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Talc Pleurodesis and VATS

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by

Alex Griffin

on 26 February 2013

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Transcript of Talc Pleurodesis and VATS

Contraindications Summary of recommendations for PT - post-op pain will be an issue for these patients, try to time PT treatment with pain medication
- early mobilisation and encouragement
of continued DBE and secretion
clearance techniques (i.e. huff) is
important How does it work? - pleural fluid, if present, is drained Advantages Before VATS, sternotomy and
thoracotomy incisions were necessary for diagnosis and treatment of many chest conditions What is talc pleurodesis? - a procedure designed to artificially
obliterate the pleural space Patient Selection Certain patient characteristics, and pleural pathology
characteristics are associated with varying levels of success Implications for physiotherapy 2. Post-operative pain VATS Video-Assisted Thorascopic Surgery VATS for
pleurodesis Other uses for VATS - biopsy for diagnosis of pulmonary, pleural
or mediastinal pathology
- decortication for empyema
- surgical stapler assisted wedge resection of lung masses
- resection of mediastinal or pleural masses
- thoracic sympathectomy for hyperhidrosis
- operations for diaphragmatic hernias or paralysis
- oesophageal resection or resection of
oesophageal masses or diverticula
- lobectomy
- mediastinal lymphadenectomy Complications Common adverse events:
- fever (10%)
- pain
- GI symptoms

Less common adverse side-effects:
- arrhythmias
- dyspnoea
- respiratory failure
- systemic inflammatory response
- empyema
- talc dissemination thank you! questions..? Talc pleurodesis and VATS ... & implications for PT management Alex Griffin
RNSH Acute practicum placement
27th of February, 2013 Overview - What is pleurodesis?
- Why perform pleurodesis?
- Talc and other chemical preparations
- How does it work?
- Contraindications & side effects
- Patient selection
- Complications
- Implications for physio Talc vs other chemical
preparations anatomy review - two pleural cavities surround the lungs - the pleura is composed of flat cells, mesothelium & supporting connective tissue - contains a thin layer of serous fluid - fluid produced by parietal circulation - 70kg adult would have 2 - 3 ml fluid in the pleural cavity - talc pleurodesis involves the
introduction of talc into
the pleural space - talc is introduced into the pleural
space, causing inflammation &
fibrosis once in the pleural space, talc causes an intense intrapleural inflammatory response ...the first reports of pleurodesis date back
to the 20th century INTRACAVITY INFLAMMATORY RESPONSE Mesothelial cells are thought to be the main cells regulating the inflammatory response They release inflammatory mediators interleukin-8, vascular endothelial growth factor & TGF-b IL-8 -> migration of leukocytes (mainly neutrophils) VEGF -> increased capillary permeability TGF-b -> facilitates fibrosis (stimulates colagen synthesis and induces fibrosis Talc is predominantly magnesium silicate Mg Si O (OH) 3 4 10 2 Various amounts of Ca, Al and Fe may be present May also contain magnesite, dolomite,
serpentine, kaolinite, calcite,
chlorite and quartz Other options... Antibiotics (tetracycline) Antineoplastic agents (bleomycin) Immunostimulants (Corynebacterium parvum and OK-432) Other chemical irritants (silver nitrate) Biological mediators of inflammation (interferon) Less commonly: autologous blood, polidocanol Talc is most commonly used in clinical practice Its therapeutic success rate is close to 90%, however it is not without inherent side effects - PREVENTION of recurrent pneumothorax or
pleural effusions - TREATMENT of persistant pneumothorax Why perform talc
pleurodesis? Physical contact between visceral and parietal
pleural layers must be achieved

... if there is incomplete expansion of the lung (e.g.
entrapment), pleurodesis will fail Not generally used in patients with:
- cystic fibrosis
- endobronchial obstruction
- thick pleural peel with trapped lung Patient preparation Concomitant medications Talc insufflation vs slurry Patient and clinical preferences empty
pleural
space? depends on
medical
circumstances glucocorticoids
&
NSAIDs duration,
degree of
invasiveness - at port sites
- around site of chest drain
- pleuritic pain/inflammation a side note... If the patient is on blood thinners,
e.g. Warfarin, Asprin, Plavix
or drugs for treating arthritis,
e.g. Celebrex, Voltarol (diclofenac),
Advil, Neurofen etc ... they are at increased risk of bleeding DBE + cough/huff
are important to overcome failure of lung to re-expand
and to prevent infection PAIN Patient will probably not want to take deep breaths ( Vt) With reduced A/E, patient is at increased risk of collapse and infection 3. Position during and
following surgery 1. Effects of GA and pleurodesis/VATS on lung & chest wall compliance, and MCC PART 1: PLEURODESIS PART 2: VATS Overview Aim to time PT treatment with pain relief EFFECTS OF GA P POSITIONING General anaesthesia can result in airways closure
due to reduced FRC cephalad displacement of diaphragm poor coordination of respiratory muscles 2. Compression atelectasis
- change in shape of chest wall and diaphragm
- muscle relaxants and paralysis 3. Absorption atelectasis
High FiO2 often used at GA induction 4. Reduced surfactant production
Lack of deep breaths and sighs during mechanical VE 5. Reduced drive to breathe
Results in reduced gas movement in & out of alveoli EFFECTS OF PROCEDURE Whenever the pleural space is opened, there is a risk of pneumothorax or pleural effusion
- assuming union of pleural layers is achieved, this should not occur Risk of damage to respiratory muscles and nerves 6. Impaired MCC
- reduced ciliary action
- increased mucous viscosity
- depressed cough reflex Post op, patients are usually positioned supine in bed FRC Mobilise Day 1 Aim for SOOB Day 1, and for as long as possible each day - VATS definition

- Advantages

- Other uses for VATS

- VATS for pleurodesis

- What causes VATS pleurodesis to fail?

- Recommendations for PT VATS uses a series of small holes, or
'ports', in the chest wall through which a
camera and small surgical instruments are
inserted Widespread use since 1990s 3 - 4 port sites:
- 4th IC space anteriorly and posteriorly
- 7th IC space anteriorly
- 7th or 8th IC space posteriorly - significant pain (division of chest wall muscles, rib #) for extended periods VATS avoids bone fractures and
muscle division duration & intensity of pain
and faster RTA In pleurodesis via VATS, the lung on the side of chest where the procedure is being performed is deflated to visualise instruments being passed into the thorax. It is reinflated, but often not completely Performed using 3-4 10mm ports Talc is administered as an aerosol, into the pleural
space. Can also be delivered as powder through a
hand-driven air pump from a glass or plastic vial All pleural fluid drained via chest drain Using camera and blunt forceps, the entire hemi-thorax is viewed and adhesions are broken down to maximise pleural SA Chest drain left in situ, -ve pressure applied
to encourage distribution of talc During procedure, patients are usually laterally positioned. So...
Lower lung = dependent
Upper lung = deflated What causes
VATS pleurodesis to fail? - trapped lung, in which lung is
enclosed in scar tissue
- loculation within the pleural space
- loss of lung elasticity
- improper positioning of chest drain,
or blocking/kinking of chest drain Talc particle size Talc preparations with a high proportion of small particles are associated with more severe local and systemic inflammatory responses Currently there are no formal standards for talc production Systemic inflammation and respiratory failure are linked to absorption of talc particles, more likely when:
- particles are small
- large amounts of talc used
- access route that facilitates systemic absorption 1. Side-lying position during procedure (Bethune, 1935) (Lee et al., 2007; Noppen et al., 2012) (Noppen et al., 1997; Doddoli et al., 2004; Noppen & De Keukeleire, 2008; Tschopp et al., 2009) Viallat et al., 1996; Shaw & Agarwal, 2004, Laisaar et al., 2006 (Genofre et al., 2007) (Noppen, 2007; Rossi et al., 2010) (Janssen et al., 2007) Noppen, 2007; Rossi et al., 2010 (Genofre et al., 2007) References Bethune, N. Pleural poudrage: new technique for the deliberate production of pleural adhesion as preliminary to lobectomy. J Thorac Surg 1935; 4:251.

Doddoli C, Barlési F, Fraticelli A, et al. Video-assisted thoracoscopic management of recurrent primary spontaneous pneumothorax after prior talc pleurodesis: a feasible, safe and efficient treatment option. Eur J Cardiothorac Surg 2004; 26:889.

Genofre EH, Marchi E, Vargas FS. Inflammation and clinical repercussions of pleurodesis induced by intrapleural talc administration. Clinics (Sao Paulo) 2007; 62:627.

Janssen JP, Collier G, Astoul P, et al. Safety of pleurodesis with talc poudrage in malignant pleural effusion: a prospective cohort study. Lancet 2007; 369:1535.

Laisaar T, Palmiste V, Vooder T, Umbleja T. Life expectancy of patients with malignant pleural effusion treated with video-assisted thoracoscopic talc pleurodesis. Interact Cardiovasc Thorac Surg 2006; 5:307.

Lee P, Hsu A, Lo C, Colt HG. Prospective evaluation of flex-rigid pleuroscopy for indeterminate pleural effusion: accuracy, safety and outcome. Respirology 2007; 12:881

Noppen M, Meysman M, d'Haese J, et al. Comparison of video-assisted thoracoscopic talcage for recurrent primary versus persistent secondary spontaneous pneumothorax. Eur Respir J 1997; 10:412.

Noppen M. Who's (still) afraid of talc? Eur Respir J 2007; 29:619.

Noppen M, De Keukeleire T. Pneumothorax. Respiration 2008; 76:121.

Rossi VF, Vargas FS, Marchi E, et al. Acute inflammatory response secondary to intrapleural administration of two types of talc. Eur Respir J 2010; 35:396.

Steger V, Mika U, Toomes H, et al. Who gains most? A 10-year experience with 611 thoracoscopic talc pleurodeses. Ann Thorac Surg 2007; 83:1940.

Shaw P, Agarwal R. Pleurodesis for malignant pleural effusions. Cochrane Database Syst Rev 2004; :CD002916.

Tschopp JM, Boutin C, Astoul P, et al. Talcage by medical
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