Treatment for Pleuritis
The treatment of pleuritis should be tailored to the underlying cause, with combination tissue plasminogen activator (TPA) and DNase therapy recommended for complicated parapneumonic effusions or empyema where initial chest tube drainage has been inadequate. 1
Diagnostic Approach
- Determine the underlying cause of pleuritis (viral, bacterial, autoimmune, etc.)
- For suspected pleural infection:
- Obtain pleural fluid samples within 24 hours for pH, glucose, LDH, protein, and culture
- Measure pleural fluid pH with a blood gas analyzer (avoid contamination with local anesthetic or heparin)
- Consider chest imaging (ultrasound, CT) to evaluate for loculations or effusions
Treatment Algorithm
1. Viral Pleuritis
- Usually self-limited, resolving within 10-14 days
- Pain management:
- NSAIDs as first-line treatment (ibuprofen or naproxen) until pain resolves 2
- Adequate analgesia is essential to allow deep breathing and prevent atelectasis
- Avoid antibiotics as they provide no benefit for viral illness 2
- Early mobilization and exercise are recommended
2. Bacterial Pleural Infection/Empyema
Initial management:
- Small-bore chest tube (14F or smaller) for drainage 1
- Start appropriate antibiotics immediately upon identification of infection
- For community-acquired infection: amoxicillin + clavulanic acid or amoxicillin + metronidazole
- For hospital-acquired infection: broader spectrum antibiotics (piperacillin-tazobactam, ceftazidime, or meropenem)
- Continue antibiotics for at least 14 days
For complicated parapneumonic effusions or empyema with inadequate drainage:
- Combination TPA and DNase therapy: 10 mg TPA twice daily + 5 mg DNase twice daily for 3 days 1
- Lower doses (5 mg TPA twice daily + 5 mg DNase twice daily) may be considered for patients with higher bleeding risk
- Single agent TPA or DNase should not be used 1
- Streptokinase should not be used for treatment of pleural infection 1
Surgical intervention:
- Consider if no improvement after 5-7 days of drainage and antibiotics
- VATS access should be preferred over thoracotomy 1
- Early consultation with thoracic surgeon is recommended for persistent sepsis with residual pleural collection
3. Autoimmune-Related Pleuritis
- Treat the underlying autoimmune condition
- NSAIDs for symptomatic relief
- Consider corticosteroids for severe symptoms
- Monitor for increased risk of infections, particularly tuberculosis in patients with lupus pleuritis 3
Special Considerations
Monitoring and Follow-up
- Monitor temperature, white blood cell count, clinical symptoms, and radiographic improvement
- Reassess if no improvement after 48-72 hours
- Follow patients until complete recovery with chest radiograph returning to near normal
Potential Complications
- Secondary thrombocytosis is common but benign
- Secondary scoliosis may occur but is usually transient
- Watch for explosive pleuritis, a medical emergency defined by rapid development of pleural effusion involving >90% of the hemithorax within 24 hours 4
Common Pitfalls to Avoid
- Delaying drainage of complicated parapneumonic effusions
- Using aminoglycosides as sole therapy (poor penetration into pleural space)
- Removing chest tubes prematurely
- Failing to adjust antibiotics based on culture results
- Misdiagnosing the underlying cause of pleuritis
Risk Stratification
- Use the RAPID score (Renal function, Age, Purulence, Infection source, Dietary factors) to risk stratify patients with pleural infection 2
- Consider pulmonary embolism in patients with pleuritic chest pain (found in 5-21% of emergency department presentations) 5
By following this evidence-based approach to pleuritis management, clinicians can optimize outcomes and reduce morbidity associated with this condition.