Chemical Pleurodesis for Malignant Pleural Effusion

A pleural effusion is an abnormal accumulation of fluid in the pleural space (the area between the two layers (parietal and visceral pleura) covering the lung). When this fluid occurs, it can cause shortness of breath, a fast heart rate (tachycardia) and difficulty breathing, especially when lying flat. These symptoms can occur gradually or suddenly. The diagnosis of a pleural effusion is usually made after obtaining a chest x-ray. Once the diagnosis of a pleural effusion is made, your doctor may recommend that a thoracentesis (removal of a sample of the fluid from the pleural effusion) be done to determine the cause of the fluid accumulation.

This procedure can done in the doctor's office or with CT or ultrasound guidance, under a local anesthetic. A small needle is inserted into the chest and is sent to the cytology department for review. It may take up to 5 days to get the results from this review. Your doctor will discuss the results with you.

Once the diagnosis is made, your doctor may recommend that you see a thoracic (chest) surgeon. This doctor will discuss the treatment options available to you. Usually, if the fluid is causing you to have trouble breathing, the thoracic surgeon may recommend chemical pleurodesis. The goal of chemical pleurodesis is to cause an irritation between the two layers covering the lung. This irritation causes an obliteration of the space between the layers where the fluid accumulated, and prevents further fluid to be able to accumulate there. There are a variety of agents, which can be used including talc and bleomycin. The procedure can be done at the bedside or in the operating room.

The bedside procedure involves the insertion of a chest tube under a local anesthetic. A sedative may be also given, either by mouth or through an intravenous catheter (IV). The chest tube is usually placed in the lower part of the chest, near your underarm. A dressing is applied to around the chest tube and is taped in place. The fluid drains through the chest tube into a collection container called a Pleur-e-vac. This container is usually connected to suction to allow adequate drainage of the fluid. Once the fluid has been adequately drained through the chest tube, a solution of talc (or other agent, depending on the preference of the surgeon) is inserted. The chest tube is then clamped, to keep the talc solution from draining out immediately. You will be asked to change positions in order for the talc to be well distributed throughout the chest. The chest tube is connected to the Pleur-e-vac.

The second option for chemical pleurodesis is to have it performed in the operating room, under video-assisted thoracoscopy (VATS) surgery. This requires a general anesthetic, which is given by an anesthesiologist. After you are asleep, the thoracic surgeon inserts the thoracoscope through a small incision in your chest. The pleural fluid is removed. If necessary, pleural biopsies can be obtained. A talc solution is then insufflated (blown in) over the lung and pleural surfaces. A chest tube is then inserted and connected to a collection container, which is connected to suction. The chest tube remains in place (with a dressing over it) until the doctor determines the fluid output to be significantly decreased.

An additional treatment option includes having a very small drainage tube inserted by the doctor. This tube is then connected to a portable bulb collection device (called a Pleurex) and you are sent home with it for 2-3 weeks to drain the effusion. Once the fluid is drained, the lung re-expands and eventually pleurodesis occurs this way as well.

Once your doctor determines the drainage is adequately decreased, the chest tube is removed (after a chest x-ray is obtained and confirms there is no significant amount of fluid left in the chest). A dressing is applied over the chest tube site and should be left in place for 24-48 hours, depending on your doctor's preference. It is common to experience a fever after this procedure and you may have some pain at the chest tube site or when taking a deep breath. Pain medication will most likely be prescribed for you. You should avoid taking Ibuprofen, or any anti- inflammatory agents for a period of time specified by your doctor after this procedure to allow irritation necessary to obliterate the pleural space. Ask your doctor when you can restart anti-inflammatory agents if you normally take these. Also be aware that if you are taking pain medicine, you can become easily constipated. Increasing fiber in your diet and eating prunes (or drinking prune juice) can help prevent constipation.

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From Supportive Cancer Care: by Ernest H. Rosenbaum, MD & Isadora R. Rosenbaum, MA
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