• Malignant pleural effusions
• Benign recurrent pleural effusion
• Recurrent pneumothorax

• Frail and/or terminally ill patients
• perform therapeutic aspiration as required. See Pleural aspiration of fluid guideline
• Presence of continuing air leak is not a contraindication to pleurodesis provided lung has expanded

Pleural effusion

• Lung must be fully re-expanded with no significant residual fluid and fluid drainage through intercostal tube must be <150 mL/day with the tube not blocked or kinked
• ultrasound thorax may be used to check complete fluid drainage
• If only partial pleural apposition achieved and patient unsuitable for surgery, attempt medical pleurodesis as this may provide symptomatic relief

Pneumothorax

• Confirm full lung expansion and position of the intercostal tube

• Check drain size is at least 10 F
• Check if chest drain interface is luer lock or bladder wash connection
• Three 50 mL plastic syringes with interface compatible with inserted chest drain (bladder wash or luer lock)
• Plastic syringe (50 mL) with luer lock
• Asbestos-free talc 4 g
• Sodium chloride 0.9% 50 mL IV infusion bag
• Lidocaine 2% (20 mg/mL) 10 mL injection
• Sodium chloride 0.9% 200 mL intravenous infusion bag
• Morphine 10 mg in 1 mL injection and naloxone 400 microgram in 1 mL injection

• If not competent in procedure, organise supervision by a clinician experienced in the procedure
• If no intercostal tube in situ, insert one. See intercostal tube drainage guideline
• use small (12-14 fg) tube

Consent

• Explain procedure including risk of failure (up to 20%)
• Obtain and record verbal consent

Preparation

• In 50 mL luer lock syringe, mix lidocaine 2% 3 mg/kg (maximum 10 mL or 200 mg) with sodium chloride 0.9% 25 mL
• if inserted drain interface compatible with a bladder wash syringe, transfer mixture to a bladder wash syringe
• Place sodium chloride 0.9% 50 mL into a chest drain 50 mL compatible syringe (to use for final flush)
• Check asbestos-free graded talc available on ward

Pleural injections

• Clamp catheter section of intercostal tube and disconnect chest tube bottle
• Connect syringe containing lidocaine to end of catheter
• Unclamp catheter and inject lidocaine solution into pleural space through end of catheter
• Reclamp catheter for approximately 10 min while preparing talc slurry

Preparing talc slurry

• Draw up sodium chloride 0.9% 40 mL in 50 mL luer lock syringe
• Inject into talc vial using either a needle or dispensing pin and shake to gradually suspend the talc in the sodium chloride 0.9%
• Withdraw talc slurry from vial into luer-lock syringe and cap
• Approximately 10 min after lidocaine has been injected, move to injecting talc slurry

Injecting talc slurry

• If inserted drain interface compatible with a bladder wash syringe, transfer talc slurry to a bladder wash syringe
• Connect syringe containing talc to end of catheter
• Unclamp catheter, inject required volume of talc into pleural space
• Follow by pre-prepared syringe of sodium chloride 0.9% 50 mL to clear agent as final flush
• Reclamp catheter for 1-2 hr
• Post-pleurodesis patient rotation is not required

Adequate analgesia

• Start with paracetamol 1 g oral 6-hrly and codeine phosphate 30-60 mg oral 6-hrly for first 24-48 hr then give as needed
• if ineffective, substitute morphine sulphate solution 10 mg oral 4-hrly for codeine phosphate

Complications

• If fluid persistently drains >250 mL/24 hr, seek senior respiratory advice
• Pyrexia up to 38°C can occur for 48 hr, and does not necessarily imply infection

Removal of drain

• Repeat chest X-ray to check lung fully expanded and there is no significant pleural fluid
• Cut drain-securing suture, withdraw tube while patient holds breath in expiration, and close wound with remaining sutures