Therapy of pleural effusions Modern techniques

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1 Therapy of pleural effusions Modern techniques Dr. Melanie Toffel Sugery of the chest

2 Pleural effusion Ethiology

3 In the normal pleural space there is a steady state in which there is a roughly equal rate of the formation (entry) and absorption (exit) of liquid. V.C.Boroaddus, uptodate.com; 12/2012

4 Causes of pleural effusions Transudative (congestive heart failure, nephrotic syndrome) Exsudative - Neoplastic disease (metastatic, mesothelioma) - Infectious disease (tuberculosis, viral or fungal infections) - Pulmonary embolization - Gastrointestinal disease (esophageal perforation, pancreas disease) - Collagen vascular disease (rheumatoid pleuritis) - After surgical produces (coronary artery bypass surgery, transplantation)

5 no single mechanism is likely to explain the development of a pleural effusion. It is likely that for many effusions, multiple factors contribute to effusion formation Quelle: uptodate; C. Broaddus; 12/2012

6 Diagnosis Analysis of the pleural effusion - color of fluid (bloody, milky, yellow) - character of fluid (pus, viscous..) - chemical analysis ph, LDH, protein, glucose) - Light s criteria (transudate or exsudate - malignant: Positive fluid cytology and/or pleural biopsy for cancer - paramalignant: Pleural fluid and pleural biopsy are negative direct or indirect tumor effects such as bronchial obstruction, lymph node infiltration

7 Questions to be answered before treatment Will chemotherapy for the underlying tumor resolve the effusion? Should the effusion be treated? What is the prognosis for life expectancy? What are the treatment options? Is the lung expandable Is there a fast or slow reaccumulation of the effusion

8 Indications for treatment Asymptomatic malignant pleural effusion does not need to be treated as long as there is a steady state Some tumor type (breast, ovarian)may respond to chemotherapy with resolution of the effusion Not responding malignant effusions causing dyspnea require palliative therapy directed at the pleural space

9 Treatment Chemotherapy Observation Therapeutic thoracentesis Chest catheter drainage only Chest catheter drainage with chemical pleurodesis (eg, talc slurry) Thoracoscopy with talc insufflation (medical or VATS) Pleural abrasion or pleurectomy Long-term indwelling pleural catheter Pleuroperitoneal shunt Heffner JE, Klein: JS Mayo Clin Proc. 2008;83(2):235

10 Pleurodesis Obliteration of the pleural space by the induction of pleural inflammation and fibrosis by instillation of sclerosant (talc)

11 Talc Mg3Si4010(OH)2 Magnesium silicate sheet asbestos-free sterilised 2-3g talc, not more 2 ways to install the talc: - At thoracoscopy using an atomiser termed talc poudrage - Via an intercostal tube as a suspension termed talc slurry Stefani et al (2006) E J Cardiothorac Surg 30(6):

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13 Talc slurry Talc slurry is a nondissolving suspension of talc powder in saline, (50 ml of sodium chloride 0.9 %, injected into the talc powder bottle) Talc slurry distributes quite poorly over the pleural surfaces, and tends to collect at the caudal sinuses Russak et al Chest 1997; 111(2): 442

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15 Adverse events - Fever - Pain - Gastointestinal symptoms - Respiratory problems (ARDS, pneumonia)

16 In-dwelling pleural catheter provide a high degree of symptom relief lung entrappment or endobronchial obstruction by tumor EWIMED pleural fluid drainage via the in-dwelling cather at home significantly fewer days in hospital fewer additional pleural procedures than those who received pleurodesis positiv impact on dyspnea, cough and fatigue Fysh et al 2012, Chest 142(2); ; Davies et al (2012) JAMA 307(22); ; Robert et al (2010)Thorax 65(2) 32-40

17 PleurX (in-dwelling catheter) Ewimed, Hechingen Germany

18 Ewimed Hechingen Germany

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20 45-70 % spontaneus pleurodesis with in-dwelling catheter Demmy et al 2012 J Natl Compr Canc Netw 10(8): ; Davies et al 2012 JAMA 307(22):

21 Shunt (pleuroperitoneal) Raley used option with trapped lung More invasive than an in-dwelling catheter - during thoracoscopy the shunt is inserted with one end in the pleural cavity and the other through a tunnel into the peritoneum - the pumping chamber is placed in a subcutaneous pocket overlying the costal margin Complication: (15%) - shunt failure - occlusion - infection

22 Ewimed Hechingen Germany

23 Pleurectomy and/or Decortication Pleurectomy: resection of of visceral and parietal pleura Decortication: removal of fibrous pleural rind Needs thoracotomy with higher morbidity and mortality

24 Indication and treatment

25 Patients with rapid entry rates good prognosis > 6 month bad prognosis < 6 month Thoracoscopy with talc poudrage Pleurectomy Chest tube Indwelling pleural catheter

26 slow reaccumulation Therapeutic thoracocentesis Prompt relief of dyspnoe Performed at the bedside Infection is possible After repeated thoracocentesis : Thoracoscopy with talcum poudrage

27 Complication for prolonged non treatment Trapped lung

28 Trapped lung

29 Trapped lung

30 Trapped lung: treatment Pleurectomy / decortication indwelling pleural catheter

31 Choosing the treatment In-dwelling pleural catheter - short time in hospital - ideal for patient with a shorter duration of survival Talc slurry via chest tube - survival for only a few months - risk for respiratory complications Thoracoscopy with talc insufflation - longer survival - during a diagnostic thoracoscopy - risk for respiratory complications

32 Choosing the treatment Pleurectomy - it is the primary therapy for patient with malignant pleura mesothelioma or - failure in treatment of malignant effusions and good prognosis Shunt (pleuroperitoneal) - for trapped lung - failed pleurodesis - it is more invasive than an in-dwelling catheter - shunt-related problems

33 Case Patient, 74 years old, Adeno carcinoma left lower lobe, since may 2012, pleural carcinoma and malignant effusions left, since 3 days fever, leucocytosis Atalectasis left lower lobe Pleural empyema

34 Problems Since 11/2012 atalectasis left lower lobe with malignant pleural effusions and trapped lung No possibility for talc poudrage Actual no chemotherapy (empyema) We will plan a lower lobe resection left with pleurectomy

35 Summary Asymptomatic patients do not need treatment First treatment of symtomatic patients: thoracentesis Further treatment depends on prognosis for life expectancy, dynamic of reaccumulation, tumor type and possibility of the lung to expand Method of choice: thoracoscopic talc poudrage In-dwelling catheter best for patients with a trapped lung and/or recurrent pleural effusion and a short expected survival time In case of failure pleurectomy and/or decortication in elected cases