PURPOSE: Talc is frequently used as a first line agent for chemical pleurodesis in recurrent pleural effusions. However the management of pleural effusions in talc failure patients is uncertain. We reviewed potential risk factors for talc failure, described the effectiveness of doxycycline as a second line sclerosing agent and studied the role of tunneled pleural catheter insertion during talc pleurodesis.
METHODS: We performed a retrospective chart review of 186 patients who underwent thoracoscopic talc pleurodesis at Lahey Clinic between 1994 and 2009. Bivariate analysis using chi-square and t-tests were conducted to evaluate the risk factors associated with talc and doxycycline failure along with comparison of tunneled pleural catheter use during talc pleurodesis.
RESULTS: Indications for chemical pleurodesis included recurrent malignant pleural effusion (n=141), recurrent benign pleural effusion (n=37) and recurrent pneumothorax (n=8). 42/186 (23%) of patients failed talc pleurodesis. Statistically significant risk factors for failure included benign pleural effusions due to cirrhosis, presence of trapped lung, presence of many adhesions, and the amount of pleural fluid drained at the time of thoracoscopy (p=0.02, 0.01, 0.04, 0.0001, respectively). Patients who failed talc pleurodesis had on average 4 more days of chest tube drainage (p=0.01) and a 5 day longer hospital stay (p=0.0001). 23 patients who failed talc received doxycycline. 5/23 (22%) of patients failed doxycycline pleurodesis. None of the aforementioned risk factors predicted doxycycline failure. Patients who received a tunneled pleural catheter had a two day reduction in chest tube drainage time (p=0.0001).
CONCLUSION: Doxycyline is shown to have good success after failed talc pleurodesis. Risk factors for talc failure did not predict doxycycline failure. Insertion of a tunneled pleural catheter during pleurodesis reduced overall duration of chest tube drainage.
CLINICAL IMPLICATIONS: Doxycycline is a reasonable treatment option in the management of patients with recurrent pleural effusions who fail thoracoscopic talc pleurodesis. Using tunneled pleural catheters with talc pleurodesis improves tube drainage time.
DISCLOSURE: Eugene Shostak, No Financial Disclosure Information; No Product/Research Disclosure Information