Until recently, tetracycline was the most widely used but is now no longer available worldwide. Doxycycline and talc are now the two recommended sclerosing agents. They are thought to work by causing inflammation of the pleural membranes. This procedure can be painful. In the awake patient, administer 15–25 ml lidocaine 1% (maximum dose 3 mg/kg) via the chest drain immediately prior to the sclerosing agent. Intravenous opioids and paracetamol may be required. Anti-inflammatory drugs, such as NSAIDs and steroids, should be avoided for up to 2 days before and after the procedure if possible. Talc has a high success rate and is usually well tolerated. Pleuritic chest pain and mild fever are the commonest side effects. However, ARDS is associated with the use of talc in less than 1% of cases. Doxycycline has no serious complications and tends to be the first choice with talc reserved for recurrent effusions. The major disadvantages of bleomycin are the cost and the need for trained personnel familiar with the handling of cytotoxic drugs.

Procedure

1. • Ensure drainage of the effusion and lung re-expansion

2. • Analgesics in the awake patient

3. • Clamp drain at patient's end and insert 50 ml bladder syringe filled with 3 mg/kg lidocaine (20 ml 1% solution for 70 kg patient)