Medical Care: Transudative effusions are usually managed by treating the underlying medical disorder. However, whether transudates or exudates, drain large pleural effusions if they are causing severe respiratory symptoms, even if the cause is understood and disease-specific treatment is available. The management of exudative effusions depends on the underlying etiology of the effusion. Pneumonia, malignancy, or TB causes most exudative pleural effusions, or effusions are deemed idiopathic. Drain complicated parapneumonic effusions and empyemas to avoid fibrosing pleuritis. Malignant effusions are usually drained to palliate symptoms and may require pleurodesis to prevent recurrence.
" Although medications cause only a small proportion of all pleural effusions, they are associated with exudative pleural effusions.
o Implicated drugs include medications that cause drug-induced lupus syndrome (eg, procainamide, hydralazine, quinidine), nitrofurantoin, dantrolene, methysergide, procarbazine, and methotrexate.
o Recognition of these iatrogenic causes of pleural effusion avoids unnecessary additional diagnostic procedures and leads to definitive therapy, which is discontinuation of the medication.
" Of the common causes for exudative pleural effusions, parapneumonic effusions have the highest diagnostic priority. Even in the face of antibiotic therapy, infected pleural effusions can rapidly coagulate and organize to form fibrous peels that might require surgical decortication. Therefore, quickly assess pleural fluid characteristics predictive of a complicated course to identify parapneumonic effusions that require urgent tube drainage, which are observed more commonly in indolent anaerobic pneumonias than in typical community-acquired pneumonia.
o Indications for urgent drainage of parapneumonic effusions include (1) frankly purulent fluid, (2) pleural fluid pH less than 7.2, (3) loculated effusions, and (4) bacteria on Gram stain or culture.
o Patients with parapneumonic effusions who do not meet criteria for immediate tube drainage should improve clinically within 1 week with appropriate antibiotic treatment.
o Radiographically reassess patients with parapneumonic effusions who do not improve or who deteriorate clinically.
" Malignant pleural effusions usually signify incurable disease with considerable morbidity and a dismal mean survival of less than 1 year.
o Drainage of large malignant effusions might relieve dyspnea caused by distortion of the diaphragm and chest wall produced by the effusion.
o Pleural sclerosis also might be necessary to prevent recurrence of symptomatic effusions.
" TB pleuritis typically is self-limited. However, because 65% of patients with primary TB pleuritis reactivate their disease within 5 years, empiric anti-TB treatment is usually begun pending culture results when sufficient clinical suspicion is present, such as an unexplained exudative or lymphocytic effusion in a patient with a positive PPD finding.
" Chylous effusions are usually managed by dietary and surgical modalities discussed below. However, recent studies suggest that somatostatin analogues also may help in reducing efflux of chyle into the pleural space.
Surgical Care:
" Surgical intervention is most often required for parapneumonic effusions that cannot be drained adequately by needle or small-bore catheters, and surgery might be required for diagnosis and sclerosis of exudative effusions.
" Video-assisted thoracoscopy with the patient under local or general anesthesia allows direct visualization and biopsy of the pleura for diagnosis of exudative effusions.
" Pleural sclerosis by insufflating talc directly onto the pleural surface using video-assisted thoracoscopy is an alternative to using talc slurries.
" Decortication is usually needed to remove a thick, inelastic pleural peel that restricts ventilation and produces progressive or refractory dyspnea. In patients with chronic, organizing parapneumonic pleural effusions, technically demanding operations might be required to drain loculated pleural fluid and to obliterate the pleural space.
" Surgically implanted pleuroperitoneal shunts are another treatment option for recurrent symptomatic effusions, most often in the setting of malignancy, but they are also used for management of chylous effusions. However, the shunts are prone to malfunction over time and can require surgical revision.
" In unusual cases, surgery might be required to close diaphragmatic defects (thereby preventing recurrent accumulation of pleural effusions in patients with ascites) and to ligate the thoracic duct to prevent reaccumulation of chylous effusions.
Diet:
" Restrictions of fat intake might help in the management of chylous effusions, although management remains controversial.
o Ongoing drainage of these effusions can rapidly deplete patients of fat and protein stores.
o Limiting oral fat intake might slow the accumulation of chylous effusions in some patients.
o Hyperalimentation or total parenteral nutrition can preserve nutritional stores and limit accumulation of the chylous effusion but probably should be restricted to patients in whom definitive therapy for the underlying cause of the chylous effusion is possible.
Further Inpatient Care:
" Monitoring pleural drainage
o Record the amount and quality of fluid drained and monitor for an air leak (bubbling through the water seal) each shift.
o Repeat the chest radiographs when drainage falls below 100 mL/d to evaluate whether the effusion has been fully drained. If a large effusion persists radiographically, reevaluate the position of the chest catheter. If the catheter is positioned appropriately, consider injecting lytics through the chest tube to break up clots that may be obstructing drainage.
o Large air leaks (steady streams of air throughout the respiratory cycle) may be indications of loose connectors or of a drainage port on the catheter that has migrated out to the skin. Alternatively, they may indicate large bronchopleural fistulae. Consequently, dressings should be taken down and the position of the catheter inspected at the puncture site. Clamping the catheter at the skin helps determine whether the air leak is emanating from within the pleural cavity (in which case it stops when the tube is clamped) or from outside the chest (in which case the leak persists).
Prognosis:
" Prognosis varies in accordance with the underlying etiology.
o Malignant effusions convey a very poor prognosis, with survival typically measured in months.
o Parapneumonic effusions, when recognized and treated promptly, typically resolve without significant sequelae. However, untreated or inappropriately treated parapneumonic effusions may lead to constrictive fibrosis.
DRUG(S) OF CHOICE
β’ Antimicrobial therapy according to pathogens and associated sensitivities
β’ Chemical pleurodesis with doxycycline 500 mg, bleomycin 60 units, or talc in a slurry, as indicated. The patient should be provided intravenous narcotic analgesia, as this procedure can cause considerable pain. Pleurodesis can be extremely effective therapy for preventing nonmalignant recurrent effusions. If
pleurodesis fails, the patient may be offered pleural abrasion, though this is not commonly performed.
β’ Chemotherapy according to current oncologic protocols
β’ Steroids and non-steroidal anti-infl ammatory drugs for rheumatologic and infl ammatory etiologies
β’ Diuresis as appropriate for effusions secondary to congestive heart failure and ascites
PATIENT MONITORING
β’ Serial chest radiographs, with frequency/interval determined by patient status/diagnosis
β’ Pulmonary function testing as indicated
β’ Serum studies, echocardiography, renal/hepatic function tests as indicated to monitor for tability/progression
of nonmalignant/noninfectious factors precipitating effusions
POSSIBLE COMPLICATIONS
β’ Chronic empyema
β’ Drainage through chest wall - pleurocutaneous fi stula
β’ Bronchopleural fi stula
β’ Toxic shock syndrome