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REGIONAL ANESTHESIA

A Spray Catheter Technique for Pleural Anesthesia: A Novel Method for Pain Control Before Talc Poudrage

Pyng Lee, MD^*, and Henri G. Colt, MD, FCCP

From the *Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Singapore; and Department of Pulmonary and Critical Care Medicine, University of California, Irvine Medical Center, Irvine, California.

Address correspondence and reprint requests to Pyng Lee, MD, Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Outram Road, Singapore 169608. Address e-mail to lee.pyng{at}sgh.com.sg.

	Abstract

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BACKGROUND: Chemical pleurodesis causes severe pain, prompting physicians to perform thoracoscopic talc poudrage under general or neuroleptanalgesia. We describe a novel method for pain control in five patients with pneumothoraces and severe chronic obstructive pulmonary disease.

METHODS: Patients were premedicated with IM pethidine and IV midazolam. The pleural space was examined with the flex-rigid pleuroscope. Before talc poudrage, 250 mg lidocaine was administered via spray catheter, and pain scores measured immediately after the procedure and on postoperative days 1 and 2 were 3, 2, and 2, respectively.

RESULTS: No complications were noted, and 30-day mortality was 0%.

CONCLUSION: Lidocaine via spray catheter is effective for pain control before pleurodesis.

	Introduction

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Secondary spontaneous pneumothorax as a complication of chronic obstructive pulmonary disease (COPD) is potentially lethal (1,2) and warrants an aggressive approach to prevent recurrence. These measures include surgical bullectomy and an intervention to cause pleural symphysis (3–5). Although video-assisted thoracic surgery is increasingly accepted as the standard treatment (6,7), it requires general anesthesia and single-lung ventilation with a double-lumen endobronchial tube. Thus, risks for morbidity and mortality associated with general anesthesia (8,9), and for laryngotracheal injuries arising from use of the double-lumen tube cannot be ignored (10).

We hypothesized that inspection of the pleural cavity using the flex-rigid pleuroscope (LTF 160/240, Olympus Japan) inserted through a 10-mm flexible trocar (Fig. 1), together with the administration of 250 mg 1% lidocaine via spray catheter before talc poudrage, would be well-tolerated under local anesthesia.

View larger version (98K): [in this window] [in a new window]   Figure 1. Flex-rigid pleuroscope comprised of a rigid 22-cm shaft and 5-cm flexible tip and disposable flexible trocar. Lidocaine is administered via spray catheter through the working channel of the pleuroscope.

	METHODS

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Patients
Patients with COPD (11) and pneumothoraces who underwent pleuroscopic talc poudrage from August 1, 2003 to July 31, 2004 were prospectively followed up until December 31, 2005. The severity of COPD (12) was derived from values of post-bronchodilator forced expiratory volume (FEV)₁ (liters) and FEV₁ (% predicted) within a year of the procedure, and fitness was assessed according to the ASA physical status classification. Patients were asked to grade their discomfort immediately after the procedure and every 8 h during their recovery on a 10-cm visual analog scale (VAS). Data on demographics, smoking, chest radiograph, procedure-related complications, chest tube drainage, hospital stay, and outcome were collected. Values were expressed as median and range. All patients gave informed written consent and the study was conducted in accordance with the 1975 Helsinki Declaration, which includes approval by the local ethics committee.

Preparation and Procedure
Pleuroscopy with talc poudrage was performed in the bronchoscopy suite. All patients were premedicated with IM pethidine 50 mg and atropine 0.6 mg 30 min before the procedure, and given intranasal oxygen. IV midazolam was titrated according to patient comfort, under the supervision of a pulmonary fellow, together with continuous electrocardiogram, arterial blood pressure, and percutaneous oximetry (13).

Patients were placed in the lateral decubitus position with the involved side of the chest cleaned and draped. About 600 mL of air was injected into the pleural space via the previously inserted chest tube to partially collapse the lung. Lidocaine 10 mL 1% was injected into the selected intercostal space beginning from the epidermis, subcutaneous tissue, intercostal muscles to the parietal pleura. Entry into the pleural space was confirmed by aspiration of air and a further 5 mL 1% lidocaine was instilled for pleural anesthesia. A 1-cm skin incision was then made above the rib, and blunt forceps dissection allowed for entrance into the pleural space. This was followed by placement of the flexible trocar, through which the pleuroscope was inserted (14). Examination of the pleural cavity was performed without stapling of bulla or repair of air leak.

Before talc poudrage, 25 mL 1% lidocaine (250 mg) was applied over the parietal pleural surface using a spray catheter introduced through the working channel of the pleuroscope. Talc poudrage was achieved by insufflating 3 g asbestos-free sterilized talc. The chest tube was removed and replaced by a 20 F tube inserted via trocar. The tube was connected to negative 20 cm H₂O suction for 2 days, and chest radiograph was performed to check tube position and lung re-expansion. The first oral dose of tramadol 50 mg was administered 3 h after the procedure and every 8 h subsequently.

	RESULTS (Table 1)

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The median age of the five male patients was 74 yr (range, 66–79). All were current smokers of 50 pack years (range, 28–55), with ischemic heart disease and ASA grade 3. The pneumothoraces measured 20%, and were managed with chest tubes and oxygen. Median FEV₁ was 43% (range, 36%–49%), FEV₁ 0.90 L (range, 0.66–0.95), forced vital capacity 2 L (range, 1.5–2.6), and body mass index was 16 kg/m² (range, 13–18).

All underwent pleuroscopic talc poudrage within 3 days of hospitalization and required 2 mg midazolam (range, 1.5–2.5). The median operative time was 32 min (range, 25–40 min), and no decrease in Sao₂ less than 92%, and hypotension or arrhythmia was observed intraoperatively.

Flex-rigid pleuroscopy and talc poudrage was performed safely in all patients without adverse events requiring open surgery, blood transfusion, or endotracheal intubation. None experienced cough during pleural manipulation or chest wall pain as a result of pressure on the intercostal nerve by the trocar. The median pain score immediately after talc poudrage was VAS 3, which decreased to VAS 2 on postoperative days 1 and 2. No additional IM or IV analgesia other than those described in the protocol was required. All patients achieved complete lung re-expansion, and cessation of air leak within 2 days of the procedure to allow chest tube removal. The postoperative hospital stay was 3 days (range, 2–3), and the 30-day mortality was 0%. No recurrence of pneumothorax was observed over a median follow-up of 21 mo (range, 19–24), giving a success rate of 100%.

	DISCUSSION

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Pain arising from pressure of the intercostal nerve during thoracoscopy, as well as from chemical pleurodesis, can be severe, prompting physicians to perform the procedure under general or neuroleptanalgesia rather than local anesthesia (15). Notably, studies have explored strategies such as four-step local anesthesia (16), regional and epidural anesthesia (17,18), and multimodal analgesia (19,20) to enhance patient comfort and outcome.

Lidocaine was chosen for its safety profile because all patients had ischemic heart disease, and whenever uptake by the pleura could be rapid, it resulted in high serum levels (21). Moreover, drug loss estimated at 30%–40% through the chest tube (22) was minimized, because it was administered as spray.

Pain, although subjective, can be measured objectively with linear scale scoring systems. Our patients' pain scores immediately after pleuroscopic talc poudrage and on postoperative days 1 and 2 were VAS 3, VAS 2, and VAS 2, respectively. These scores were lower than the median VAS 5 for the same duration reported by patients with primary pneumothoraces who had undergone thoracoscopic talcage under local anesthesia and received opioids (23). Similarly, they were also lower than the reported VAS 8 after talc without prior lidocaine, and VAS 6 on days 1 and 2 (unpublished data) (13).

Although limited to five patients, our technique of meticulously anesthetizing the selected intercostal space, use of flexible trocar, and easy maneuverability of the pleuroscope, not only provided adequate local pain control, but also facilitated pleural examination with minimal cough and enhanced patient comfort. Further pleural anesthesia with lidocaine spray and postoperative opioids also led to good tolerability after talc poudrage.

	Footnotes

 
Accepted for publication September 25, 2006.

	REFERENCES

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