Management of Loculated Pleural Effusion
Patients with loculated pleural effusions should receive early chest tube drainage, and when simple drainage is inadequate, intrapleural fibrinolytic therapy should be administered to break up septations and improve fluid clearance. 1, 2
Initial Assessment and Imaging
- Use transthoracic ultrasound as the primary imaging modality to identify septations, with 81-88% sensitivity and 83-96% specificity—superior to CT scanning for detecting loculations 2
- Reserve CT scanning for mediastinal loculations or those involving fissures where ultrasound is limited by overlying lung 2
- Always use ultrasound guidance when performing pleural interventions on loculated collections, as this reduces complications and increases procedural yield 2
Treatment Algorithm Based on Etiology
For Parapneumonic/Infected Loculated Effusions:
- Insert a chest tube early when loculation is identified, as the presence of loculation on imaging is associated with poorer outcomes and longer hospital stays 1, 2
- Use small bore catheters (10-14 F) as the initial choice for drainage, as they are less uncomfortable than large bore tubes and equally effective 1
- Administer intrapleural fibrinolytic agents when chest tube drainage alone is inadequate 2, 3
- Options include urokinase, streptokinase, or tissue plasminogen activator (alteplase) 2
- Standard dosing: alteplase 0.1 mg/kg once daily with 1-4 hour dwell time before reopening the chest tube 2
- Expected outcomes: 85-90% complete resolution, increased drainage in 93-100% of patients, shorter hospital stays (6.2 vs 8.7 days), and avoidance of surgery in ~90% of cases 2
- Initiate appropriate antibiotic therapy alongside drainage: cefuroxime and metronidazole, or benzyl penicillin and ciprofloxacin 2
- A respiratory physician or thoracic surgeon should be involved in all cases requiring chest tube drainage for pleural infection 1
For Malignant Loculated Effusions:
- Use an indwelling pleural catheter (IPC) as first-line therapy for symptomatic malignant effusions with loculation, as it allows ongoing drainage without requiring complete lung expansion 2
- IPCs are preferred over chemical pleurodesis because pleurodesis will fail if loculations prevent lung re-expansion 2
- Intrapleural fibrinolytics can be administered through IPCs to improve drainage in symptomatic loculations, though they do not improve dyspnea or pleurodesis success rates in malignant effusions 2
Surgical Intervention
- Consider Video-Assisted Thoracoscopic Surgery (VATS) if medical management fails after approximately 7 days 1, 2
- VATS allows direct visualization and mechanical breakdown of septations, with outcomes similar to chest tube drainage with fibrinolytics in randomized trials 2
- If thoracoscopy is unsuccessful, thoracotomy with decortication may be indicated unless the patient is too debilitated 3
Evidence for Fibrinolytic Therapy
Controlled studies demonstrate that fibrinolytic therapy results in:
- Greater radiological lung expansion (85% showing >40% reduction in pleural opacity vs 35% with placebo) 2
- Higher daily drainage volumes 2
- Shorter hospital stays 2, 4
- Favorable safety profile with bleeding complications in only 2-8.5% of patients 2
Critical Pitfalls to Avoid
- Never attempt pleurodesis in patients with non-expandable lung due to loculations—it will be ineffective and will not result in definitive fluid control 2
- Do not delay drainage of large loculated effusions (>40% of hemithorax) or those causing respiratory distress, as delay is associated with increased morbidity and potentially increased mortality 1, 2
- Do not rely solely on CT for detection of septations when ultrasound is available 2
- Avoid performing pleural interventions in asymptomatic patients with malignant pleural effusion 2
- Do not use pH litmus paper or pH meters for pleural fluid pH measurement—only blood gas analyzers are reliable 1