What is the treatment for inflamed pleura (pleuritis)?

Treatment for Inflamed Pleura (Pleuritis)

Treatment of pleuritis depends critically on the underlying cause, with infectious pleuritis requiring immediate antibiotics and drainage, while non-infectious inflammatory causes respond to treatment of the underlying condition.

Initial Diagnostic Evaluation

The first step is determining whether the pleuritis is infectious or non-infectious, as this fundamentally changes management:

• Perform diagnostic thoracentesis within 24 hours if pleural infection is suspected to guide antibiotic selection and determine need for drainage 1, 2
• Measure pleural fluid pH, glucose, and lactate dehydrogenase (LDH) as these parameters determine management intensity 3
• Obtain blood cultures in all patients with suspected parapneumonic effusion 1
• Use ultrasound as the preferred initial imaging modality to confirm effusion and guide thoracentesis 1, 2

Key Pleural Fluid Parameters for Infectious Pleuritis

• pH <7.2 indicates high risk requiring chest tube drainage 3
• pH ≥7.4 indicates low risk with no immediate drainage needed 3
• LDH >900 IU/L warrants chest tube consideration, especially with fever, high fluid volume, glucose ≤4.0 mmol/L (72 mg/dL), or septations on ultrasound 3
• Glucose <3.3 mmol/L suggests high probability of complicated parapneumonic effusion/infection when pH measurement unavailable 3

Treatment of Infectious Pleuritis (Most Common)

Antibiotic Therapy

Start antibiotics immediately once pleural infection is identified 1:

For community-acquired pleural infection:

• Cefuroxime 1.5g IV three times daily PLUS metronidazole 400mg orally three times daily (preferred regimen) 4
• Alternative: Benzyl penicillin 1.2g IV four times daily PLUS ciprofloxacin 400mg IV twice daily 4
• Alternative: Meropenem 1g IV three times daily PLUS metronidazole 400mg orally three times daily 4

For hospital-acquired pleural infection:

• Piperacillin-tazobactam 4.5g IV four times daily 4, 1
• Alternative: Ceftazidime or meropenem 1

Critical antibiotic considerations:

• Avoid aminoglycosides as they penetrate poorly into pleural space and are inactive in acidic pleural fluid 4, 1
• Metronidazole is essential for anaerobic coverage in community-acquired infections, particularly with aspiration risk 4
• Continue oral antibiotics at discharge for 1-4 weeks, longer if residual disease present 1

Drainage Procedures

Initial drainage should use small-bore chest tubes (14F or smaller) 3, 2:

• Insert chest tube at outset for enlarging effusions or those compromising respiratory function rather than repeated thoracentesis 1
• Use ultrasound guidance for all drain placements 1
• Do not use early VATS or thoracotomy as initial treatment over chest tube drainage 3

Management of Persistent Collections

If chest tube drainage ceases but residual collection remains:

• Consider combination tissue plasminogen activator (TPA) plus DNase 3, 2

  • Regimen: 10mg TPA twice daily PLUS 5mg DNase twice daily for 3 days 3
  • Alternative lower-dose: 5mg TPA twice daily PLUS 5mg DNase twice daily for 3 days (may be equally effective) 3
  • Obtain patient consent due to bleeding risk 3
  • Reduce TPA dose in patients on anticoagulation 3

• Do NOT use single-agent TPA or DNase alone (ineffective) 3

• Do NOT use streptokinase 3

• Saline irrigation (250mL three times daily) can be considered when TPA/DNase or surgery unsuitable 3

Surgical Intervention

Consider surgical referral if no improvement after 5-7 days of appropriate antibiotics and drainage 1, 2:

• VATS is preferred over thoracotomy when surgery required, resulting in less postoperative pain, shorter hospital stays, and fewer complications 3, 2
• Ensure respiratory physician or thoracic surgeon involvement for all patients requiring chest tube drainage 1

Treatment of Non-Infectious Inflammatory Pleuritis

Rheumatoid Pleuritis

• Disease-modifying antirheumatic drugs are the primary treatment 2
• In medically refractory cases with severe restriction, consider pleurectomy/decortication 5

Lupus Pleuritis

• Corticosteroids and immunosuppressive agents (cyclophosphamide, prednisone) are first-line 5
• Decortication may be viable for refractory pleuritis causing severe restriction despite maximal medical therapy 5

Malignant Pleuritis

• Treat primary malignancy 2
• Consider pleurodesis for recurrent effusions 2

Critical Pitfalls to Avoid

• NSAIDs may worsen the course of community-acquired pneumonia and increase pleuropulmonary complications; avoid in suspected infectious pleuritis 6
• Delayed chest tube drainage increases morbidity, hospital stay, and possibly mortality 1
• Group A Streptococcus can cause "explosive pleuritis" with rapid progression within 24 hours, requiring aggressive early intervention 7
• Alternative diagnoses (rheumatoid effusion, malignancy/mesothelioma) can mimic parapneumonic effusion with low pH and loculations 3
• Up to 15% of nonspecific pleuritis cases subsequently develop pleural malignancy, requiring extended follow-up 1, 2

Follow-Up and Monitoring

• Assess fever, inflammatory markers, and symptoms regularly during treatment 1, 2
• Perform follow-up imaging to ensure resolution and absence of loculations 1, 2
• Document treatment response at 5-8 days after initiating drainage and antibiotics 2
• Extended radiological monitoring is crucial for nonspecific pleuritis where malignancy suspected but initial biopsies negative 2