Chemical pleurodesis for malignant pleural effusion

Malignant pleural effusion is a common complication of primary and metastatic pleural malignancies. It is usually managed by drainage and pleurodesis, but there is no consensus as to the best method of pleurodesis, this study was designed to compare the effectiveness, side effects, and cost of different chemical pleurodesis agents used in patients with malignant pleural effusion. Seventy-five patients with malignant pleural effusion were assigned into five groups each of 15 patients, Talc slurry 5 gm, Tetracycline500 mg, Bleomycin1 IU/kg, Iodopovidone [2%] and patients underwent tube drainage only. Tube thoracotomy was performed in all patients and agents were administered through the chest tubes. Tetracycline, talc slurry, iodopovidone andbleomycin, resulted inan insignificantly different success rates of 80%, 80%, 66.6%.73.3%, at 30 days and, 66.6%, 73.3%, 60%, 66.6%, at 60 days respectively while tube alone was much lower, 40% and 26.7% respectively. Chest tubes were removed after an average of 7.2 +/- 1.4 days for tetracycline, 7 +/- 0.8 days for talc slurry, 7.6 +/- 0.9 days for iodopovidone and 6.4 +/- 1.5 days for bleomycin which did not differ significantly. Chest pain was more common in the tetracycline group, dyspnea was more common in the talc group, and fever was more common in the iodopovidone group. Since tetracycline, talc slurry, iodopovidone, andbleomycin achieved comparable success rates in this study, we suggest that the drug availability and cost are important factors in choosing a sclerosing agent in developing countries

Pleurodesis using different agents in malignant pleural effusion

Malignant pleural effusions [MPE] are characterized by rapid reaccumulation, after tapping, and many symptoms related. Pleurodesis, for the management of MPE, is intended to achieve symphysis between parietal and visceral pleura, and to prevent relapse of pleural effusion. Many chemical agents are tried to induce abrasion and damage of the pleural mesothelial layer to achieve this symphysis. The aim of this study is to compare the results of medical pleurodesis, using 4 different chemical agents in these cases, to reach an efficient one with minimal complications. Between July 2010 and July 2012, 40 patients with MPE, divided into 4 groups, underwent medical pleurodesis using 4 chemical agents in comparison: bleomycin, doxycycline, povidone iodine and 5-fluorouracil. Immediately and for 3 months after the procedure, the results of pleurodesis were assessed and the final reported success rates were 70% for bleomycin, 80% for doxycycline and 80% for povidone iodine, while 5 fluorouracil had the lowest success rate [50%] [P-value < 0.05]. Bleomycin, doxycycline and povidone iodine are nearly equally effective and safe pleurodetic agents when used in the optimal dose, while 5-fluorouracil had a much higher failure rate. Although povidone iodine and doxycycline are as effective and safe as bleomycin, they are cheaper alternatives and more available chemical agents for pleurodesis in cases with MPE

Pleurodese nos derrames pleurais malignos: um inquérito entre médicos em países da América do Sul e Central / Pleurodesis for malignant pleural effusions: a survey of physicians in South and Central America

OBJETIVO: A pleurodese é uma alternativa eficaz no controle dos derrames pleurais malignos, mas existem controvérsias a respeito de sua indicação e técnica. O objetivo deste estudo foi avaliar como é realizada a pleurodese em países da América do Sul e Central. MÉTODOS: Profissionais que realizam pleurodese responderam um questionário sobre critérios de indicação para pleurodese, técnicas utilizadas e desfechos. RESULTADOS: Nossa amostra envolveu 147 profissionais no Brasil, 49 em outros países da América do Sul e 36 em países da América Central. Mais de 50 por cento dos participantes realizavam pleurodese somente se confirmada a malignidade no derrame pleural. Entretanto, escalas de dispneia e de status de performance eram raramente utilizadas para indicar o procedimento. Aproximadamente 75 por cento dos participantes no Brasil e na América Central preferiam realizar a pleurodese somente no caso de recidiva do derrame, e a expansão pulmonar deveria variar de 90 por cento a 100 por cento. O talco slurry foi o agente mais utilizado, instilado via drenos de calibre intermediário. A toracoscopia foi realizada em menos de 25 por cento dos casos. Febre e dor torácica foram os efeitos adversos mais comuns, e empiema ocorreu em < 14 por cento dos casos. A média de sobrevida após o procedimento variou entre 6 e 12 meses. CONCLUSÕES: Há variações consideráveis quanto aos critérios de indicação para pleurodese, técnicas utilizadas e desfechos entre os países. Talco slurry é o agente mais frequentemente utilizado, e a toracoscopia é a primeira escolha no Brasil. Os baixos índices de complicações e o tempo de sobrevida elevado indicam que a pleurodese é efetiva e causa poucos efeitos adversos.

OBJECTIVE: Pleurodesis is an effective alternative for the control of malignant pleural effusions. However, there is as yet no consensus regarding the indications for the procedure and the techniques employed therein. The objective of this study was to evaluate how pleurodesis is performed in South and Central America. METHODS: Professionals who perform pleurodesis completed a questionnaire regarding the indications for the procedure, the techniques used therein, and the outcomes obtained. RESULTS: Our sample comprised 147 respondents in Brazil, 49 in other South American countries, and 36 in Central America. More than 50 percent of the respondents reported performing pleurodesis only if pleural malignancy had been confirmed. However, scores on dyspnea and performance status scales were rarely used as indications for the procedure. Nearly 75 percent of the respondents in Brazil and in Central America preferred to perform pleurodesis only for recurrent effusions and stated that lung expansion should be 90-100 percent. Talc slurry, instilled via medium-sized chest tubes, was the agent most often employed. Thoracoscopy was performed in less than 25 percent of cases. Fever and chest pain were the most common side effects, and empyema occurred in < 14 percent of cases. The mean survival time after the procedure was most often reported to be 6-12 months. CONCLUSIONS: There was considerable variation among the countries evaluated in terms of the indications for pleurodesis, techniques used, and outcomes. Talc slurry is the agent most commonly used, and thoracoscopy is the technique of choice in Brazil. Pleurodesis is an effective procedure that has few side effects, as evidenced by the low complication rates and high survival times.

Procedimientos quirúrgicos en 156 casos de derrame pleural: resultados inmediatos / Surgical procedures in 156 cases of pleural effusion: immediate results

Introducción: el derrame pleural es una entidad clínica frecuente, su estudio y manejo son importantes para resolverlo. El objetivo fue evaluar los resultados inmediatos de los procedimientos diagnósticos y terapéuticos en casos consecutivos de derrame pleural. Material y métodos: durante un periodo de 12 meses, de 787 pacientes hospitalizados, 156 (19.8 %) presentaron derrame pleural. También se evaluaron 22 casos de neumotórax considerados como derrame gaseoso y 10 con empiema crónico. Resultados y discusión: en 23 casos no neoplásicos, la toracentesis diagnóstica y evacuadora resolvió el derrame. El drenaje con sonda intrapleural conectada a sello de agua se practicó en 133: en 109 (81.9 %) se resolvió el derrame y en 24 se practicaron otros procedimientos. En este grupo el derrame fue neoplásico en 35 y no neoplásico en 98, incluidos 36 iatrogénicos; 22 casos de neumotórax se consideraron como derrame gaseoso y fueron tratados con sonda intrapleural; 10 casos de empiema crónico fueron estudiados como secuelas de derrames, no fueron resueltos con los procedimientos mencionados. Hubo diferencia significativa entre derrames neoplásicos y no neoplásicos (p = 0.001), y entre casos manejados con procedimientos de invasión mínima y sonda intrapleural (p = 0.001), por comparación de proporciones. Se comenta la utilidad de la pleurodesis y la toracoscopia en el tratamiento del derrame. En casos crónicos la toracostomía en ventana y mioplastia consecutiva tienen indicación precisa. Conclusiones: el diagnóstico y tratamiento oportunos del derrame pleural son importantes. La colocación de sonda pleural resuelve la mayoría de los casos (89.9 %). El neumotórax debe ser igualmente manejado. El empiema crónico requiere toracostomía en ventana y mioplastia. Las maniobras descuidadas o inadecuadas provocan derrames de naturaleza iatrogénica.

BACKGROUND: Pleural effusion is a common clinical entity. Proper diagnosis and management are important for successful treatment. We undertook this study to evaluate immediate results of the procedures used in a group of cases with pleural effusion. METHODS: Of 2589 patients at first consultation, 787 were hospitalized and 156 had pleural effusion. Diagnostic and therapeutic procedures used were evaluated. RESULTS: With thoracentesis and evacuation of liquid, 23 nonneoplastic cases had resolution. Chest tube drainage with water seal was performed in 133 patients. This procedure suppressed the effusion in 109 patients, but in 24 patients another approach was necessary. In this group there were 35 neoplastic and 96 nonmalignant cases, the latter 36 were provoked by iatrogenic management. Twenty two cases of pneumothorax considered as gaseous effusion and 10 cases of chronic empyema sequelae of pleural effusions were also studied. Proportion comparison demonstrated significant differences between neoplastic and nonneoplastic effusions (p =0.001) and in cases managed with minimally invasive procedures and chest tube drainage (p =0.001). The performance of pleurodesis and thoracoscopy is discussed. In chronic cases, indications of open window thoracostomy and myoplasty are elucidated. CONCLUSIONS: In pleural effusion, opportune diagnosis and proper management are essential. Drainage tube can solve the majority of cases. Pneumothorax must be treated in the same way. In chronic empyema, open window thoracostomy and myoplasty are indicated. Careless patient management and poor treatment lead to iatrogenic complications.

Importancia del pH del derrame pleural maligno en la efectividad de la pleurodesis química con Bleomycina

Con el objeto de averiguar si el pH del Líquido Pleural del paciente con Derrame Pleural Maligno (DPM) altera la eficiencia de la Preurodesis Química con Bleomycyna, se realizó este procedimiento con dosis de 1mg/k, a 33 pacientes del Hospital Santa Clara de Bogotá entre los meses de febrero de 1991 y enero de 1993. Para ingresar al estudio los pacientes debían cumplir los siguientes requisitos: 1) No haber recibido tratamiento previo para su enfermedad neoplásica (radio, quimioterapia, drenajes previos, etc.). 2) Reexpansión completa del pulmón y drenaje total del derrame pleural Post-toracostomía cerrada. 3. Puntaje de Karnofsky mayor de 60. 4) Medición del pH del líquido pleural. 5) Comprobación por biopsia pleural de compromiso metastásico de la pleura. Se realizó control clínico y radiológico de los pacientes a los 30 días de realizada la Pleurodesis Química. 3 pacientes no ingresaron a este análisis: Uno por fallecer antes del plazo descrito y dos por haber presentado Empiema como complicación. Se comparó la efectividad de la Pleurodesis con Bleomycina en los pacientes que tenían pH del líquido pleural menor a 7.3 con el grupo de pacientes que tenían cifras mayores e iguales a esa cifra: se encontró que la efectividad del procedimiento era del 30 por ciento en el primer grupo y del 85 por ciento en el segundo. (p = 0.01). La "respuesta parcial" se consideró como efectividad en ambos grupos. Así se sugiere, por primera vez en la literatura disponible, que la efectividad de la pleurodesis con Bleomycina, del mismo modo que ocurre con la Tetraciclina, varía de acuerdo al pH previo del líquido pleural.