Volume 8 Issue 3 - Australasian Society for Ultrasound in Medicine

ASUM Ultrasound Bulletin 2005 August; 8 (3): 23–27DIAGNOSTIC ULTRASOUNDUltrasound guided chemical pleurodesiswith doxycyclineRP Davies MBBS, FRACR, MoHealth Law, MoHealth Services Management AB , T McClymont, MBBS A ,D Boshell, MBBS AADept of Radiology, Orange Base Hospital, Greater Western Area Health Service,New South Wales, AustraliaBCorrespondence to R Davies email rdavies@adelaide.on.netAbstractDiagnosis of pleural effusion by radiograph or ultrasound is reliable and accurate. Treatment ofmalignant pleural effusion remains problematic. Where a symptomatic pleural effusion fails to respondto systemic chemotherapy, options include palliative thoracentesis and pleurodesis. Palliative thoracentesisrequires multiple hospital attendances and may produce only short-term relief. Pleurodesisinvolves the instillation of a sclerosing agent into the pleural space resulting in a diffuse inflammatoryreaction with local activation of the coagulation pathway and fibrin deposition. Talc as a sclerosingagent can be administered as either a talc poudrage at the time of thoracoscopy using an atomiser oras talc slurry via a large bore intercostal tube. Common side effects reported are pleuritic chest painand fever. Chemical pleurodesis using tetracycline had a modest efficacy (reported success rate around65%), but was relatively inexpensive, well tolerated and the side effects were infrequent, mild andtransient. Production of tetracycline ceased in 1998.A locally developed pleurodesis protocol is described using doxycycline as the sclerosing agentadministered via ultrasound-guided small-bore intercostal cannula placement. Long-acting localanaesthetic is instilled into the pleural cavity to minimise post-procedure discomfort. The procedurecan be performed as a day case at low added cost compared with palliative ultrasound-guided thoracentesis.This preliminary report suggests the protocol described could be more widely applied, appears tobe well tolerated and has acceptable morbidity. Initial results are encouraging. A prospective trial isrequired to compare efficacy and morbidity with the currently used alternatives.IntroductionRecurrent pleural effusion is a recognised complicationof breast, lung and other malignancy sometimes resultingfrom the disruption and obstruction of lymphatic channelsby malignant cells1. The effusion and associated masseffect compressing the ipsilateral lung can result in ongoingrespiratory symptoms (dyspnoea and chest pain) andcan have a significant impact on a patient’s quality of life.Pleural effusions can be identified and quantified using radiography,ultrasonography or other cross-sectional imaging 2 .Once identified, the treatment options available for managingrecurring malignant pleural effusions vary accordingto local preferences and available expertise. Treatmentoptions include chemotherapy, palliative thoracentesis andpleurodesis 3 , depending on the patient’s well being, responseto previous treatments and life expectancy. Bonnefoi andSmith 4 found that chemotherapy could achieve symptomaticrelief in 78% of patients with malignant pleural effusion.However, if chemotherapy is contraindicated or the pleuraleffusion fails to respond to systemic chemotherapy, an alternatetreatment approach is often required 3.Repeated therapeutic thoracentesis (pleural aspiration)is used in treating recurrent pleural effusion as this obviatesthe need for routine hospitalisation and provides transientrelief for frail patients and those with a limited life expectancy3 . The main limitation of pleural aspiration withoutany additional therapy is the likelihood of rapidly recurrentpleural effusion 5,6 . Pleurodesis following pleural aspirationdecreases the chance of pleural effusion recurrence 6,7 , andhas been a widely used long-standing method of controllingrecurrent pleural effusions 8 . Pleurodesis involves the instillationof a sclerosing agent into the pleural space resultingin a diffuse inflammatory reaction with the local activationof the coagulation system with fibrin deposition 9 . Thisinflammatory process aims to obliterate the pleural space 8preventing re-accumulation of the pleural effusion. Despitethe use of a large number of agents no ideal sclerosingagent has been adopted. Talc was first used as a sclerosingagent in 1935 10 and can be administered as either a talcpoudrage at the time of thoracoscopy using an atomiser oras talc slurry via an intercostal tube. Success rates for talcrange from 80% to 100% 11–14 . The most common side effectsreported are pleuritic chest pain and fever. Adult respiratorydistress syndrome (ARDS) is a rare and potentially fatalcomplication of intrapleural talc 15 . Chemical pleurodesisusing tetracycline became less popular 16 but was performeduntil 1998 when production was discontinued. Tetracyclinehas a modest efficacy (average success rate of 65%), butASUM Ultrasound Bulletin 2005 August; 8 (3)23