Pleurodesis

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Original Editor - Rosie Swift Top Contributors - Rosie Swift, Vidhi Jain, Gabi Solomon, Vidya Acharya, Alexandra Stead and Kim Jackson

Introduction

Pleurodesis is a medical procedure designed to obliterate the pleural space by inducing adhesions between the parietal and visceral pleura. It is done to prevent fluid or air from repeatedly accumulating in that space, most often in patients with recurrent malignant pleural effusions (from cancers like lung, breast, or ovarian) or persistent pneumothorax.

Several approaches exist for performing pleurodesis, each differing in technique, invasiveness, and clinical application

• Chemical pleurodesis: This approach uses a sclerosing agent, most commonly talc is instilled directly into the pleural cavity via a chest tube, triggering controlled inflammation and subsequent fibrosis that causes the visceral and parietal pleural surfaces to fuse, permanently sealing the pleural space. It stands out as the preferred choice due to its lower complication rates in comparison to alternative procedures, making it the most widely adopted method.

• Surgical pleurodesis: This is done through medical thoracoscopy, video-assisted thoracoscopy (VATS), or open thoracotomy, where either a sclerosis agent is placed in the pleural cavity or mechanical abrasion (also termed dry abrasion) is achieved by draining the pleural fluid using a tunnelled catheter (induces pleurodesis without instillation of a sclerosing agent).

• Mechanical pleurodesis: Mechanical pleurodesis achieves pleural symphysis through direct physical abrasion of the pleural surfaces, performed under thoracoscopic or open thoracotomy visualisation. This technique is indicated in the management of recurrent pleural effusions, spontaneous or recurrent pneumothoraces, and as an adjunctive measure in malignant pleural disease.

Regardless of the approach used, the procedural and post-procedural care follows a broadly consistent protocol. Analgesia such as an NSAID or opiate, is usually given for the duration of the procedure. Patients can expect to be an inpatient for at least 24 hours following the procedure, longer if surgical pleurodesis is performed. Occasionally a single stitch may be used to close the insertion site of the chest drain.

Indication

Lung pleura

The pleural space between the parietal and visceral pleura usually contains around 50ml of pleural fluid. Under pathological conditions, such as pneumothorax or pleural effusion, air or excess fluid can build up in the pleural space. If this becomes recurrent and significantly symptomatic, pleurodesis may be indicated, refractory to standard management.

Any condition which causes extra fluid to collect in the pleural cavity may require a pleurodesis. These include: heart failure, pneumonia, tuberculosis, cancer, liver and kidney disease and inflammation of the pancreas.

Typically, a recurrent pleural effusion (particularly if malignant) or recurrent or persistent pneumothorax may be treated by pleurodesis.

Clinical Presentation

Depending on the reason that the pleurodesis is required, patients may present with signs of pleural effusion or pneumothorax, such as:

• Breathlessness
• Chest pain
• Cough
• Fever
• Tachycardia
• Tachypnoea
• Fatigue

Complications

Complications from chemical pleurodesis include:

• Chest pain
• Fever
• Acute respiratory distress syndrome
• Breathlessness (localised inflammatory reaction to the procedure)
• Infection at the insertion site
• Empyema
• Development of loculated effusions (talc loculations)

Complications from surgical pleurodesis include:

• Pneumothorax
• Injury to the chest wall, arteries, or lungs
• Blood clots, pulmonary embolism

In the case of failed pleurodesis, pleurectomy may be required to control malignant pleural effusions. Patients must be good surgical candidates and have a reasonably long expected survival because total radical pleurectomy/decortication requires a thoracotomy and is a major surgical procedure associated with considerable morbidity and some mortality.

Physiotherapy Post-Pleurodesis Surgery

Following pleurodesis, physiotherapy plays a vital role in optimising recovery, restoring lung function, and preventing post-operative complications such as atelectasis, reduced chest wall mobility, and deconditioning. A structured physiotherapy programme is initiated early in the post-operative period and is tailored to the individual patient's clinical status, drain management, and tolerance to activity.

Early mobilisation

Minimum of 60 m be walked four times on day 1, 80 m on day 2, 100 m on day 3 and then continuing or increasing this as able throughout the rest of their admission.

Patients are encouraged to mobilise at a pace where they achieve a breathlessness of 3-4 on the Borg ten-point scale.

Physiotherapists need to be cautious when mobilising patients with drains, especially when the drains are on suction. In such cases, it is advisable to utilise portable suction to ensure the safety and well-being of the patients during mobilisation.

Airway Clearance Techniques

The use of airway clearance techniques and lung recruitment techniques such as active cycle of breathing (ACBT), Intermittent Positive Pressure Ventilation (IPPV), cough assist, manual techniques and Forced Expiratory Technique (FET) are used as clinically indicated.

Posture and arm exercises

Posture and arm exercises should also be used each day as they have been shown to reduce shoulder dysfunction post-operatively and regain functional activities of daily living.

Wound support

Patient should be taught a supported cough to mechanically support the wound to reduce pain and improve confidence in coughing post-operatively, which will ultimately help in clearing the secretions.

Lung Expansion Techniques

The use of incentive spirometry (IS) remains widespread in the post-operative physiotherapy management of major surgical patients; however, several studies and meta-analyses have shown no additional benefit to the use of IS compared with standard physiotherapy of mobilization, breathing exercises and coughing at reducing the incidence of Post Pulmonary Complications or reducing hospital length of stay.

Segmental breathing exercises have demonstrated superior efficacy in improving chest expansion compared to deep breathing exercises following pleurodesis. A two-week physiotherapy intervention utilising segmental breathing techniques yielded significantly greater thoracic expansion outcomes in the treatment group. These findings suggest that segmental breathing exercises may be the preferred respiratory physiotherapy approach in the post-operative management of patients following pleurodesis.

Conclusion

Pleurodesis is an effective and established procedure for managing recurrent pleural effusions and persistent pneumothorax. Selection of the most appropriate technique should be individualised based on clinical presentation, underlying cause, and patient suitability, with chemical pleurodesis remaining the preferred approach due to its lower complication profile.

Post-operative physiotherapy, encompassing early mobilisation, airway clearance, lung expansion, and wound support, is essential in minimising complications and restoring function. Segmental breathing exercises in particular have shown superior outcomes in improving chest expansion following pleurodesis. A coordinated multidisciplinary approach remains key to optimising patient recovery.