Volume 8 Issue 3 - Australasian Society for Ultrasound in Medicine

RP Davies, T McClymont and D BoshellFigure 1 A longitudinal scan shows approximate dimensions of themalignant pleural effusion. There is dependant echogenic materialin keeping with altered bloodFigure 2 During ultrasound guided subcutaneous local anaestheticinjection the 25 g needle was visualised longitudinally, to ensuredelivery of fluid adjacent to the parietal pleural surface to minimisepatient discomfort during needle puncture of the pleural surfaceFigure 3 The sheathed cannula is visualised during entry to thepleural fluid. The angle is planned to allow continued drainageas the lung re-expands during fluid drainageit was relatively inexpensive, well tolerated and the sideeffects were infrequent, mild and transient 17 . The search fora chemical sclerosant to replace tetracycline, along with aneffective protocol for its use, has been the catalyst for thisstudy into the practicality and effectiveness of doxycyclineas a sclerosing agent.Case reportA 52-year-old female presented with dyspnoea on minimalexertion after walking five metres and orthopnea requiringsix pillows. There was a four-month history of cough,dyspnoea and right-sided chest pain. A chest x-ray and CTrevealed a right-sided pleural effusion, also demonstratedand measured by ultrasound (Figure 1). The diagnosisof non-small cell adenocarcinoma of primary pulmonaryorigin was made following pleural biopsy. Chemotherapywas commenced, initially with a standard protocol (taxotereweekly changed three months later to gemcitabinefortnightly). The pleural effusion increased and drainagefor symptom relief was requested. Ultrasound guided drainage(Figure 2) of 500 ml of pleural fluid was undertaken atpresentation and three weeks later ultrasound demonstrateda recurrent volume of approximately 250 cc. Six weeksafter the initial tap, a further 250 cc was drained underFigure 4 Ultrasound guided insertion of a small bore 5 Fr intercostalcannula was performed on multiple occasions with clearvisualisation of the echogenic side holes (arrowed) within themalignant pleural effusionultrasound guidance. Three weeks after that a further 160ml of pleural fluid was aspirated under ultrasound guidanceachieving only one week free from exertional dyspnoeaafter which recurrent progressive exertional dyspnoea wasagain reported by the patient.An ultrasound of the pleural space showed an estimated500 ml recurrent effusion. Doxycycline pleurodesis (as perthe protocol in the Table 1) was undertaken. Minor patientdiscomfort only was reported during subcutaneous localanaesthetic injection (lignocaine 2% 3–5 ml, Figure 3) andinsertion of a small bore 5 Fr intercostal cannula (5Fr. 10cm Yueh sheathed needle, WA Cook, Eight Mile Plains,Brisbane, Australia, Figure 4). There was no further discomfortwhile 360 cc of pleural fluid was drained over afour-hour period. The drain was then capped. CT indicatedan estimated residual volume of 70 cc remaining in thepleural space. With conscious intravenous sedation usinga narcotic/benzodiazepine protocol, intrapleural instillationof Marcaine 0.4% 150 mg in 30 ml (bupivicaine hydrochloride100 mg/20 ml, Astra Zeneca Pty Ltd, Sydney, NSW,Australia) and doxycycline 500 mg in 25 ml (Vibramycin100mg/5 ml, Pfizer, Germany) was injected via the intercostalcannula. The patient reported no discomfort duringthe procedure and four hours of post procedure monitoring24 ASUM Ultrasound Bulletin 2005 August; 8 (3)