Therapeutic Indications

Pleurodesis for Malignant Pleural Efusion

The term pleurodesis is used to describe pleural symphysis achieved by mechanical or chemical means. There exists a large volume of literature comparing pleurodesis agents and effcacy. The more commonly described chemical pleurodesis agents are talc, bleomycin, doxycycline, and betadine. A Cochrane review published in 2020 comparing chemical pleurodesis agents showed that talc results in fewer pleurodesis failures compared to bleomycin or doxycycline [20]. Pleurodesis via chest tube (talc slurry) is essentially as effcacious as talc insuf ation via medical thoracoscopy (talc poudrage). Indwelling pleural catheters offer an alternative to either talc slurry or talc poudrage and in many patients will result in auto-pleurodesis. Daily drainage may increase pleurodesis rates and allow for earlier catheter removal [21]. Reddy and colleagues described a technique that combined talc poudrage via medical thoracoscopy followed by insertion of an indwelling pleural catheter [22]. This combined procedure reduced the length of hospital stay from 3.5 days to 1.8 days and the time to pleural catheter removal to a median of 7.5 days. A small study only published in abstract form described a similar technique combining medical thoracoscopy with parietal pleural biopsy followed by tunneled pleural catheter placement without talc poudrage. Similar to the rapid pleurodesis protocol described by Reddy, tunneled pleural catheters could be removed at the 2 week follow-up visit in 92% of patients and 96% of patients were discharged the day of the procedure [22]. Although less invasive means of palliation of malignant pleural effusions are available, thoracoscopy has the advantage of being able to inspect the pleural space, perform directed biopsies and achieve effective pleurodesis safely and expeditiously.

Pleurodesis of Pneumothorax

Little has been written in recent years about the role of medical thoracoscopy for pneumothorax. The most recent guidelines come from the European Respiratory Society Task Force in 2015 [23]. The task force performed a comprehensive review of the literature on which it based its recommendations. Talc pleurodesis for the prevention of recurrence of spontaneous pneumothorax has a long history and has been associated with an effcacy rate of >90%. Recurrence rate following talc poudrage was 5% compared to 27% following chest tube drainage without pleurodesis [24]. The safety of talc has been raised due to concern for the systemic absorption of the particles and the subsequent development of adult respiratory distress syndrome. This may be particularly true for small particle size talc which may lead to greater systemic absorption and more intense pleural in ammation [25]. As the talc supply in Europe does appear to be safe, European pulmonologists have developed treatment algorithms including talc poudrage for pleurodesis after pneumothorax and there is a drive to include medical pleuroscopy with talc poudrage even earlier in the algorithm, at the index collapse rather than awaiting relapse [26]. The rationale is to minimize recurrence of the pneumothorax considering the high relapse rate described above. The role of medical thoracoscopy with talc poudrage in secondary pneumothorax is poorly studied as these patients often have complex medical histories that impact on their ability to tolerate even moderate sedation.

Thoracoscopic Drainage

Medical thoracoscopy can be a valuable tool in the management of both parapneumonic effusions and empyemas. Infectious pleural effusions may rapidly become more complex as fbrin deposition occurs. Over time the thin fbrinous bands become thicker and more complex, with