Pleurodesis

Pleurodesis is a surgical procedure in which a permanent pleurosymphysis is performed. For this purpose, the parietal pleura is permanently connected to the visceral pleura by means of fibrous sclerotherapy with drugs.

Pleurodesis serves to prevent recurrences of pneumothorax, pleural effusion, etc.

Indication

The indication for pleurodesis is given in patients with recurrent pleural effusion or pneumothorax. These patients suffer from symptoms such as dyspnoea (especially under stress), chesty cough and chest pain. Since the clientele is predominantly patients with malignant diseases in an advanced stage, care should be taken to ensure that the Karnofsky Index is still 40 or > 40. Patients with a lower index are only expected to have a survival time of < 30 days.

Pleurodesis can be performed with different pharmacological substances that have different efficacy and potential for side effects. These include:

1. talcum:

The success rate is 93%. Undesirable side effects include chest pain (7%) and fever (16%).

Dosage: 2,5 - 10 g

2. tetracycline:

The success rate is 67%. Undesirable side effects include chest pain (14%) and fever (10%).

Dosage: 500 mg - 20 mg / kg bw

3. doxycycline

The success rate is 72 %. Undesirable side effects include thoracic pain (40%).

Dosage: 500 mg

4. bleomycin

The success rate is 54%. Undesirable side effects include chest pain (28 %), fever (24 %) and nausea (11 %).

Dosage: 15 - 240 units

5. corynebacterium parvum

The success rate is 76 %. Undesirable side effects include chest pain (43 %), fever (59 %), nausea (3 %) and chesty cough (6 %). Dosage: 3,5 - 14 mg

Talcum has therefore the highest effectiveness and the lowest complication rate and is therefore used most frequently.

The effectiveness of pleurodesis is higher if the pleural space has been completely emptied beforehand.

However, a significant discrepancy in the complication rate of ARDS (Adult Respiratory Distress Syndrome) between the USA and Europe is striking. In English-speaking countries, 4 - 9 % of pleurodeses have ARDS, whereas in continental Europe the rate is almost 0 %.

One suspects a cause in the particle size. In the USA 50 % of the particles have a size of < 15 µg. In Germany, on the other hand, the size of the particles is between 10 µg and 50 µg. Particles < 3 µg should not have a fibrosing effect.

In about 21.8% of pleural effusions, these are caused by a malignant disease. A pleurodesis is usually only performed in an advanced tumour stage, at a point in time when a curative approach is no longer possible. Exact figures are not available.

Complications: Empyema, ARDS

Contraindication: A prerequisite for the success of a pleurodesis is the ability of the lung to be able to fully unfold again after emptying the pleural space.

However, this possibility is no longer given with the following diseases:

• Bronchial obstruction
• Atelectasis
• pronounced pleural carcinosis (so-called tied up lung)

Patients with such diseases should be excluded from pleurodesis at the beginning of treatment, as no improvement is to be expected from the procedure.

1. Gerok W et al.(2007) Die Innere Medizin - Reference work for the medical specialist S 474
2. Herold G et al (2017) Internal Medicine S 431
3. Köhler D et al (2010) Pneumology 331 - 332
4. Kolschmann S et al (2006) Effectiveness and underlying mechanisms of talcumpleurodes in malignant pleural effusion. Pneumology 2. 89-95