What Type of Procedure is a Pleurodesis?

Pleurodesis Indications, Procedure, and Complications

diagram of the lungs
A pleurodesis is a procedure often done for pleural effusions. istockphoto.com

Pleurodesis is a procedure sometimes performed for people with lung cancer and other conditions. What does this procedure entail and when might it be recommended?

Pleurodesis – The Definition

Pleurodesis is a procedure that is designed to get the two layers of the lung lining (the pleura) to stick together. This works to obliterate the space between the layers (the pleural cavity) so that fluid (water, blood, or pus) can no longer build up between the layers.

There is ordinarily three to four teaspoons of fluid between the outside (parietal) and inside (visceral) pleural membranes. When a pleural effusion occurs, due to both benign and malignant causes, this amount of fluid builds up and the pleural space can sometimes hold a few extra liters of fluid.

Before a pleurodesis is recommended, doctors want to first see that a pleural effusion (or pneumothorax) will recur again in the future. If it is a one-time event, performing a thoracentesis to remove the fluid is often all that is needed. Unfortunately, benign pleural effusion (and pneumothoraces) and especially malignant pleural effusion often recur.

Pleurodesis Procedure

In a pleurodesis, a chemical is injected between the two pleural layers via a chest tube. These chemicals then cause inflammation which in turn causes scarring. This scarring pulls and holds the two membranes together so that fluid or air can no longer build up and collect in the space.

The inner pleural lining is called the visceral pleura, and the outside pleural membrane is called the parietal pleura. Depending upon the underlying condition, the procedure may be done through a small incision (video-assisted thoracoscopy or VATS) or a thoracotomy (open lung surgery.)

There are two types of pleurodesis, which are often used together:

  • Mechanical pleurodesis causes inflammation and scarring by mechanically rubbing the parietal (outside) pleura with gauze.
  • Chemical pleurodesis involves injecting a chemical (most often talc) between the pleural membranes to create inflammation and scarring (fibrosis.)

Reasons a Pleurodesis May be Performed

There are several conditions for which a pleurodesis may be done, which in turn result from medical conditions such as lung cancer, mesothelioma, cystic fibrosis, and other illnesses.

  • Malignant pleural effusion – People with lung cancer, breast cancer, or metastases to the lung from other cancers may develop a malignant pleural effusion, a pleural effusion which contains cancer cells. When this is the case there are 2 options. One is to do a thoracentesis and place a stent that will continually drain the fluid in the effusion to another part of the body (an indwelling pleural catheter or tunneled pleural catheter.) The other is pleurodesis.  
  • Recurrent pleural effusion
  • Persistent pneumothorax - A pneumothorax is a term used to describe a collapsed lung. If a pneumothorax occurs and a chest tube is placed, the pneumothorax often resolves. If the pneumothorax persists (a persistent air leak,) or goes away and then recurs, further treatment to resolve the pneumothorax or prevent a recurrence are needed.
  • Recurrent pneumothorax

Before a Pleurodesis - Preparation

Before a pleurodesis is performed, physicians consider several things.

Most importantly, it’s important that removing the pleural fluid results in an improvement of symptoms (decreased shortness of breath) for those with cancer. A pleural effusion which is not causing symptoms such as chest pain or shortness of breath in this setting is usually left alone. In addition to this, some physicians recommend the procedure only if life expectancy is greater than one month.

On the other hand, spontaneous pneumothoraces may occur in people who are young and otherwise healthy.

In this case, the procedure may be done to prevent another pneumothorax from occurring in the future.

Complications

In general, a pleurodesis procedure is well tolerated. For a certain percentage of people, the procedure will be ineffective and further treatment with an indwelling catheter to drain the fluid, or a pleurectomy (removal of the pleural) will be needed. Another concern, for people who may have a lung transplant in the future, is that a previous pleurodesis can make this procedure more difficult.

For those who have pleural effusion due to minor conditions, or have recurrent pneumothoraces (often related to a hereditary factor,) pleurodesis can bring reassurance that another effusion or pneumothorax will not occur when immediate medical help is not available.

Example: Frank's lung cancer was causing recurrent pleural effusions, so his doctor recommended that he have a procedure called pleurodesis.

Sources:

Davies, H. et al. Effect of an Indwelling Pleural Catheter vs Chest Tube and Talc Pleurodesis for Relieving Dyspnea in Patients With Malignant Pleural Effusions. The TIME2 Randomized Controlled Trial. JAMA. 2012. 307(22):2383-2389.

Dugan, K., Laxmanan, B., Murgu, S., and D. Hogarth. Management of Persistent Air Leaks. Chest. 2017 Mar 3. (Epub ahead of print).

Fortin, M., and A. Tremblay. Pleural controversies: indwelling pleural catheter vs pleurodesis for malignant pleural effusions. Journal of Thoracic Disease. 2015. 7(6):1052-7.

Lenker, A., Mayer, D., and S. Bernard. Interventions to Treat Malignant Pleural Effusions. Clinical Journal of Oncology Nursing. 2015. 19(5):501-504.

Thomas, J., and A. Musani. Malignant pleural effusions: a review. Clinics in Chest Medicine. 2013. 34(3):459-71.

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