What is the initial management of a patient with pleural effusion?

From the Guidelines

The initial management of a patient with pleural effusion should focus on identifying the underlying cause while providing symptomatic relief, with thoracentesis being the first step to drain fluid for diagnostic and therapeutic purposes, as recommended by the British Thoracic Society guideline for pleural disease 1.

Key Considerations

• A careful history and physical examination of the patient remains the most important first step when evaluating someone with an undiagnosed pleural effusion, as it can often elucidate the likely cause and guide further investigations 1.
• Thoracic ultrasound (TUS) should be performed on every patient at their initial presentation and again whenever a pleural procedure is being performed, as it provides information on the size and character of the effusion and helps identify signs of malignancy 1.
• If it is not safe to proceed with a pleural aspiration, a CT scan should be obtained as the next step, including the chest, abdomen, and pelvis if malignancy is suspected, or a CT of the thorax with pleural contrast if malignancy is not likely 1.

Diagnostic and Therapeutic Approach

• Perform thoracentesis to drain fluid for diagnostic and therapeutic purposes, collecting samples for laboratory analysis including cell count, protein, LDH, glucose, pH, cytology, and microbiological studies, with ultrasound guidance recommended to improve safety and success rates 1.
• For symptomatic patients with moderate to large effusions, therapeutic drainage of 1-1.5 liters of fluid provides relief while minimizing the risk of re-expansion pulmonary edema, and supplemental oxygen should be provided if the patient is hypoxemic.
• Specific treatment depends on the underlying etiology, with parapneumonic effusions requiring antibiotics, malignant effusions potentially needing pleurodesis with talc or doxycycline, and transudative effusions from heart failure requiring diuretics.

Recurrent Effusions and Pain Management

• For recurrent effusions, consider placing an indwelling pleural catheter or performing pleurodesis, with the choice of procedure depending on the patient's symptoms, lung expandability, and underlying etiology 1.
• Pain management with acetaminophen or NSAIDs is important during and after procedures, and should be tailored to the individual patient's needs.

From the Research

Initial Management of Pleural Effusion

The initial management of a patient with pleural effusion involves a systematic approach to determine the etiology of the effusion.

• The patient's history and physical examination should guide the evaluation, as the causes of pleural effusion can vary widely, including heart failure, infection, malignancy, and pulmonary embolism 2.
• Small bilateral effusions in patients with decompensated heart failure, cirrhosis, or kidney failure are likely transudative and do not require diagnostic thoracentesis 2.
• Thoracocentesis should be performed for new and unexplained pleural effusions to determine the nature of the fluid and to guide further management 3.
• Laboratory testing, including chemical and microbiological studies, as well as cytological analysis, can help distinguish pleural fluid transudate from an exudate and provide further information about the etiology of the disease process 3, 2.

Diagnostic Evaluation

The diagnostic evaluation of pleural effusion includes:

• Chest radiography to determine laterality and detect moderate to large pleural effusions 2.
• Point-of-care ultrasound to detect small effusions and features that could indicate complicated effusion or malignancy, and to guide thoracentesis 2.
• Computed tomography of the chest to exclude other causes of dyspnea and suggest complicated parapneumonic or malignant effusion 2.
• Pleural fluid analysis, including Gram stain, cell count with differential, culture, cytology, protein, l-lactate dehydrogenase, and pH levels 2.

Treatment

The treatment of pleural effusion depends on the underlying etiology of the effusion.

• Transudative effusions are usually managed by treating the underlying medical disorder 3.
• Exudative effusions require specific treatment, such as drainage and pleurodesis for malignant effusions, and antibiotics and intercostal drainage for empyemas 3, 4.
• Pleural biopsy may be recommended for evaluation and exclusion of various etiologies, such as tuberculosis or malignant disease 3.