements of the body’s immune system – such as inflammation-signaling cells, proteins involved in cell growth, and immune cells – create a chain reaction that ends up in the production of fibrous adhesions. These adhesions make the two layers stick together, preventing any fluid or air from building up again. The success of this treatment relies heavily on the normal functioning of the cells lining the pleural space and a strong inflammatory response. For this reason, understanding the detailed anatomy of the pleural space and the mechanisms causing abnormal fluid dynamics is vital to make sure this procedure is effective.
Why do People Need Pleurodesis
The main reason a person might need a procedure called a pleurodesis is if they have a condition known as malignant pleural effusion. This is a serious condition where fluid builds up in the space between the lungs and the chest wall, and it is often related to cancer. It can cause feelings of breathlessness and reduce a person’s quality of life. Pleurodesis is a procedure that stops this fluid from building up again, which can help to relieve these symptoms.
This procedure might also be recommended for people who keep getting a build-up of fluid in the chest (called a pleural effusion) or air in the chest (called a pneumothorax). Whether the cause is cancerous or not, the frequent recurrence of these conditions can be problematic.
There are several ways to manage these conditions, but pleurodesis is only chosen after a detailed talk with the patient. This helps the doctor make sure the procedure fits with the patient’s wishes and health goals. If a person is not a good candidate for surgery, a medical pleurodesis, which uses medicines instead of surgery, may be a better choice.
Pleurodesis can be done using chemicals or mechanically. Chemical pleurodesis is recommended for malignant pleural effusions, stubborn non-cancerous effusions (for example those related to a leak in the lymphatic system, liver disease, kidney disease, or heart failure), a first-time primary pneumothorax, or a repeat secondary pneumothorax.
On the other hand, mechanical pleurodesis is used in similar cases but can also deal with the underlying cause at the same time. For example, during a type of minimally invasive surgery called VATS (Video-Assisted Thoracoscopic Surgery), doctors can carry out pleurodesis while also removing small air-filled sacs (called subpleural blebs or bullae) that may be causing recurrent pneumothorax. By removing the space where fluid or air builds up, pleurodesis lowers the chances of recurrence and improves long-term results.
When a Person Should Avoid Pleurodesis
Pleurodesis, a treatment that sticks the two layers of the tissue surrounding the lungs together, is not suitable for everyone. If you’re suffering from a condition that could make the treatment unsuccessful or dangerous, it’s not recommended. One major reason you might not be able to have pleurodesis is a condition known as a nonexpandable lung (NEL). This often happens to people with malignant pleural effusion, a condition where fluid accumulates in the space around the lungs. This fluid build-up can stop the lungs from expanding because it blocks or fills up the breathing tubes or infiltrates the lung lining.
How do you know if you have NEL? Symptoms include having fluid in the lungs even after it’s been drained, being unable to drain all the fluid, severe coughing, or chest pain when the fluid is being drained. When the lung can’t expand due to the fluid, this causes negative pressure in the area around the lungs, making more fluid leak out into this space and leading to the fluid coming back again and again. It’s important to know if you have this condition, as it would make treatment attempts useless, possibly even harmful, and it could reduce your quality of life. If your lung is trapped due to a tumor, there are other treatments that are more effective, such as draining the fluid intermittently or having a permanent drain inserted into the space around the lungs.
Pleurodesis relies on the tissue surrounding the lungs being able to touch. If your lungs can’t fully expand, for example due to NEL or not being able to drain all the fluid, this can make pleurodesis unsuccessful. One way to identify NEL is to measure the pressure in the space around the lungs while the fluid is being drained. If the pressure increases by 19 cm of water or more for every liter of fluid removed, this is a sign that the lung can’t fully expand and that pleurodesis is likely to fail. As such, doctors generally don’t recommend this treatment for patients with a high pressure reading, and they usually recommend a physical form of pleurodesis instead. There may, however, be exceptions for people with tiny, isolated pockets of air in the chest (known as loculated pneumothoraces), or for people who refuse physical pleurodesis.
Other factors that can make pleurodesis unsuccessful include having had radiation for chest issues before, or having a chest tube in for more than 10 days. Factors that increase the risk of death from pleurodesis include having less than 50% normal ability to perform daily activities (measured using the Karnofsky index), being underweight (body mass index less than 25 kg/m2), being male, and having cancer. Moreover, if doctors expect you to live less than 3 months, they usually recommend draining fluid as needed instead of pleurodesis. Lastly, you shouldn’t get pleurodesis if you have an active infection in the area around your lungs, bleeding issues, you’re not stable enough for the procedure, you don’t give your consent, or if there is more than a cup and a quarter of fluid draining out of your chest.
Equipment used for Pleurodesis
Pleurodesis is a medical procedure that manages fluid buildup in the space around the lungs (known as the pleural cavity). This is done by creating inflammation which leads to scars or adhesions in the lung lining (parietal and visceral pleura). A perfect substance or sclerosing agent for achieving this would be affordable, readily available, easy to use, highly effective in causing the scarring and would cause few side effects. However, no perfect substance exists at this point. Various substances like a patient’s own blood, doxycycline, iodopovidone, Streptococcus pyogenes A3 (also known as OK-432), and silver nitrate have been tried.
Talc is widely considered the safest and most effective option currently available. Pleurodesis with talc has an 80% to 95% success rate, depending on factors such as the talc dosage, how often it’s applied, the patient’s specific condition, and overall health. While other substances are usually effective, they are not superior to talc.
Some of the sclerosing agents that can be used for pleurodesis include:
* Talc
* Tetracyclines (like minocycline, doxycycline)
* Silver nitrate
* Iodopovidone
* Bleomycin
* Corynebacterium parvum
* Erythromycin
* Fluorouracil
* Interferon beta
* A patient’s own blood
* Mitomycin C
* Cisplatin
* Cytarabine
* Doxorubicin
* Etoposide
* Bevacizumab (can be given either through the vein or into the pleural space)
* OK-432
The decision to use a particular agent depends on factors such as local expertise, availability of specific agents, and the exact condition for which the procedure is being performed. The agent is delivered into the pleural space through a tube. The tube can vary in size from larger ones (24 French or Fr) to smaller ones (12 Fr).
In addition to the sclerosing agent, other items needed for the procedure include:
* A chest drain tube with a three-way stopper
* A 25-milliliter (ml) drug-filled injection (lidocaine) to numb the area
* Sterile gloves
* Sterile saltwater solution (50 ml of saline)
* 20 ml and 50 ml injection syringes
* Pain medication other than nonsteroidal anti-inflammatory drugs
Avoiding larger chest tubes (over 16 French) is recommended because smaller ones result in smaller cuts and less pain during and after insertion. However, a study comparing large and small tubes for delivering the sclerosing agent showed no difference in terms of success rates and complication rates. Another study (TIME1 trial) suggested that larger tubes might be more effective than smaller ones for successful pleurodesis.
Who is needed to perform Pleurodesis?
Doctors who specialize in lung conditions, called pulmonologists, can conduct a treatment known as medical pleurodesis. This treatment can usually be done right at the patient’s bedside with the help of local anesthesia, a type of medication that numbs a specific area of the body so you don’t feel pain during the procedure.
However, a different version of this treatment, mechanical pleurodesis, has to be done in an operating room. This procedure needs general anesthesia, a medicine that makes you sleep and not feel any pain. It is carried out by a thoracic surgeon, a special kind of doctor who operates on organs in the chest. This could involve either an open thoracotomy, which is a bigger cut in the chest, or a procedure called VATS (video-assisted thoracoscopic surgery), which uses a small camera and smaller cuts.
Preparing for Pleurodesis
Before having a medical procedure called pleurodesis, there are a few important steps to make sure things go as smoothly as possible. The first step is to select and evaluate the right patients for the procedure. This helps to improve the success of the treatment, reduce possible complications, and ensure patient safety.
Next, the doctors should discuss with the patient about why this procedure is needed, what other options there may be, and what risks are associated with it. This is a process known as informed consent, and it’s important because it makes sure that the patient understands everything fully and agrees to the treatment.
It is also necessary for the medical team to mark the area where the procedure will take place and check that the patient has been fasting (meaning they have not eaten anything), often referred to as ‘nil per os’.
Preparation of the team involves making sure all necessary equipment is available. This includes chest tubes (tubes placed in the chest to drain fluid or air), sclerosants (substance used to cause intentional scarring), and imaging tools (machines that help doctors see inside the body). In addition to this, the readiness of the team, who will help with the procedure, must be confirmed.
A plan for sedation (medication to help the patient relax or sleep) and anesthesia (medication to block the feeling of pain) should also be established beforehand.
Lastly, for a type of pleurodesis that uses chemicals, a chest tube should already be in place, the lung should be fully expanded against the chest wall, and there should be less than 100 mL of fluid drained from the chest in the last 24 hours.
How is Pleurodesis performed
There are different methods to treat excessive fluid build-up in your chest, a condition known as pleural effusion. The goal of these treatments is to stick the two layers of tissue (pleura) that line your lungs together. This prevents fluid from accumulating in the space between these layers, making it easier for you to breathe. This process is known as a pleurodesis.
The methods used for pleurodesis can vary depending on the hospital, your doctor’s preference, the type of disease you have, and other factors like how well you tolerate pain. One common approach is chemical pleurodesis. This involves using a substance that causes scarring, like talc powder, to irritate the lining of your lungs and make them stick together. The talc, which is mainly a type of mineral, triggers a strong response from your body that causes inflammation and scarring. This can be administered through a small tube that is inserted into your chest or via a special surgical procedure. Generally, using a smaller tube is preferred as it can be less painful for you.
Your doctor may numb the area with a local anesthetic before they administer the talc. After the talc is given, the tube will be closed off for a few hours to let the talc work effectively. During this time, you may need additional medication to manage any pain. After a few hours, the tube will be reopened to resume draining any leftover fluid. You’ll have a chest X-ray a day after the procedure to confirm that no air or fluid is stuck in your chest.
Another approach for pleurodesis is a surgical procedure known as pleurectomy, which involves removing the lining of your lungs. This is typically done if other approaches didn’t work or you have a specific type of disease, such as mesothelioma. However, this procedure can be complex and may not improve your life expectancy, so it’s only considered if you’re in good health otherwise.
A third option is mechanical pleurodesis, which is done through a small surgical procedure. During this treatment, a special instrument is used to gently scrape the lining of your lungs and cause scarring. After your doctor confirms that the scraping was successful, a small tube will be inserted into your chest to drain any remaining fluid or air.
The choice of which method to use will depend on various factors like your overall health, the severity of your symptoms, the root cause of the fluid build-up, and your doctor’s judgment.
Possible Complications of Pleurodesis
Pleurodesis is a procedure used to treat recurring fluid buildup in the chest or lung collapse (also known as recurrent pleural effusions and pneumothoraces). While it can effectively manage these conditions, it’s not without its risks. The success rates can vary depending on the patient’s health, the type of tumor involved, and specific details about how the procedure is performed.
Possible complications of Pleurodesis can include:
- Pain and inflammation: Chest pain can occur due to the inflammation caused by the chemical agents or physical friction used in the procedure. Fever can also occur as the body responds to inflammation.
- Infection: If strict cleanliness guidelines aren’t followed during the procedure, there’s a risk of infection in the chest cavity.
- Breathing troubles: Some potential complications can affect the lungs, like a punctured or collapsed lung (pneumothorax), blood in the chest cavity (hemothorax), fluid buildup in the lungs due to rapid re-expansion (reexpansion pulmonary edema), and a severe lung condition known as acute respiratory distress syndrome (ARDS).
- General body inflammation: System-wide inflammation, irregular blood clotting, and blood clots in the lungs (pulmonary embolism) have all been associated with chemical pleurodesis.
- Procedure failure: In some situations, the lung gets trapped or isn’t able to fully expand, or there’s not enough inflammation to seal the lung to the chest wall, leading to procedural failure.
- Surgical complications: There are also risks related to being put under general anesthesia, surgical wound infection, and lung collapse after surgery (atelectasis).
The success of this procedure can greatly depend on multiple factors. How well the procedure works can be influenced by the amount and type of cancer present, and the specific qualities of the fluid in the chest cavity. If a type of cancer like diffuse mesothelioma or metastatic carcinomas is present, it can limit the body’s inflammation response. In one study, they found that low pH and glucose levels in the chest fluid were linked to shorter survival times and higher failure rates.
Healthcare providers need to carefully select suitable patients, perform the procedure with attention to detail, and adjust the treatment plan based on the patient’s specific needs. Regular check-ups after the procedure are essential to identify and manage any side effects early on.
What Else Should I Know About Pleurodesis?
Pleurodesis is a medical procedure aimed at patients suffering from too much air or fluid, like pus, blood, or other liquids, building up between the lungs and the chest wall. This excess air or fluid can reduce the patient’s ability to breathe comfortably, cause chest pain, and affect their quality of life. The procedure prevents this harmful build-up by causing the two layers of tissue lining the lungs to stick together, closing off the space where fluid can gather.
This treatment is particularly useful for patients with advanced cancer, as it can assist in reducing the need for repeated procedures to drain the fluid, enabling them to live more comfortably. However, a patient’s individual circumstances, such as the acidity (pH) and sugar (glucose) levels of the fluid, the size of tumor, and the lung’s ability to expand, can affect the procedure’s success.
Pleurodesis can also provide a lasting solution for recurring pneumothorax, which is a condition where air collects in the chest, causing a lung to collapse. It is an especially valuable treatment option for high-risk patients who may not be suitable candidates for more invasive surgeries. There are different types of pleurodesis treatments available. The patient’s specific conditions, their preferences, and the medical team’s experience will help determine the most suitable option.
This procedure can also help patients suffering from non-cancerous conditions, such as chylothorax (leakage of a type of body fluid into the chest) and hepatic hydrothorax (fluid build-up due to severe liver disease), especially when other treatments are not effective. By directly addressing the root cause and preventing recurrence, pleurodesis can alleviate symptoms, reduce the need for repeated hospital visits and invasive procedures, therefore playing a vital role in managing lung-related diseases.
