Pleural Effusions


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Pleural Effusions

  1. 1. Treatment for Pleural Effusions Candice Reyes, MS III
  2. 2. Overview • Pleural fluid is produced at 0.01 mL/kg/body weight/hour; a normal volume in the pleural space is 5–15 mL • Transudative effusions occur in the absence of pleural disease; 90% of cases result from congestive heart failure • Exudative effusions are most commonly due to pneumonia (parapneumonic effusions) and malignancy (malignant effusions)
  3. 3. Overview • Analysis of pleural fluid allows for identification of the pathophysiologic process leading to accumulation of pleural fluid – Increased production due to increased hydrostatic or decreased oncotic pressures (transudates) – Increased production due to abnormal capillary permeability (exudates) – Decreased lymphatic clearance of fluid (exudates) – Infection in the pleural space (empyema) – Bleeding into the pleural space (hemothorax) • A definitive diagnosis is made through cytology or identification of causative organism in 25% of cases • In 50–60% of cases, classification of the effusion leads to a presumptive diagnosis
  4. 4. Signs and Symptoms • Dyspnea, cough, or chest pain with respirations • Symptoms are more common in patients with underlying cardiopulmonary disease • Large effusions are more likely to be symptomatic • Bronchial breath sounds and egophony above the effusion are caused by compressive atelectasis • Massive effusions may cause contralateral shift of the trachea and bulging of intercostal spaces • A pleural friction rub indicates infarction or pleuritis
  5. 5. Differential • Atelectasis • Chronic pleural thickening • Lobar consolidation • Subdiaphragmatic process
  6. 6. Medications • Appropriate Antibiotics for pleural infections
  7. 7. Surgery • Thoracotomy may be required in hemothorax to control hemorrhage, remove clot, and treat complications • Chest tube insertions – Rarely indicated for transudates – May be useful in malignant effusions – Indicated for some complicated parapneumonic effusions and empyema
  8. 8. Therapeutic Procedures • Pleurodesis involves placing an irritant into the pleural space to obliterate it by producing adhesions; side effects are pain and fever; premedication is necessary – Doxycycline is 70–75% effective – Talc is 90% effective – Rarely indicated for transudates – Often used for recurrent malignant effusions • Intrapleural fibrinolysis – Streptokinase, 250,000 units or urokinase 100,000 units in 100 mL of saline can improve drainage of empyema or complicated parapneumonic effusions with loculations
  9. 9. Transudative effusions • Treatment is directed at the underlying cause • Therapeutic thoracentesis may offer only transient relief from dyspnea • Tube thoracostomy and pleurodesis are rarely indicated
  10. 10. Malignant Effusions • Systemic therapy may address the underlying malignancy • Repeated thoracentesis or chest tube insertion (tube thoracostomy) may be needed as local therapy to relieve symptoms related to the effusion itself • Pleurodesis can reduce reaccumulation of fluid • Alternative strategy is indwelling pleural catheter (eg, Pleurex) – Facilitates home drainage for suitable ambulatory patients – Provides relief while avoiding hospitalization – Has about 40% rate of spontaneous pleurodesis
  11. 11. Parapneumonic effusions • Simple effusions (free-flowing, sterile) will resolve with treatment of the pneumonia and do not require drainage • Complicated effusions should be drained via chest tube if fluid analysis reveals pH < 7.2 or glucose < 60 mg/dL; drainage should be considered for pH 7.2–7.3 or LDH > 1000 mg/dL • Empyema should be drained via chest tube
  12. 12. Hemothorax • If small-volume and stable, observation is adequate • All other cases should be treated with immediate drainage via a large-bore chest tube