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Ann Thorac Surg 1999;67:917-921
© 1999 The Society of Thoracic Surgeons

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Original Article

Pleurodesis by autologous blood, doxycycline, and talc in a rabbit model

^a Division of Respiratory and Critical Care Medicine, Department of Medicine, University of Missouri, Kansas City School of Medicine, Kansas City, Missouri USA

Accepted for publication October 9, 1998.

Address reprint requests to Dr Herndon, University of Missouri, Kansas City, School of Medicine, Gold 5 Lab, 2411 Holmes, Kansas City, MO 64108
e-mail: bherndon{at}cctr.umkc.edu

	Abstract

Top Abstract Introduction Material and methods Results Comment Acknowledgments References

 
Background. Management of recurrent spontaneous pneumothorax or symptomatic pleural effusion often uses thoracoscopic pleurodesis, about which many questions remain. Both effectiveness and toxicity of agents currently used for pleurodesis were evaluated in a rabbit model.

Methods. Agents administered were autologous blood 1 mL/kg, talc slurry (70 mg · mL^-1 · kg^-1), and doxycycline 10 mg/mL, given through a chest tube to 30 rabbits. Controls had only chest tubes inserted. At 30 days surfaces were graded by gross observation and histologic examination. Blood and lung tissue from all animals were analyzed for enzymes and blood chemistries.

Results. Gross observations showed mediastinal thickening and adhesions with doxycycline, and threadlike adhesions with talc. Autologous blood was only slightly more effective than a chest tube alone. Talc significantly increased angiotensin converting enzyme activity in serum, whereas doxycycline changed liver function enzymes and produced tissue toxicity.

Conclusions. Doxycycline produced effective pleurodesis but yielded remarkably severe local effects. The distant sequelae of talc and doxycycline pleurodesis—histologic changes in the contralateral lung and serum enzyme elevations—suggests undesirable systemic effects for the commonly used agents, and autologous blood exhibited no significant pleurodesis, short-term. The search for the ideal agent for chemical pleurodesis continues.

	Introduction

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Spontaneous pneumothorax is a common problem facing thoracic surgeons, occurring in nearly 0.01% of individuals in a year [1]. This is life threatening in many patients and a recent survey of thoracic surgeons and pulmonologists suggests that 16% to 20% of respondents would treat first recurrence of spontaneous pneumothorax with a tube thoracostomy plus a sclerosant [2]. Pleural inflammation, fibrotic change, neovascularization, and eventual collagen deposition after the instillation of a sclerosing agent are considered necessary for pleurodesis. Sclerosing agents successfully used clinically and in experimental trials include doxycycline [3, 4], talc [5–8], and other agents, all of which have shown some efficacy as well as toxicity.

Some case series have reported success with autologous blood patch for persistent air leaks in pneumothoraces or for pleurodesis [9–11], a process of injecting the patient’s own blood into the pleural space through a chest tube. Outside the vascular system, blood is known to be related to adhesion formation and fibrosis. If effective in the chest, autologous blood would be a safe and inexpensive agent to effect pleurodesis.

Most recently, talc has been the preferred agent with reported greater success rates than other agents [5–8, 12, 13]. There has been some speculation on talc’s potential short- and long-term risks, but to date, these concerns have not been conclusively addressed. Over a decade ago, it was suggested [14] that the change in angiotensin-converting enzyme (ACE) activity could be a specific index corresponding to the progression of alveolar capillary damage in pathologic pulmonary conditions such as adult respiratory distress syndrome. Silicosis has been consistently linked with increased lung ACE activity [15, 16]. There exists the possibility that talc (magnesium silicate) would upregulate ACE in a manner similar to silicon dioxide. Our preliminary work suggests that the major pleurodesis agents have considerable systemic toxicity [17]. In humans, doxycycline has been reported to produce esophageal ulcers on oral administration, pain and fever when administered intrapleurally, as well as documented hepatotoxicity [18–20].

In this study, autologous blood pleurodesis was compared to doxycycline and talc, and the pleurodesis of all agents compared to the inflammatory response from a chest tube alone. Pleurodesis at 30 days was scored by both gross and histologic observation. Systemic effects of the locally administered agents were determined by clinical chemical measurements on lung tissue homogenates and serum.

	Material and methods

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Subjects and design
The protocol was approved by the Institutional Animal Care and Use Committee, and all animals were housed in the facilities of the University of Missouri-Kansas City Medical School. In the University experimental operating theater under sterile technique, 30 female NZ white rabbits (4 kg) were randomly assigned for these studies. The design, a test of autologous blood as dependent variable versus three "control" variables, was apportioned as follows. Twelve animals received uncoagulated autologous blood, 1 mL/kg; 8 received sterile talc slurry 70 mg/kg in 1 mL/kg saline; 6 received 10 mg/kg doxycycline (Sigma, St. Louis, MO); and 4 animals received a chest tube only. Under direct visualization the parietal pleura was entered and a Silastic catheter was secured in the pleural space. The lung was reexpanded. One of the three sclerosing agents was instilled into the tube, flushed with air, and the animals were rotated to assure dispersion to the entire pleural surface. After 1 hour, the lung was reexpanded, the catheter was removed, and the pleural tunnel secured. The control group received no drug but were prepared with a chest tube left in place 1 week (with the outer tip sutured under the skin to prevent a path for infection). All animals were left to heal with both lungs expanded, important both to outcome and in establishing a clinically relevant model.

Pathology and histology
At gross necropsy, 30 days after pleurodesis, the ribs were resected along the midclavicular line allowing full access to the pleural surfaces. Pleurodesis was graded grossly based on a previously described scheme [3]: 0, normal pleura; 1, few scattered adhesions; 2, generalized scattered adhesions; and 3, complete obliteration of the pleural space by adhesions. Photographs were taken, and blood and tissue were collected.

Full-thickness biopsies of both pleural surfaces and surrounding tissues were taken at the inferior and superior thorax representing the upper and lower lobes of the lung and pleura. Sections were stained by both hematoxylin and eosin and Masson’s trichrome stain for collagen. Review was made by a pathologist who was blinded to the treatment agent. The slides were graded for inflammation/cellularity and scored as compared to control by the following previously described system [3]: 0, absence of cellularity and neovascularization; 1, mild cellularity and neovascularization; 2, moderate cellularity and neovascularization; and 3, severe cellularity and neovascularization. Pleural thickness was measured by eyepiece micrometer and compared to control.

Blood chemistries
Clinical chemical measures on rabbit serum and homogenates of both test and contralateral lungs were measured using a clinical SMA20 (Technicon/Bayer, Tarrytown, NY). The ACE was measured spectrophotometrically using previously published methods [21]. Values were compared between treatment groups.

Statistical analysis
This research report describes a prospective, randomized, observer-blinded, controlled study that compared blood, talc, doxycycline, and a chest tube alone for 1) their effectiveness in achieving pleurodesis in a rabbit model, and 2) their effect on blood chemistries and special enzymes. Scores for gross pathology and histopathology were expressed as mean ± standard deviation. Analysis of variance (Kruskal-Wallis) with appropriate post-tests was used for statistical comparisons. A p value less than 0.05 was considered statistically significant.

	Results

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Gross necropsy
Pleurodesis was scored by blinded investigators as the chests were opened (Fig 1 ). The scores are summarized in Table 1. The chest tube control produced no adhesion or pleurodesis on gross observation at 30 days. In overall gross necropsy score (adhesion and visible granuloma formation) doxycycline was 2.5; talc slurry was 2.18, and autologous blood 0.25. Blood scored the same as a chest tube remaining 1 week (0.25) (see Table 1). The groups were significantly different (p = 0.006, analysis of variance). Grossly, doxycycline produced the most significant pleurodesis (p < 0.05 compared to chest tube control). However, doxycycline also created pulmonary and liver toxicity. In two of the doxycycline-treated rabbits at the 30-day necropsy, the treated pleural space was filled with hemorrhagic fluid; the lung was obliterated and generalized adhesions were seen between the mediastinum and the diaphragm. No organisms grew from the liquified lung fluid on culture. The surfaces of the livers in these animals were mottled with diffuse punctuated hemorrhages visible. Contralateral (untreated) lungs were also scored at necropsy (Table 1) with unremarkable results except in doxycycline treatment, which showed distant adhesions (p < 0.05 compared to talc and autologous blood).

View larger version (75K): [in this window] [in a new window]   Fig 1. Typical 30-day necropsy photographs of rabbit chest instilled with pleurodesis-producing agents: (A) talc, (B) doxycycline, (C) autologous blood.

View larger version (97K): [in this window] [in a new window]   Fig 2. Histology: examples of changes seen with pleurodesis-producing agents. (A) Lung with extensive angiogenesis (arrows) seen with talc and autologous blood. New vessels clearly apparent on Masson’s trichrome-stained sections. (B) Inflammatory response at the pleural surface, talc. (C) Chest wall showing muscle and the thickened collagen layer at the surface, doxycycline. All Masson’s trichrome, 400x.

View larger version (152K): [in this window] [in a new window]   Fig 3. Rabbit liver 30 days after administration of 10 mg/kg doxycycline through chest tube, hematoxylin and eosin, 400x. Fatty infiltration is present in many hepatocytes, and nuclei are pyknotic. Trichrome staining (not shown) evidenced a moderate increase in collagen fibers, especially in the periportal spaces.

Angiotensin-converting enzyme (mU/mg protein) was also analyzed in both serum and lung homogenate from each group. The ACE concentration in lung homogenate, which showed the most significant difference, is shown in Figure 4. The ACE concentration is significantly different between groups (p = 0.01, analysis of variance) with talc treatment significantly elevated compared to other groups (Dunn’s post-test, p < 0.05).

View larger version (36K): [in this window] [in a new window]   Fig 4. Angiotensin-converting enzyme (ACE) in lung tissue homogenate of rabbits treated with sclerotic agents as shown, 30 days previously. Talc treatment significantly elevates angiotensin-converting enzyme in the treated lung and contralateral, untreated lung (p < 0.05 analysis of variance and Dunn’s post-test). Serum demonstrated a similar pattern at lower levels. Angiotensin-converting enzyme values of both the treated and contralateral lungs are given.

	Comment

Top Abstract Introduction Material and methods Results Comment Acknowledgments References

Both grossly and microscopically, doxycycline was the more potent pleurodesis agent. In the rabbit model we used, however, considerable toxicity resulted. Preliminary trials (data not shown) were run to establish our acutely nontoxic experimental dose of 10 mg/kg, a common dose for the rabbit model and less doxycycline (mg/kg) than is suggested for human pleurodesis in a controlled clinical study [6].

It is possible that doxycycline source and compounding may be related to the toxicity we saw. For these experiments a highly purified doxycycline hydrochloride salt was freshly compounded (buffered saline) for each use. There are known to be both and ß epimers of doxycycline hydrochloride salt with the epimer having the greater biological activity. It has not been possible to determine the configuration or percent epimer of the doxycycline used in this animal study for comparison to clinically administered drug. There exists, however, the potential for a difference in bioactivity between mixtures, and that difference could be translated into the pulmonary toxicity exhibited by the test animals.

Talc slurry produced in our animal model moderately effective pleurodesis on gross observation at an equivalent dosage level (70 mg/kg) to that used clinically in our institution. This quantity is slightly below median for published animal studies. Both serum chemistry and histology suggest distant effects by talc. Angiotensin-converting enzyme activity increased in both serum and lung homogenate of the talc-treated animals. Talc-treated rabbits exhibited pleural angiogenesis (Fig 2). New vascular endothelial activity could account for part of the elevated ACE concentration in the talc test group.

In summary, the three sclerosants, talc, doxycycline, and autologous blood, produced significant histologic change at the treated pleural surface, but only talc and doxycycline produced grossly discernable adhesion at 30 days in this rabbit model. Both talc and doxycycline produced histologic changes in the contralateral untreated lung and blood chemistry changes, suggesting some systemic effect. Liver transaminases were elevated in doxycycline-administered animals only. Significantly increased ACE activity was found in serum and lung homogenate of rabbits given talc pleurodesis compared to other groups. It is of interest, considering that talc (magnesium silicate) sclerosant produces elevated serum ACE, that high ACE activity is also found in human silicosis. Nevertheless, of the efficacious agents talc exhibited fewer acute side effects and therefore, may be the potentially safer agent for use clinically. Autologous blood, although free of toxicity, produced only histologic evidence of pleurodesis potential at 1 month (angiogenesis at the pleural surface). Considering the window of recurrence after pneumothoraces, it is doubtful that autologous blood has a role in this treatment setting with the information currently at hand.

	Acknowledgments

Top Abstract Introduction Material and methods Results Comment Acknowledgments References

 
The work was sponsored by the Sarah Morrison Bequest to the University Department of Medicine.

	References

Top Abstract Introduction Material and methods Results Comment Acknowledgments References

 

1. Yoak M.B., Lambert C.J., Jr Video-assisted thoracoscopic surgery for management of spontaneous pneumothorax. W V Med J 1997;93:176-178.[Medline]
2. Baumann M.H., Strange C. The clinician’s perspective on pneumothorax management. Chest 1997;112:822-828.[Abstract/Free Full Text]
3. Hurewitz A.N., Lidonicci K., Wu C.L., Reim D., Zucker S. Histologic changes of doxycycline pleurodesis in rabbits. Effect of concentration and pH. Chest 1994;106:1241-1245.[Abstract/Free Full Text]
4. Herrington J.D., Gora-Harper M.L., Salley R.K. Chemical pleurodesis with doxycycline 1 g. Pharmacotherapy 1996;16:280-285.[Medline]
5. Zimmer P.W., Hill M., Casey K., Harvey E., Low D.E. Prospective randomized trial of talc slurry vs bleomycin in pleurodesis for symptomatic malignant pleural effusions. Chest 1997;112:430-434.[Abstract/Free Full Text]
6. Bresticker M.A., Oba J., LoCicero J., III, Greene R. Optimal pleurodesis: a comparison study. Ann Thorac Surg 1993;55:364-367.[Abstract]
7. Light R.W., Vargas F.S. Pleural sclerosis for the treatment of pneumothorax and pleural effusion. A review. Lung 1997;175:213-223.[Medline]
8. Yim A.P., Chan A.T., Lee T.W., Wan I.Y., Ho J.K. Thoracoscopic talc insufflation versus talc slurry for symptomatic malignant pleural effusion. Ann Thorac Surg 1996;62:1655-1658.[Abstract/Free Full Text]
9. Dumire R., Crabbe M.M., Mappin F.G., et al. Autologous "blood patch" pleurodesis for persistent pulmonary air leak. Chest 1992;101:64-66.[Abstract/Free Full Text]
10. Robinson C.L. Autologous blood for pleurodesis in recurrent and chronic spontaneous pneumothorax. Can J Surg 1987;30:428-429.[Medline]
11. Blanco I.B., Blanco S., Argiz H.C., Delcamino F.C., Perez J.G. Pleurodesis with autologous blood—results in a series of 17 cases followed for more than one year. Revis Clin Español 1997;197:406-410.
12. Colt H.G., Russack V., Chiu Y., et al. A comparison of thoracoscopic talc insufflation, slurry and mechanical abrasion pleurodesis. Chest 1997;111:442-448.[Abstract/Free Full Text]
13. Cohen R.G., Sheley W.W., Thompson S.E., et al. Talc pleurodesis: talc slurry versus thoracoscopic talc insufflation in a porcine model. Ann Thorac Surg 1996;62:1000-1002.[Abstract/Free Full Text]
14. Nukiwa T., Matsuoka R., Takagi H., Ishii Y., Arai T., Kira S. Responses of serum and lung ACE activities in the early phase of pulmonary damage induced by oleic acid in dogs. Am Rev Resp Dis 1982;126:1080-1086.[Medline]
15. Brice E.A., Friedlander W., Bateman E.D., Kirsch R.E. Serum ACE activity concentration and specific activity in granulomatous interstitial lung disease, TB, and COPD. Chest 1995;107:706-710.[Abstract/Free Full Text]
16. Fernandez J.M.A., Alonso M.E. ACE in sarcoidosis, TB, silicosis and coal mining workers. Ann Med Intern 1994;11:588-590.
17. Molteni A, Mitchem R, Herndon B, Reisz G. "Lung local and distant fibrotic response to infusion of pleurodetic-inducing agents" Abstract p. 55, 9th International Colloquium on Pulmonary Fibrosis, Oaxaca, Mexico, 10–13 Nov 1996.
18. Lanza F.L. Esophageal ulceration produced by doxycycline—review of the literature and comparison of the injury from doxycycline hydrate and hydrochloride with that from doxycycline monohydrate. Curr Ther Res Clin Exper 1988;44:475-484.
19. Windsor P.G., Como J.A., Windsor K.S. Sclerotherapy for malignant pleural effusions: alternatives to tetracycline. Southern Med J 1994;87:709-713.[Medline]
20. Bjornsson E., Lindberg J., Olsson R. Liver reactions of oral low-dose tetracyclines. Scand J Gastroenterol 1997;32:390-395.[Medline]
21. Cushman D.W., Cheung H.S. Spectrophotometric assay and property of the ACE of rabbit lung. Biochem Pharmacol 1971;20:37-48.

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