What is the treatment for pleurisy?

Treatment of Pleurisy

Treat pleurisy with NSAIDs for pain control while aggressively investigating and treating the underlying cause, which ranges from benign viral infection to life-threatening conditions like pulmonary embolism, pneumonia, or empyema. 1, 2

Immediate Assessment and Risk Stratification

Before diagnosing simple pleurisy, you must exclude life-threatening causes:

• Rule out pulmonary embolism first (found in 5-21% of patients presenting with pleuritic pain), followed by myocardial infarction, pericarditis, pneumothorax, and pneumonia 3, 1, 2
• Obtain chest radiography, vital signs assessment, and ECG in all patients with pleuritic chest pain 3, 1
• Look specifically for fever and tachycardia (suggesting infection or PE), pleural friction rub, decreased breath sounds, and dullness to percussion 3

Treatment Based on Underlying Etiology

For Viral or Idiopathic Pleurisy (Most Common)

• NSAIDs are the primary treatment for pain management in viral or nonspecific pleuritic chest pain 1, 2
• Viral causes include Coxsackieviruses, RSV, influenza, parainfluenza, mumps, adenovirus, CMV, and EBV 2
• No specific antiviral therapy is typically needed; treatment is supportive 1

For Parapneumonic Effusion or Empyema

If pleural effusion is present, management escalates based on size and characteristics:

• Small effusions (<10mm): Treat with antibiotics alone 3
• Larger effusions or respiratory compromise: Perform thoracentesis or chest tube drainage 3

Antibiotic regimens for community-acquired pleural infection:

• First-line: Cefuroxime 1.5g IV three times daily PLUS metronidazole 500mg IV three times daily 4, 3
• Alternative regimens: Benzyl penicillin 1.2g IV four times daily plus ciprofloxacin 400mg IV twice daily, OR meropenem 1g IV three times daily plus metronidazole 4
• Penicillin allergy: Clindamycin alone is effective 4
• Avoid aminoglycosides due to poor pleural space penetration and inactivation by acidic pleural fluid 4, 5

Drainage procedures:

• Use small-bore chest tubes or pigtail catheters placed under ultrasound or CT guidance 4, 3
• If drainage is inadequate after 48-72 hours, check tube position and consider intrapleural fibrinolytic therapy with TPA and DNase for loculated effusions 6, 3
• Surgical consultation is indicated if no response after approximately 7 days of drainage and antibiotics 4, 5

Transition to oral antibiotics after clinical improvement:

• Amoxicillin-clavulanate (amoxicillin 1g three times daily plus clavulanic acid 125mg three times daily) is first-line 4, 3
• Continue oral antibiotics for 1-4 weeks after discharge, longer if residual disease persists 4

For Tuberculous Pleurisy

• Standard 6-month anti-tuberculosis regimen (INH, RIF, PZA, EMB for 2 months, then INH and RIF for 4 months) is adequate 6
• Do NOT use adjunctive corticosteroids routinely for tuberculous pleural effusions—four prospective, double-blind, randomized trials showed no benefit in preventing residual pleural thickening or long-term sequelae 6
• One study showed increased risk of Kaposi sarcoma with prednisolone in HIV-associated tuberculous pleurisy 6

For Tuberculous Empyema

• Requires drainage (often surgical) PLUS anti-tuberculosis chemotherapy 6
• Optimal duration not established but typically prolonged 6

Monitoring and Follow-Up

• Reassess at 48-72 hours; signs of clinical deterioration or persistent fever require escalation of treatment 3
• Resolution confirmed by fever resolution, improved respiratory status, decreased WBC count, and pleural fluid neutrophil count <250/mm³ 4, 3
• In patients with pneumonia who smoke or are >50 years old, document radiographic resolution with repeat chest X-ray at 6 weeks 2

Adjunctive Therapies

• Physical rehabilitation (directed breathing exercises and laser biostimulation) significantly improves lung function parameters (VC, FEV1, PEF) and hemidiaphragm mobility in exudative pleurisy 7
• Early mobilization and exercise are recommended during recovery 5
• Adequate analgesia is important, particularly in patients with chest drains 5

Critical Pitfalls to Avoid

• Never diagnose simple pleurisy without excluding PE, MI, pericarditis, pneumothorax, and pneumonia first 3, 1
• Never use oral antibiotics as initial monotherapy for empyema—this is inadequate and increases mortality risk 4
• Never omit anaerobic coverage in pleural infections 4
• Never clamp a bubbling chest drain; if a patient with a clamped drain develops breathlessness or chest pain, unclamp immediately 5
• Delayed antibiotic initiation in empyema increases morbidity and mortality 4, 3