Pleurisy Management Overview
Pleurisy requires prompt diagnosis and targeted treatment based on the underlying cause, with appropriate antibiotic therapy for infectious cases and drainage procedures for complicated effusions to reduce morbidity and mortality. 1
Definition and Clinical Presentation
- Pleurisy is inflammation of the pleural membrane characterized by sharp, stabbing chest pain that worsens with breathing
- Symptoms include pleuritic chest pain, dyspnea, and sometimes fever
- Physical examination may reveal dullness to percussion and decreased breath sounds if effusion is present
Diagnostic Approach
Initial Evaluation
- Chest radiography is the first-line imaging test to confirm pleural effusion 2, 1
- Ultrasound should be used to:
- CT scans are not recommended routinely but help characterize complex cases 2, 1
Laboratory Testing
- Blood cultures should be performed in all patients with suspected pleural infection 2
- Pleural fluid analysis is essential for diagnosis:
- Pleural fluid pH <7.2, glucose <3.3 mmol/L, or LDH >900 IU/L indicate need for drainage 1
- Pleural lymphocytosis requires exclusion of tuberculosis and malignancy 2
Management Based on Etiology
Infectious Pleurisy (Parapneumonic Effusion/Empyema)
Antibiotic Therapy
- All patients should receive antibiotics immediately upon identification of pleural infection 2, 1
- For community-acquired infection:
- For hospital-acquired infection:
- Avoid aminoglycosides due to poor pleural penetration 2
- Continue antibiotics for at least 14 days, adjusting based on culture results 1
Drainage Procedures
- Indications for drainage:
- Frank pus
- pH <7.2
- Glucose <3.3 mmol/L
- LDH >900 IU/L
- Large symptomatic effusions
- Loculated collections 1
- Small-bore chest tubes (14F or smaller) under ultrasound guidance are preferred 2, 1
- For complicated effusions with loculations, consider combination therapy with tissue plasminogen activator (TPA) 10mg twice daily + DNase 5mg twice daily for 3 days 1
- Avoid single-agent TPA or DNase and streptokinase 1
Surgical Intervention
- Consider surgical drainage (preferably VATS) for patients who fail to improve after 5-7 days of drainage and antibiotics 1
- Indications include:
- Persistent sepsis
- Organized empyema
- Multiloculated effusions not responding to tube drainage 1
Tuberculous Pleurisy
- Standard 6-month anti-tuberculosis regimen 1
- Consider adjunctive corticosteroids (prednisolone 0.75 mg/kg/day, tapered over 2-3 months) to hasten symptom relief and fluid reabsorption 3
Viral Pleurisy
- Common causative agents include coxsackieviruses, respiratory syncytial virus, influenza, parainfluenza, mumps, adenovirus, cytomegalovirus, and Epstein-Barr virus 4
- Supportive care and pain management with NSAIDs 1, 4
Drug-Induced Pleurisy
- Discontinue the offending medication (commonly ergotamine derivatives, bromocriptine, dantrolene) 5
- Monitor for resolution of symptoms and effusion
Pain Management
- NSAIDs are first-line treatment for pleuritic chest pain 1
- Options include ibuprofen and naproxen, continued until pain resolves 1
- For severe pain, consider intrapleural bupivacaine if fibrinolytic agents are used 1
Follow-up and Monitoring
- Track temperature, white blood cell count, clinical symptoms, and radiographic improvement 1
- Reassess if no improvement after 48-72 hours:
- Review antibiotic coverage
- Evaluate for inadequate drainage
- Consider resistant organisms or non-infectious causes 1
- For patients with pneumonia, document radiographic resolution with repeat chest radiography six weeks after initial treatment, especially in smokers and those over 50 years 4
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 1
- Consider underlying malignancy in cases of recurrent or persistent pleurisy 1