What is the diagnosis and treatment for pleurisy (inflammation of the pleura)?

From the Guidelines

Pleurisy should be managed with initial drainage using a small bore chest tube (14F or smaller) for pleural infection, as recommended by the British Thoracic Society guideline for pleural disease 1. Pleurisy is inflammation of the pleura, the thin membrane that lines the lungs and chest cavity, typically causing sharp chest pain that worsens with breathing, coughing, or sneezing.

Key Management Strategies

• Treatment focuses on addressing the underlying cause and managing symptoms
• For pain relief, nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen or naproxen are recommended
• For pleurisy caused by bacterial infections, antibiotics are necessary, while viral causes typically resolve on their own within 1-2 weeks with supportive care
• Deep breathing exercises help prevent lung complications
• Rest is important during recovery, but gentle movement prevents stiffness
• Applying heat to the affected area can provide additional pain relief

Important Considerations

• Pleurisy pain occurs because inflammation makes the normally smooth pleural surfaces rough, causing friction during breathing
• If you experience severe chest pain, difficulty breathing, or fever, seek immediate medical attention as pleurisy can sometimes indicate serious underlying conditions like pneumonia or pulmonary embolism
• The British Thoracic Society guideline for pleural disease 1 provides the most recent and highest quality recommendations for managing pleurisy, including the use of small bore chest tubes for initial drainage of pleural infection.

From the Research

Definition and Causes of Pleurisy

• Pleurisy is a condition characterized by pleuritic chest pain, which can be caused by various factors, including pulmonary embolism, pericarditis, pneumonia, myocardial infarction, and pneumothorax 2
• The diagnosis of pleurisy can be made after excluding other significant causes of pleuritic pain through history, physical examination, and chest radiography 2
• Viral pleurisy is among the most common causes of pleurisy, and other etiologies can be evaluated through additional diagnostic testing in selected patients 2

Diagnosis and Treatment of Pleurisy

• Treatment of pleurisy typically consists of pain management with nonsteroidal anti-inflammatory drugs, as well as specific treatments targeted at the underlying cause 2
• Pleural effusion, an excessive accumulation of fluid in the pleural space, can pose a diagnostic dilemma and requires determination of its etiology for appropriate treatment 3
• Thoracocentesis should be performed for new and unexplained pleural effusions, and laboratory testing can help distinguish pleural fluid transudate from an exudate 3

Management of Pleural Effusion

• Transudative effusions are usually managed by treating the underlying medical disorder, while exudative effusions require management based on the underlying etiology 3
• Malignant effusions are usually drained to palliate symptoms and may require pleurodesis to prevent recurrence 3
• Empyemas need to be treated with appropriate antibiotics and intercostal drainage, and surgery may be needed in selected cases 3

Antibiotic Treatment of Pleural Infection

• The optimal duration of antibiotics in the management of parapneumonic effusion and pleural infection is unclear, with some studies suggesting that shorter antibiotic courses may be equally efficacious to longer courses in certain patients 4
• The usefulness of corticosteroids in the management of pleural infection is also unclear, with one study finding no benefit from the use of dexamethasone in unselected patients with pneumonia and pleural effusion 4
• Further studies are required to confirm the findings of these trials and determine the optimal treatment approach for pleural infection 4

Penetration of Antibiotics into Empyemic Pleural Fluid

• The degree to which antibiotics penetrate into the infected pleural space can vary significantly, with penicillin and metronidazole penetrating most easily 5
• The penetration of antibiotics into empyemic pleural fluid should be considered when selecting antibiotics for the treatment of patients with empyema 5