What is the management plan for a patient with pleural effusion requiring Intensive Care Unit (ICU) consultation?

From the Guidelines

I strongly recommend an ICU consult for a patient with pleural effusion, particularly if the patient is symptomatic, to ensure appropriate management and monitoring, as suggested by the American Thoracic Society guidelines 1. When managing a patient with pleural effusion in the ICU, it is essential to consider the underlying cause and the patient's symptoms.

• The ICU team should perform thoracentesis for diagnostic and therapeutic purposes, collecting pleural fluid for analysis (cell count, protein, LDH, glucose, pH, cytology, and cultures) 1.
• Initial treatment includes oxygen supplementation, positioning the patient with the affected side elevated, and addressing the underlying cause.
• If the effusion is large or causing respiratory distress, therapeutic drainage is necessary, and ultrasound-guided drainage is recommended to reduce complications, as it has been shown to decrease the risk of pneumothorax and other complications compared to landmark technique 1.
• For infectious effusions, appropriate antibiotics should be started (e.g., ceftriaxone 1-2g IV daily plus azithromycin 500mg IV daily for pneumonia-associated effusions).
• Chest tube placement may be required for large effusions, empyema, or recurrent effusions.
• Continuous monitoring of vital signs, oxygen saturation, and respiratory status is essential.
• ICU consultation is particularly important for patients with respiratory compromise, hemodynamic instability, or when mechanical ventilation may be needed, as they require close monitoring and management of potential complications.
• The ICU team can also manage complications like pneumothorax or re-expansion pulmonary edema that may occur during drainage procedures, and indwelling pleural catheters (IPCs) or chemical pleurodesis may be considered for patients with symptomatic malignant pleural effusions, as suggested by the ATS/STS/STR clinical practice guideline 1.

From the Research

ICU Consult for Pleural Effusion

• Pleural effusions are common in critically ill patients, with most being of limited clinical significance, but some requiring aggressive management 2.
• The causes of pleural effusions in ICU patients can be categorized into transudative and exudative, with transudative effusions commonly caused by volume overload, decreased plasma oncotic pressure, and altered pleural pressure, and exudative effusions caused by pulmonary or pleural infection, pulmonary embolism, postsurgical complications, and malignancy 2.
• Bedside ultrasound is a sensitive and specific tool for diagnosing pleural effusions in mechanically ventilated patients, and can help identify septation and homogenous echogenicity, which may suggest an exudative effusion 2, 3.
• Thoracentesis should be carried out under ultrasound guidance, and antibiotic regimens for parapneumonic effusions should be based on current pneumonia guidelines, with anaerobic coverage included in the case of empyema 2, 4.
• Decompression of the pleural space may be necessary to improve respiratory mechanics, as well as to treat complicated effusions, and small-bore catheters inserted under ultrasound guidance may be used for non-septated effusions 2, 5.
• In mechanically ventilated critically ill adult patients with pleural effusion and hypoxia, drainage of pleural effusion is conditionally recommended to improve oxygenation, particularly in patients with a P:F ratio <200 and pleural effusion volume estimate >500 mL 6.

Management of Pleural Effusion

• The management of pleural effusion depends on the underlying etiology, with transudative effusions usually managed by treating the underlying medical disorder, and exudative effusions requiring specific treatment based on the underlying cause 4.
• Malignant effusions are usually drained to palliate symptoms and may require pleurodesis to prevent recurrence, and empyemas need to be treated with appropriate antibiotics and intercostal drainage 4, 5.
• Surgery may be needed in selected cases where drainage procedure fails to produce improvement or to restore lung function and for closure of bronchopleural fistula 4.
• A systematic approach is necessary for the rapid recognition, clinical cause identification, and definitive management of potential urgent pleural effusions in the emergency department setting 5.