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Correspondence |

Pleurodesis and Ablation of the Pleural Cavity FREE TO VIEW

Vincent Acton, MBBS (Syd)
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FINANCIAL/NONFINANCIAL DISCLOSURES: None declared.

CORRESPONDENCE TO: Vincent Acton, MBBS (Syd), 1202 Highgate, 127 Kent St, Sydney, NSW 2000, Australia


Copyright 2016, American College of Chest Physicians. All Rights Reserved.


Chest. 2016;149(5):1351-1352. doi:10.1016/j.chest.2015.10.058
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I note that in the interesting counterpoint article by Gillespie and DeCamp discussing the use of small-bore pleural catheters in the management of malignant pleural effusions in CHEST (July 2015), the authors commented on how best to ablate the pleural space to prevent reaccumulation of pleural fluid (pleurodesis). This reflects the widespread view that successful pleurodesis requires obliteration of the pleural space.

It is surprising that a search of the medical literature fails to identify any series finding obliteration of the pleural space in those who have previously undergone pleurodesis because pleurodesis is such a common form of management of both symptomatic malignant pleural effusion and persisting or recurrent pneumothorax. Could the authors kindly speak to this issue? It seems unlikely that such obliteration is so common that it is never mentioned. An alternative could be that it is extremely rare.

It is well recognized that chemical pleurodesis produces pleural sclerosis (fibrinous exudate, collagen deposition, and fibrosis) and may produce pleural adhesions of variable extent. However adhesions alone do not prevent the development of loculated effusions or tethered pneumothoraces.

It might be considered that these pleural changes reduce the transudation and exudation of fluid producing malignant effusions and reduce the increased visceral pleural permeability associated with recurrent pneumothorax. Some support for this is noted by Bintcliffe et al who similarly comment that the use of a blood patch in cases of pneumothorax “could provide clotting over the wound as a mechanism of healing the air leak rather than a means of achieving symphysis of the pleural surface.”

This change of view may result in limited change in clinical practice. It has been noted that at subsequent thoracoscopy or thoracotomy, the pleural changes following pleurodesis are greatest in proximity to the instilling catheter and that a relative advantage of talc poudrage “might be explained by a diffuse distribution of talc particles within the pleural cavity.” Both observations would seem to reinforce the advantage of multiple changes in posture following pleurodesis to promote dispersion of the sclerosant and the extent of pleural sclerosis achieved.

Recognition of the seeming rarity of ablation of the pleural cavity may influence the approach if ipsilateral intervention is required following previous pleurodesis. If such ablation is unlikely, ultrasound examination, with or without image-guided air instillation, may well confirm a persisting pleural cavity, allowing video-assisted thoracoscopic surgery rather than thoracotomy.

References

Gillespie C.T. .DeCamp M.M. . Counterpoint: Should small-bore catheter placement be the preferred initial management for malignant pleural effusions? No. Chest. 2015;148:11-13 [PubMed]journal. [CrossRef] [PubMed]
 
Clive A.O. .Bhatnagar R. .Psallidas I. .Maskell N.A. . Individualised management of malignant pleural effusion. Lancet Respir Med. 2015;3:505-506 [PubMed]journal. [CrossRef] [PubMed]
 
Acton V. . Is pleurodesis for the treatment of primary spontaneous pneumothorax a misnomer–and if it works, does it matter? J Thorac Cardiovasc Surg. 2015;149:397-398 [PubMed]journal
 
Bintcliffe O.J. .Hallifax R.J. .Edey A. .et al Spontaneous pneumothorax: time to rethink management? Lancet Respir Med. 2015;3:578-588 [PubMed]journal. [CrossRef] [PubMed]
 

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References

Gillespie C.T. .DeCamp M.M. . Counterpoint: Should small-bore catheter placement be the preferred initial management for malignant pleural effusions? No. Chest. 2015;148:11-13 [PubMed]journal. [CrossRef] [PubMed]
 
Clive A.O. .Bhatnagar R. .Psallidas I. .Maskell N.A. . Individualised management of malignant pleural effusion. Lancet Respir Med. 2015;3:505-506 [PubMed]journal. [CrossRef] [PubMed]
 
Acton V. . Is pleurodesis for the treatment of primary spontaneous pneumothorax a misnomer–and if it works, does it matter? J Thorac Cardiovasc Surg. 2015;149:397-398 [PubMed]journal
 
Bintcliffe O.J. .Hallifax R.J. .Edey A. .et al Spontaneous pneumothorax: time to rethink management? Lancet Respir Med. 2015;3:578-588 [PubMed]journal. [CrossRef] [PubMed]
 
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