Pleurodesis

A 39 year old male presented to CCH Trauma with multiple GSW to his right chest.  A right sided chest tube was placed with evacuation of hemothorax however was noted to have a persistent pneumothorax.  A second chest tube was placed with resolution of pneumothorax when the tube was placed to wall suction.  However when the chest tube was placed to waterseal, pneumothorax recurred.  Plan was made to attempt pleurodesis.

Pleurodesis is a procedure that can be completed for recurrent pneumothorax or pleural effusion. The goal is to appose the visceral and parietal pleura to obliterate the pleural space.  The procedure can be done chemically or surgically.  Surgical pleurodesis can be completed via thoracoscopy or thoracotomy.  The parietal pleura can be mechanically irritated with a rough pad or the parietal pleura can be resected.  Chemical pleurodesis can be completed at bedside in patients with a chest tube.  It is completed using a chemical irritant, which is instilled in the pleural space resulting in an inflammatory reaction that obliterates this space.  Commonly used irritants are talc, doxycycline, and povidone iodine.

Steps for beside chemical pleurodesis with doxycycline

1.      Make sure patient can tolerate clamping of chest tube for 2 hours without experiencing shortness of breath or tension pneumothorax.  Nursing staff must be notified that chest tube is being clamped and patient needs close monitoring.  If any signs of decompensation, immediately remove clamp from chest tube.

2.      Order 1gm of doxycycline mixed with 50ml of saline to make a slurry

3.      Adequately control the patient’s pain

a.       Instill 20 ml of 1% lidocaine through the chest tube into the pleural cavity

b.      Give patient IV pain medication and possible sedation

4.      Instill 50mL of doxycycline through the chest tube and clamp the tube

5.      After one hour, unclamp the tube, place it to wall suction.

6.      Obtain chest X-Ray to evaluate effectiveness of pleurodesis

7.      Maintain chest tube to wall suction for 24 hours then transition to waterseal, if pneumothorax does not recur, chemical pleurodesis was effective.  If pneumothorax recurs, patient will need surgical pleurodesis

by Dr. Purvi P. Patel