Pleural effusion management

Pleural effusion management

Pleural effusion is an excessive collection of fluid in the pleural space. It is rarely a primary disease process and is usually secondary to other diseases.

Clinical presentation

Symptoms

• Progressive dyspnoea

• Cough

• Pleuritic chest pain

Physical findings

These findings are usually present when pleural fluid exceeds 300 mL:

• Dullness to percussion

• Decreased tactile fremitus

• Asymmetrical chest expansion

• Pleural friction rub

• Displacement of the trachea and mediastinum toward the side of the effusion

Investigations

Basic investigations

• Chest X-ray (CXR)

• Full blood picture (FBP)

• Erythrocyte sedimentation rate (ESR)

• Serum ADA

• Point-of-care bedside ultrasound (USS)

Pleural fluid analysis

Pleural fluid investigations should be requested according to the suspected diagnosis.

• Pleural fluid cytology

• Pleural fluid culture

• Pleural fluid GeneXpert

• Pleural fluid ADA

• Pleural fluid LDH

• Pleural fluid glucose

• Pleural fluid pH

• Pleural fluid cell count

• Pleural fluid amylase

• Pleural fluid triglycerides and cholesterol

• Pleural fluid bilirubin

Additional investigations

• Tumour markers as indicated:

  • CA 15

  • CEA

  • CA 125

  • Others as indicated

• Rheumatoid factor (RF) if indicated

• Autoimmune profile or individual markers:

  • ANA

  • ACE

  • Others as indicated

• Renal function tests:

  • Creatinine

  • Blood urea nitrogen (BUN)

• Liver function tests:

  • Albumin

  • Total bilirubin

  • Direct bilirubin

  • PT

  • PTT

  • INR

  • ALT

  • AST

  • GGT

  • ALP

Cardiorespiratory investigations

• Echocardiography (ECHO)

• Electrocardiography (ECG)

• CT scan chest with contrast

• Thoracoscopy

• Pleural biopsy (when malignancy is suspected)

• Bronchoscopy

Staging of pleural infections and recommendations for drainage

Non-pharmacological treatment

Serial thoracentesis

• Appropriate for non-complicated pleural effusions.

• May require an average of eight thoracenteses over 2–4 weeks.

Chest tube drainage

• Chest tubes may be:

  • Large-bore: 24F–34F

  • Small-bore: 8F–24F

• For viscous pleural pus, surgical practice recommends large-bore chest tubes (28F–32F).

Fibrinolytic therapy

May utilize:

• Streptokinase

• Urokinase

• Recombinant tissue plasminogen activator (rtPA)

Indications:

• Empyema

• Complicated parapneumonic pleural effusions

Thoracoscopy

Includes:

• Medical thoracoscopy

• Video-assisted thoracoscopic surgery (VATS)

Indications:

• Fibrinopurulent pleural infection

• Loculated pleural effusion

Thoracotomy, decortication, and open drainage

• Thoracotomy remains the principal salvage procedure after unsuccessful thoracoscopy.

• Failure is defined by failure of lung expansion to the chest wall.

Indications for thoracostomy or decortication

• Organized empyema in patients unable to tolerate thoracotomy

• Trapped lung

• Chronic empyema with bronchopleural fistula

• Chronic empyema not amenable to surgery

• Critically ill or toxic patients with:

  • Mediastinitis

  • Bronchopleural fistula requiring mediastinal drainage or fistula closure

Management of malignant pleural effusion

Treatment options include:

• Chest tube drainage

• Radiation therapy

• Chemotherapy

• Surgical pleurectomy

• Pleuroperitoneal shunt

• Pleurodesis

• Decortication