What is the treatment for pleurisy?

Treatment of Pleurisy

The treatment of pleurisy must focus on addressing the underlying cause while providing appropriate symptomatic relief, with antibiotics and drainage procedures required for infectious cases. 1

Diagnostic Approach

• Obtain chest imaging (radiograph, ultrasound) to confirm pleural effusion
• Perform thoracentesis for pleural fluid analysis including:
  • pH (critical value: <7.2 indicates need for drainage)
  • Glucose (<3.3 mmol/L indicates likely infection)
  • LDH (>900 IU/L suggests complicated parapneumonic effusion)
  • Gram stain and culture
  • Cell count (lymphocytosis may indicate TB or malignancy)
• Blood cultures should be performed in all patients with parapneumonic effusion 2

Treatment Algorithm

1. Non-infectious Pleurisy (viral, autoimmune, PE)

• Pain management: NSAIDs are first-line therapy 3
• Treat underlying cause:
  • Pulmonary embolism: Low-molecular-weight heparin initially 4
  • Tuberculous pleurisy: Standard anti-TB regimen (may benefit from adjunctive corticosteroids) 5
  • Viral pleurisy: Supportive care with NSAIDs

2. Infectious Pleurisy (bacterial)

• Antibiotics: Start immediately upon identification of pleural infection 2, 1

  • Community-acquired:
    • IV: Cefuroxime 1.5g TDS + metronidazole 400mg TDS, OR
    • Oral: Amoxicillin 1g TDS + clavulanic acid 125mg TDS
  • Hospital-acquired:
    • Piperacillin-tazobactam 4.5g QDS IV, OR
    • Meropenem 1g TDS IV ± metronidazole
  • Avoid aminoglycosides due to poor pleural penetration 2, 1

• Drainage indications:

  • Frank pus (empyema)
  • pH <7.2
  • Glucose <3.3 mmol/L
  • LDH >900 IU/L
  • Large effusions causing symptoms
  • Loculated collections 2

• Drainage technique:

  • Use small-bore chest tubes (14F or smaller) under ultrasound guidance 2
  • Connect to underwater seal drainage system kept below chest level
  • Monitor drainage output and patient response

• For persistent collections/loculations:

  • Consider intrapleural fibrinolytics: TPA 10mg twice daily + DNase 5mg twice daily for 3 days 2
  • Avoid single-agent TPA or DNase (ineffective)
  • Avoid streptokinase (not recommended) 2

3. Surgical Management

• Consider if patient fails to improve after 5-7 days of drainage and antibiotics 2
• VATS preferred over thoracotomy for surgical drainage 2
• Indications:
  • Persistent sepsis with residual collection
  • Organized empyema requiring decortication
  • Multiloculated effusions not responding to tube drainage 1

Monitoring Response

• Track temperature curve, white blood cell count, clinical symptoms
• Follow radiographic improvement
• If no improvement after 48-72 hours:
  • Reassess antibiotic coverage based on culture results
  • Evaluate for inadequate drainage or resistant organisms
  • Consider surgical consultation 1

Common Pitfalls to Avoid

• Delaying drainage of complicated parapneumonic effusions
• Using aminoglycosides as sole therapy
• Removing chest tubes prematurely
• Failing to adjust antibiotics based on culture results
• Misdiagnosing the underlying cause (PE is common in young patients with pleuritic pain) 3, 4
• Using excessive force during chest tube insertion 1

By following this algorithmic approach and addressing both the underlying cause and symptomatic management, most cases of pleurisy can be effectively treated with good outcomes.