Pleurodesis

Pleurodesis is a procedure that adheres the outside of the lung to the inside of the chest cavity to prevent the lung from collapsing again.  If you have a persistent leak and/or have had a pneumothorax previously, your doctor may ask you to consider pleurodesis as a preventative measure.  Although pleurodesis isn't a foolproof remedy against future pneumothoraces, it generally diminishes their likelihood.  Also, if you do have a pneumothorax after you’ve had pleurodesis, the collapse is more likely to be partial, and intervention may not be required.  The procedure may be done by a number of different techniques.

Mechanical Pleurodesis

The pleura is a membrane which envelopes the lung adjacent to the chest well.  A mechanical pleurodesis is performed manually by a surgeon who gently strokes the pleura with a piece of gauze.  Mechanical pleurodesis roughens up the pleura so that when the abrasion heals, the lung adheres to the chest wall.  Sometimes the procedure is done in combination with some type of chemical pleurodesis, such as talc (below).  In general, LAM experts prefer mechanical pleurodesis without talc for patients with LAM since lung transplantation can be more difficult after talc or pleurectomy.

Chemical Pleurodesis

A chemical pleurodesis involves instilling a chemical irritant into the pleural space, which causes adhesion between the chest wall and the lining of the lung.  Chemical pleurodesis can be done either through a chest tube, while you’re awake in a hospital room, or it can be done under general anesthesia via surgery.  Sometimes a combination of chemical and mechanical pleurodesis is used.

Talc pleurodesis: One of the most common methods of chemical pleurodesis is performed using surgical talc and a chest tube.  In fact, if a patient already has a chest tube in place, a talc procedure is often recommended.  When the air has been expelled, a talc slurry is instilled through the chest tube into the chest cavity.  Alternatively, during surgery, talc can be blown into the chest cavity using a bulb syringe, a method called talc poudrage. The talc acts as a sclerosing agent, that is, something that causes the pleura lining of the lung and the pleura lining of the chest wall to stick together.  Suction is used after this procedure to remove any remaining air in the pleural space.  Talc pleurodesis or poudrage often produces a burning sensation in the chest as the area heals, but this procedure tends to be very effective, and it’s also less expensive than surgery.

Other Chemicals: In addition to talc, other chemical irritants such as doxycycline can be used.

Pleurectomy

If pleurodesis doesn’t work or if you have recurrent pneumothoraces, you may be a candidate for a pleurectomy.  This surgery involves stripping off pleura from the inside of the chest wall to promote the fusion of the lung and the chest wall.

Surgery

To perform the procedures just mentioned most doctors use one of the following two procedures to gain access to your lungs.

Thoracotomy

This is a general term for open-chest surgery, a type of surgery that is used for many reasons and procedures.  While the patient is under general anesthesia, the surgeon makes an incision that runs approximately from the front to the back (by the shoulder blades) of the chest in between two ribs.  This incision allows the doctor access to the lung.  A thoracotomy is used for mechanical pleurodesis, for some chemical pleurodesis procedures, and for pleurectomy. Thoracoscopy (below) is a more modern approach to pleurodesis, and thoracotomy should only rarely be necessary for pleurodesis.
A patient usually requires about a week long stay in the hospital after a thoracotomy, but full recovery can take several months.  During recovery, the patient should practice deep-breathing techniques to help prevent pneumonia.  And, as with any surgery, bleeding and infection are always risks.  Remember, too, to take whatever pain medications you require.

Thoracoscopy or VATS

Video-assisted thorascopic surgery (VATS) is performed using a tiny fiber-optic camera (called a thorascope) and is a much less invasive procedure than a thoracotomy.   Instead of using one large incision to gain access to the chest, one or more small finger-sized incisions, or ports, are made in your side and used to insert the scope and other surgical instruments.  The thorascope transmits images of the inside of your chest onto a video monitor, guiding the surgeon in maneuvering the instruments to complete the procedure.  These smaller incisions, unlike a larger surgical incision, typically result in less pain and faster recovery time.  For these reasons, VATS has become the preferred method for surgical lung biopsies and other lung surgeries.

Recovery From Treatments

Try to stay ahead of pain after any of these procedures.  When your doctors offer you pain medications, take them if you need them.  It’s much more difficult to stop pain after it has become intense than it is to prevent pain in the first place.  Suffering needlessly isn’t heroic.  You may be in a significant amount of pain for a few days but, after the first few days, your pain should be manageable.  The pain and discomfort generally continue to decrease over a few weeks.

You may also experience shortness of breath and fatigue for a week or two following your release from the hospital and you may need a month or more of rest before you’re able to return to work.  Don’t push yourself.  You don’t want to risk another lung collapse by not recuperating sufficiently.  Although it may take several weeks to fully recover, you’ll probably be able to resume some of your regular activities more quickly. However, be certain that all of your pain is gone and your reaction times are back to normal before you drive again

Once the healing is complete, there are usually no residual effects.  Your breathing, however, may feel strange at first, as if something has changed.  Unfortunately, some discomfort or a pulling sensation in the chest area can continue for months after pleurodesis.

Tips For An Easier Recuperation

  • Sleep in a recliner for a few days or even a couple of weeks.  The semi-upright position may help lessen the pain as trying to raise the upper part of your body to get out of bed can be painful.
  • Buy a bra that is larger than your usual size.  You’ll probably need support a few days after pleurodesis, but your chest may be a bit too swollen from the procedure for your regular bra to fit.
  • Don’t lift heavy objects until your doctor allows you to do so.

Transplant After Pleurodesis

Many women have been told that lung transplantation after pleurodesis is impossible.  While that may have previously been the case, it’s no longer true.  Many women with LAM, collectively having had every type of pleurodesis, have undergone successful lung transplants.  However, transplant surgery is more complicated if you’ve had one of these procedures.

While pleurodesis no longer rules out transplant, a lung that has been adhered to the chest wall is more difficult to remove and removing it therefore, takes more time.  The longer a surgery—any surgery—takes, the longer you’re under anesthesia and, in this case, the greater your risk of excessive bleeding.

To increase your chances of a successful transplant, your surgeon may suggest a single-lung transplant, transplanting only the lung that has not undergone pleurodesis.  Whatever decision you and your surgeon reach, be assured that your welfare will always be of paramount importance.

Questions for Your Health Care Provider

  • At what stage is pleurodesis needed to improve my condition?
  • How often have you performed this procedure?
  • Would you recommend local or general anesthesia?
  • How long will it take me to recover?
  • Are there activities I should avoid?
  • What is the likelihood of leakage after pleurodesis?