What is the treatment for pleurisy?

Treatment of Pleurisy

The treatment of pleurisy should focus on managing the underlying cause, with NSAIDs as first-line therapy for pain relief, appropriate antibiotics for infectious causes, and drainage procedures for complicated cases. 1

Diagnosis and Initial Assessment

• Key diagnostic tests:

  • Pleural fluid analysis (pH, glucose, LDH, protein, cell count)
  • Blood cultures
  • Chest imaging (X-ray, ultrasound, CT as needed)
  • Pleural biopsy when etiology remains unclear

• Important indicators for drainage:

  • Frank pus
  • pH < 7.2
  • Glucose < 3.3 mmol/L
  • LDH > 900 IU/L
  • Large symptomatic effusions
  • Loculated collections

Treatment Algorithm

1. Pain Management

• First-line: NSAIDs (ibuprofen or naproxen) until pain resolves 1
• Second-line options:
  • Acetaminophen
  • Narcotic analgesics if other options ineffective
  • Intrapleural bupivacaine for severe pain during drainage procedures

2. Treatment Based on Etiology

A. Infectious Pleurisy

• Antibiotic therapy:

  • Start immediately upon identification of pleural infection 1
  • Community-acquired infections:
    • IV options: Cefuroxime 1.5g TDS + metronidazole, benzyl penicillin + ciprofloxacin, or meropenem + metronidazole
    • Oral options: Amoxicillin + clavulanic acid, amoxicillin + metronidazole, or clindamycin
  • Hospital-acquired infections:
    • Piperacillin-tazobactam 4.5g QDS IV
    • Ceftazidime 2g TDS IV
    • Meropenem 1g TDS IV
  • Important: Avoid aminoglycosides due to poor pleural penetration 2, 1
  • Continue antibiotics for at least 14 days, adjusting based on clinical response and culture results

• Drainage procedures:

  • Use small-bore chest tubes (14F or smaller) for initial drainage 2
  • Connect to underwater seal drainage system kept below chest level
  • Ensure tube patency by flushing with saline if drainage is poor

• For complicated parapneumonic effusions or empyema with loculations:

  • Consider combination tissue plasminogen activator (TPA) and DNase therapy
  • Recommended regimen: 10mg TPA twice daily + 5mg DNase twice daily for 3 days 2
  • Single agent TPA or DNase should not be used 2
  • Streptokinase should not be used due to lack of efficacy and increased complications 2

B. Tuberculous Pleurisy

• Standard 6-month anti-tuberculosis regimen 2
• Routine use of adjunctive corticosteroids is not recommended 2, 3

C. Viral or Non-specific Pleurisy

• NSAIDs for symptomatic relief 1, 4
• Supportive care
• Follow-up imaging at 6 weeks for patients over 50, smokers, or those with persistent symptoms 4

3. Surgical Management

• Consider surgical consultation if no improvement after 5-7 days of drainage and antibiotics 1
• Indications for surgery:
  • Persistent sepsis
  • Organized empyema
  • Multiloculated effusions not responding to tube drainage
• VATS is preferred over thoracotomy due to:
  • Shorter hospital stay (2.3 days shorter)
  • Less postoperative pain
  • Fewer complications
  • Slightly lower mortality 2

Monitoring and Follow-up

• Track temperature, white blood cell count, clinical symptoms, and radiographic improvement
• Reassess if no improvement after 48-72 hours:
  • Review antibiotic coverage based on culture results
  • Evaluate for inadequate drainage
  • Consider resistant organisms or non-infectious causes

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 of pleurisy
• Overlooking potential underlying malignancy in cases of recurrent or persistent pleurisy

By following this evidence-based approach, the management of pleurisy can be optimized to improve outcomes and reduce complications.