What is the diagnosis and treatment for pleural effusion?

From the Guidelines

Pleural effusion diagnosis and treatment should be guided by the underlying cause and severity, with thoracentesis and treatment of the underlying condition being the primary approach, as recommended by the British Thoracic Society guideline for pleural disease 1.

Diagnosis

The diagnosis of pleural effusion involves a careful history and physical examination, with thoracic ultrasound (TUS) being a crucial diagnostic tool to assess the size and character of the effusion, as well as to guide invasive procedures 1.

• A detailed occupational history, including any previous asbestos exposure, is also vital information when investigating all pleural effusions.
• If it is not safe to proceed with a pleural aspiration, a CT scan should be obtained as the next step.

Treatment

Treatment depends on the underlying cause and severity of the pleural effusion, with the following approaches being considered:

• For symptomatic effusions, thoracentesis (needle drainage) is often performed both for diagnosis and symptom relief 1.
• If the effusion is due to infection (empyema), antibiotics are necessary, typically including coverage for common respiratory pathogens such as Streptococcus pneumoniae or Staphylococcus aureus.
• For parapneumonic effusions, a 7-14 day course of appropriate antibiotics is recommended.
• Malignant effusions may require pleurodesis using agents like talc or doxycycline to prevent recurrence.
• Diuretics like furosemide 20-40mg daily can help manage effusions caused by heart failure or volume overload.
• Chest tube placement is indicated for large or recurrent effusions, particularly if infected.

Management of Specific Causes

• For heart failure-related pleural effusions, pleural interventions such as IPCs or pleurodesis may be considered for symptomatic relief 1.
• For end-stage renal failure-related pleural effusions, aggressive medical management or renal replacement therapy (RRT) may be adequate, but pleural interventions such as serial thoracocentesis or IPCs may be necessary for refractory cases 1.

From the Research

Diagnosis of Pleural Effusion

• The diagnosis of pleural effusion involves determining whether the effusion is a transudate or an exudate, with thoracocentesis and laboratory testing of the pleural fluid being crucial in making this distinction 2, 3
• The serum to pleural fluid protein or albumin gradients may help better categorize the occasional transudate misidentified as an exudate by Light's criteria 3
• Pleural fluid puncture (pleural tap) enables the differentiation of a transudate from an exudate, which remains the foundation of the further diagnostic work-up 4
• Chemical and microbiological studies, as well as cytological analysis, can provide further information about the etiology of the disease process 2

Treatment of Pleural Effusion

• The treatment of pleural effusion depends on its etiology, with transudative effusions usually being managed by treating the underlying medical disorder 2, 5
• Exudative effusions require management based on the underlying etiology, with malignant effusions often being drained to palliate symptoms and may require pleurodesis to prevent recurrence 2, 4
• Empyemas need to be treated with appropriate antibiotics and intercostal drainage, with surgery being an option in selected cases where drainage procedure fails to produce improvement or to restore lung function and for closure of bronchopleural fistula 2
• The range of therapeutic options for pleural effusion has recently become much wider, including pleurodesis, thoracoscopy, video-assisted thoracoscopy, and the placement of a permanently indwelling pleural catheter 4

Management of Recurrent Pleural Effusions

• Patients with recurrent, symptomatic pleural effusions secondary to heart failure have a selection of treatment options that can be individualized based on the patient's prognosis, functional status, need for future intervention, and desires 5
• The management of symptomatic pleural effusions in heart failure has evolved in the last two decades, with newer forms of therapy being less invasive and resulting in less procedural morbidity, recuperation, and cost 5