A teenage boy presented to the ED with complaints of right-sided chest pain worse with inspiration and shortness of breath. He had a history of a cystic lung disease of unknown etiology and previously had a left-sided spontaneous pneumothorax. After the pneumothorax, he had a pleurodesis, and eventually, underwent an elective prophylactic right-sided pleurodesis. These procedures had been done about 1.5 years prior to his current presentation. He reported that his current symptoms felt similar to when he had a pneumothorax in the past, but not quite as severe.
VS: HR 65, BP 109/70, RR 15, SpO2 100% on RA
The first thing that the providers wanted to know was if he had a pneumothorax. Normally, in our ED, ultrasound would be the first diagnostic test done to determine if there was a pneumothorax, however, is there still lung sliding after a pleurodesis?
Pleurodesis is supposed to adhere the parietal and visceral pleura together to prevent a pneumothorax or pleural effusion from occurring. One could reason, then, that there would not be sliding present after a pleurodesis, as sliding is created by the parietal and visceral pleura sliding along each other.
The providers taking care of the patient decided to look at the lungs just to see.
Here is the right side (affected side):
What do you see?
It looks like there is sliding, however, the surface of the lung looks odd. It has a lumpy bumpy appearance. We are guessing that is a reaction and scarring from the pleurodesis.
For comparison, the clinician looked at the other (left) side:
You can see that there is a similar, lumpy, appearance to the lung with sliding present.
The patient went on to have a chest x-ray that did not reveal the etiology of his symptoms. Per the request of his pulmonologist, a CT scan of the chest was also obtained, which also revealed no etiology of the symptoms.
In our literature search, there was limited data on whether or not there is lung sliding after pleurodesis. There was one study that we found that was published in the European Journal of Cardiothoracic Surgery in which patients who had undergone pleurodesis had lung ultrasound performed after the procedure to assess if the procedure was successful or not.1 If lung sliding was absent in multiple locations after the procedure, it was considered successful. The authors also concluded that areas where sliding was still present after the pleurodesis were at risk of recurrent pneumothorax. Based off of this study, it seems like the young man in this case did not have a successful pleurodesis on either side, and is at risk for a recurrent pneumothorax.
Have any of you taken a look at the lungs of someone who has undergone a pleurodesis? Was there lung sliding present or not? Was there the same lumpy bumpy appearance of the pleural interface?
- After a successful pleurodesis, lung sliding by definition will be absent because the parietal and visceral pleura should be adhered to each other. (Side note: this makes telling the difference between a successful pleurodesis and a pneumothorax very difficult!)
- If there is lung sliding after pleurodesis, the procedure was not completely successful, and the patient is at risk of recurrence of pneumothorax or pleural effusion.
Leo F, Dellamonica J, Venissac N, Pop D, Mouroux J. Can chest ultrasonography assess pleurodesis after VATS for spontaneous pneumothorax? Eur J Cardiothorac Surg. 2005;28(1):47-49.