Tetracycline Pleurodesis During Active Pulmonary-Pleural Air Leak for Prevention of Recurrent Pneumothorax

doi:10.1378/chest.81.1.78

Chest

Volume 81, Issue 1, January 1982, Pages 78-81

https://doi.org/10.1378/chest.81.1.78 Get rights and content

Pleurodesis with a sclerosing agent was attempted in an animal model in which a pneumothorax with an active air leak was created. Adult rabbits had a small left thoracotomy and then a 1-cm controlled cut in the lung surface. Animals served as control, or tetracycline was administered. The chest tube was removed after the air leak stopped. Animals were sacrificed after 20 days. Group A was control rabbits (6); group B had powdered tetracycline placed at thoracotomy; group C, tetracycline solution, 2 ml/kg, 25 mg/ml (4); and group D, tetracycline solution, 1 ml/kg, 50 mg/ml (10). Control rabbits showed few adhesions, and the pleura appeared to be normal by histologic examination. There was a spectrum of results with tetracycline, but with the concentrated tetracycline solution (group D) histologic examination showed uniform pleurodesis and thickening of the pleura. In group D it took no longer for the pulmonary air leak to seal than with the group A (control) rabbits. We conclude that concentrated tetracycline solution is effective in causing pleurodesis even when an active air leak is present. The lung, however, must be kept expanded so that symphysis can occur between the visceral and parietal pleura.

Section snippets

Methods and Materials

Twenty-four New Zealand white rabbits weighing 3 to 5 kg were anesthetized with Innovar (Critikon), 1 ml/kg intravenously (IV), and atropine, 0.5 mg intramuscularly (IM). Ampicillin, 250 mg IM, was administered preoperatively. The left chest was shaved and scrubbed with Betadine (Purdue Frederick). Under aseptic conditions, a 3-cm posterolateral thoracotomy over the eighth rib was performed. The lateral inferior edge of the left lower lobe of the lung was grasped with smooth forceps, and a 1-cm

Results

Detectable air leaks by water trap ceased in all rabbits within 24 hours. Table 2 categorizes the results for each rabbit. In group A (control), two of six rabbits had grade 0 pleurodesis. Weak focal peri-incisional adhesions related to the thoracotomy incision were noted in three others (grade 1). The two rabbits with grade 0 pleurodesis had mild, total lung atelectasis with small serous pleural effusions. One rabbit died early.

In group B (powdered tetracycline-treated animals), one rabbit

Discussion

The use of sclerosing agents to cause pleurodesis is not new. Numerous agents have been used in the past, including silver nitrate, kaolin, talc, lipidol, cyanoacrylate, dicetylphosphate, and quinacrine.3, 5, 6, 7, 8, 9, 10 Most of these agents have been abandoned because of systemic reactions of one type or another. Talc poudrage has been condemned by some because of documented talc cerebral embolism in both the experimental animal and in man.11, 12 Quinacrine frequently requires multiple

References (17)

GH Joynt et al.
Treatment of spontaneous pneumothorax with kaolin
Chest
(1958)
RH Adler
A talc powder aerosol method for the prevention of recurrent spontaneous pneumothorax
Ann Thorac Surg
(1968)
CR Youmans
Surgical management of spontaneous pneumothorax by bleb ligation and pleural dry sponge abrasion
Am J Surg
(1970)
SA Sahn et al.
The pH of sclerosing agents: a determinant of pleural symphysis
Chest
(1979)
AR Askew
Parietal pleurectomy for recurrent pneumothorax
Br J Surg
(1976)
HM DuBose
Spontaneous pneumothorax: medical and surgical management
N Engl J Med
(1953)
HC Maier
The pleura
EH Austin et al.
The treatment of recurrent malignant pleural effusion
Ann Thorac Surg
(1979)

There are more references available in the full text version of this article.

Cited by (42)

Efficacy of tigecycline pleurodesis: A comparative experimental study
2011, Journal of Surgical Research
Citation Excerpt :
In the mid 1960s, intrapleural instillation of tetracycline combined with chest drainage was the preferred method of chemical pleurodesis, mainly for patients with malignant pleural effusions [1, 2] and for recurrent pneumothorax [3–5].
We investigated whether tigecycline (TIGE) is more effective than talc in inducing pleurodesis in rabbits.
Fifty-six New Zealand rabbits were utilized in a two-phase study: Effects at 14 d (phase I) and at 28 d (phase II) were assessed. Saline solution (SAL n = 3), talc slurry (TALC 200 mg/kg, n = 5), and TIGE at different concentrations (mg/kg): TIGE0.5 (n = 5); TIGE1 (n = 5); TIGE3 (n = 5); TIGE25 (n = 5); TIGE50 (n = 5) were randomly injected, for each phase, through a right chest drainage. TIGE0.5 and TIGE1 were ineffective during phase I and were thus excluded from further investigation. At post mortem examination, pleurodesis was graded grossly and microscopically by three observers blinded to treatment groups.
Phase I: pleurodesis was more effective in TIGE25 and TIGE50 (P < 0.001); TALC was better than TIGE0.5 (P < 0.001), and TIGE1 (P = 0.49), macroscopically. Pleural thickness was significantly higher in TIGE25 compared with SAL, TALC, TIGE0.5, TIGE1, and TIGE3 (P < 0.01). No significant differences were evident between TALC and TIGE3, both macroscopically (P = 0.90) and microscopically (inflammation P = 0.99, fibrosis P = 0.96, pleural thickness P = 0.99). Phase II: better effectiveness of TIGE50 compared with all other groups (P < 0.001) except TIGE 25 (P = 0.29); results similar to phase I for TALC and TIGE3 (P = 0.99), macroscopically. Microscopically greater inflammation in TALC compared with TIGE3 (P < 0.05) and in TIGE50 to TIGE3 (P = 0.05). Significant complications occurred in all TIGE50 group. One of TIGE25 and one of TIGE50 died of respiratory distress and of right hemothorax+ascites, respectively.
Intrapleural TIGE3 mg/kg is as effective as talc in inducing pleurodesis in rabbits. The intrapleural TIGE toxicity threshold was reached at TIGE25 mg/kg concentration.
Bronchopleural fistula: An update for intensivists
2010, Journal of Critical Care
Citation Excerpt :
Determining ideal ICC suction pressures requires frequent reassessment of fistula flow rate. Intercostal catheters can be used as a portal for delivery of sclerosing agents for pleurodesis if pneumothorax is present: for local anesthetics if analgesia is an issue or antibiotics into the pleural cavity, which, when combined with drainage of an empyema, may assist in disinfection of pleural cavity before a BPF is repaired [32,33]. Video assisted thoracoscopy (VAT) and pleurodesis, however, may be a superior option enabling the operator to visualize the fistula site and the pleural cavity.
Bronchopleural fistula is a potentially fatal condition that may result after a variety of clinical conditions, most commonly after pulmonary resection. Either surgical or bronchoscopic repair is required to definitively correct these lesions, though a small number may resolve spontaneously with optimal ventilatory care and other options available to an intensivist in the management of this complex condition. The successful management of a bronchopleural fistula depends on formulating a treatment strategy tailored to individual patient needs.
Incidence and Risk Factors of Persistent Air Leak After Major Pulmonary Resection and Use of Chemical Pleurodesis
2010, Annals of Thoracic Surgery
Citation Excerpt :
Sclerosants are known to incite a vigorous inflammatory response in the pleura providing substrate for symphysis and obliteration of the pleural space and cessation of air leak. Sclerosants that can be used include talc, doxycycline, minocycline, bleomycin, tetracycline, silver nitrate, quinacrine, and iodopovidone [30–32]. These are typically instilled through the indwelling chest tube.
Persistent air leak (PAL; defined as air leak > 5 days) after major pulmonary resection is prevalent and associated with significant morbidity. This study examines an incompletely characterized treatment for the management of PAL, chemical pleurodesis.
A retrospective case-control study examining all isolated lobectomies and bilobectomies by thoracotomy was performed. The PALs (1997 to 2006) and controls (2002 to 2006) were identified from a prospective database. Incidence, risk factors, management, and outcome were defined.
Over 9 years, 78 PALs were identified in 1,393 patients (5.6%). Controls consisted of 700 consecutive patients. Propensity score analysis matching case and controls showed no predictive risk factors for air leak using a logistic regression model. Univariate analysis demonstrated that female gender, smoking history, and forced vital capacity were predictive risk factors. Treatment of PAL consisted of observation (n = 33, 42.3%), pleurodesis (n = 41, 52.6%), Heimlich valve (n = 3, 3.8%), and reoperation (n = 1, 1.3%). Seventy-three patients (93.6%) required no further intervention. One patient required a muscle flap, one readmission for pneumothorax, and one empyema resulting in death. Sclerosis was successful in 40 of 41 patients (97.6%). Mean time to treatment was 8.4 ± 3.6 days, mean duration of air leak was 10.7 ± 4.5, and mean duration of air leak postsclerotherapy was 2.8 ± 2.2 days. Postoperative pneumonia occurred with increased frequency in PAL patients (6 of 45 [13.3%] vs 34 of 700 [4.9%], p = 0.014). PAL was associated with increased length of stay (14.2 vs 7.1 days, p < 0.001) and time with chest tube (11.5 vs 3.4 days, p < 0.001).
Air leaks remain an important cause of morbidity. Pleurodesis is an effective option in management of PAL after major pulmonary resection.
A spontaneous pneumothorax in a "buffalo chest"
2007, Revista Portuguesa de Pneumologia
Spontaneous contralateral pneumothorax after pneumonectomy is a rare condition. A high index of suspicion is required for a correct diagnosis. Management can be challenging, as surgical intervention, if necessary, is a very high risk procedure.
Chemical pleurodesis can be a simple and effective measure in cases with no major air leak. We describe the case of a 21-year-old female with spontaneous pneumothorax in a single lung, which posed several diagnostic and therapeutic problems. The presence of a “buffalo chest” made the initial chest x-ray interpretation difficult. The patient had an important air leak without complete pulmonary expansion and thoracic surgery was considered of risk. Accordingly, instillation of talc slurry through one of the thoracic drains was undertaken with eventual resolution. We are convinced that bronco-pleural fistula resolution was facilitated by slurry talc, despite complete lung expansion never having been achieved.
O pneumotórax contralateral após pneumonectomia é uma situação rara. É necessário um alto índice de suspeição para um correcto diagnóstico, na ausência de exames complementares de diagnóstico. O tratamento é um desafio, uma vez que a intervenção cirúrgica, se necessária, é um procedimento de risco. A pleurodese química pode ser uma medida simples e eficaz, em casos sem fístula broncopleural importante.
Descrevemos o caso clínico de uma doente de 21 anos com pneumotórax espontâneo em pulmão único, que colocou várias dificuldades, diagnósticas e terapêuticas. A presença de pulmão vicariante dificultou a interpretação inicial do RX torácico. A doente apresentava fístula broncopleural de alto débito, sem expansão pulmonar completa, mesmo após colocação de um segundo dreno torácico, e a cirurgia torácica foi considerada de risco. Foi efectuada instilação de talco através de um dos drenos torácicos, com posterior resolução.
Estamos convencidos de que a resolução da fístula broncopleural foi facilitada pela talcagem, mesmo sem expansão pulmonar total, que nunca se tinha conseguido.
Intrapleural administration of a large amount of diluted fibrin glue for intractable pneumothorax
2000, Chest
Citation Excerpt :
Pleurodesis achieved by an intrapleural infusion of chemical agents is preferred to surgery for patients with intractable pneumothorax, in whom thoracotomy is contraindicated and, occasionally, for patients with a prolonged air leak after pulmonary resection in association with an intrapleural dead space. Pleurodesis has been performed to promote pleural adhesion using talc,1,23,45,67 bacterial components (such as OK-4328 or C parvum18), antibiotics (such as tetracycline,11,12 doxycycline13,14 or minocycline hydrochloride15,1617), autologous blood,9,10 and anticancer agents (such as mitomycin C8 or adriamycin18). These techniques all achieve adhesion by triggering an inflammatory response through irritation of the pleura, thus causing severe chest pain and fever.
Pleurodesis using chemical agents has been applied to high-risk patients with pneumothorax. This treatment, however, is sometimes unsuccessful in patients with intractable pneumothorax or intrapleural dead space. We developed a technique for the intrapleural administration of diluted fibrin glue as a treatment for such patients.
Fibrin glue was diluted fourfold with saline solution and/or contrast medium. Pleurodesis with a large amount of the diluted fibrin glue was performed in 40 high-risk patients with intractable pneumothorax and in 13 postthoracotomy patients with persistent air leakage associated with an intrapleural dead space.
The air leaks were stopped by administration of the glue in all patients of both groups. During the follow-up period, a recurrence rate of 12.5% was observed in the former group. These recurrent pneumothoraces also were successfully treated by glue administration with no further recurrence. In the 13 postthoracotomy patients, there was no recurrence after the initial treatment. Pyrexia (12.5%) and chest discomfort (4.1%) were observed as side effects, but there were no findings of severe chest pain or thoracic empyema.
These results suggest that intrapleural administration of a large amount of diluted fibrin glue is a useful treatment for intractable pneumothoraces in high-risk or postthoracotomy patients who have an intrapleural dead space.
Autologous blood-patch pleurodesis for secondary spontaneous pneumothorax with persistent air leak
1999, Respiratory Medicine

View all citing articles on Scopus

View full text

Chest

Experimental ApproachesTetracycline Pleurodesis During Active Pulmonary-Pleural Air Leak for Prevention of Recurrent Pneumothorax

Section snippets

Methods and Materials

Results

Discussion

Chest

Ann Thorac Surg

Am J Surg

Chest

Parietal pleurectomy for recurrent pneumothorax

Br J Surg

Spontaneous pneumothorax: medical and surgical management

N Engl J Med

The pleura

The treatment of recurrent malignant pleural effusion

Ann Thorac Surg

Experimental Approaches
Tetracycline Pleurodesis During Active Pulmonary-Pleural Air Leak for Prevention of Recurrent Pneumothorax