What is the treatment approach for a patient with pleurisy, considering the underlying cause and symptoms?

Treatment of Pleurisy

The treatment of pleurisy depends critically on the underlying cause: uncomplicated viral pleurisy requires only NSAIDs for pain control, while pleural infection (empyema/parapneumonic effusion) demands immediate antibiotics plus chest tube drainage, and complicated cases may require intrapleural fibrinolytics (TPA/DNase) or surgical intervention. 1, 2

Initial Assessment and Diagnosis

Before treating pleurisy, you must exclude life-threatening causes that present with pleuritic pain 2:

• Pulmonary embolism (found in 5-20% of emergency department presentations with pleuritic pain) 2
• Myocardial infarction, pericarditis, pneumothorax, and pneumonia 2
• Perform chest radiography, and consider ECG if cardiac or PE suspected 2
• Ultrasound must be used to confirm pleural fluid collections 1

Once these are excluded, determine if the pleurisy is:

1. Simple inflammatory pleurisy (viral, autoimmune)
2. Pleural infection (parapneumonic effusion/empyema)
3. Other causes (malignancy, tuberculosis, etc.)

Treatment of Simple Pleurisy (Non-Infectious)

For uncomplicated viral or inflammatory pleurisy, treatment consists of NSAIDs for pain management 2:

• This is the mainstay when infectious and life-threatening causes are excluded 2
• Address any underlying systemic disease (e.g., autoimmune conditions) 3, 4

Treatment of Pleural Infection (Parapneumonic Effusion/Empyema)

Immediate Management

All patients with pleural infection require hospital admission and immediate treatment with both antibiotics and drainage 1:

Antibiotic Therapy

Start IV antibiotics immediately upon diagnosis 1, 5:

For community-acquired pleural infection 1, 5:

• Cefuroxime 1.5g three times daily IV + metronidazole 400mg three times daily orally 5
• Alternative: Benzyl penicillin 1.2g four times daily IV + ciprofloxacin 400mg twice daily IV 5
• Antibiotics must cover Streptococcus pneumoniae and anaerobes 1

For hospital-acquired pleural infection 1, 5:

• Piperacillin-tazobactam 4.5g four times daily IV 5
• Alternative: Ceftazidime 2g three times daily IV or meropenem 1g three times daily IV 5
• Broader spectrum coverage is required for nosocomial infections 1

Critical antibiotic considerations 1, 6:

• Avoid aminoglycosides (including gentamicin)—they have poor pleural penetration and are inactivated in acidic pleural fluid 1, 6
• Adjust antibiotics based on pleural fluid culture results when available 1, 5
• Continue antibiotics for 2-4 weeks depending on clinical response 5

Drainage Procedures

Initial drainage should use a small-bore chest tube (14F or smaller) 1:

• Ultrasound must guide thoracocentesis or drain placement 1
• Insert drains at the optimal site suggested by ultrasound 1
• Never use substantial force or a trocar to insert a drain 1
• Small-bore drains (including pigtail catheters) minimize patient discomfort with no loss of efficacy compared to large-bore drains 1

If drainage ceases but residual collection remains, flush with 20-50 mL normal saline to ensure tube patency 6:

Advanced Treatment for Persistent Infection

If initial chest tube drainage fails and a residual pleural collection persists 1:

Intrapleural Fibrinolytic Therapy

Combination TPA and DNase should be considered when initial drainage has ceased 1:

• Dosing: 10mg TPA twice daily + 5mg DNase twice daily for 3 days 1
• Alternative lower-dose regimen: 5mg TPA twice daily + 5mg DNase twice daily for 3 days (may be equally effective) 1
• This combination reduces length of hospital stay and improves radiographic outcomes 1
• Single-agent TPA or DNase should NOT be used—they are ineffective 1
• Streptokinase should NOT be used—it increases complications without benefit 1
• Obtain patient consent due to bleeding risk 1

Saline Irrigation

Saline irrigation (250 mL three times daily) can be considered when TPA/DNase or surgery is not suitable 1, 6:

• May reduce the need for thoracic surgery 1, 6
• Never add gentamicin or other antibiotics to irrigation solution 6

Surgical Intervention

Refer for surgical treatment if persistent sepsis and pleural collection despite chest tube drainage and antibiotics 1:

• Discuss with thoracic surgeon early if medical management fails after 7 days 1
• VATS (video-assisted thoracoscopic surgery) is preferred over thoracotomy when surgery is needed 1:
  • VATS results in 2.3 days shorter hospital stay 1
  • Less postoperative pain 1
  • Fewer complications (152/1000 vs 197/1000 patients) 1
  • Lower mortality (35/1000 vs 47/1000 patients) 1

For patients unfit for general anesthesia 1:

• Consider local anesthetic surgical rib resection 1
• Re-imaging and placement of additional image-guided catheters 1

Special Considerations

Tuberculous Pleurisy

For TB pleurisy, standard anti-TB chemotherapy for 6 months is adequate 7:

• Complete drainage of effusion at initial thoracoscopy is essential 7
• Corticosteroids (prednisone 0.75 mg/kg/day) do NOT provide clinically relevant benefit and are not routinely recommended 7
• Neither earlier symptom relief nor reduced pleural thickening occurs with steroid addition 7

Pleuro-Peritoneal Leaks in Peritoneal Dialysis Patients

Immediate management: discontinue PD and consider thoracocentesis for symptom relief 1:

• Temporary PD cessation (2-6 weeks) is successful in 53% of cases 1
• Alternative: low-volume PD exchanges in reclining position 1
• Tube thoracostomy-directed pleurodesis successful in 48% of cases 1
• VATS with pleurodesis has 88% success rate for large diaphragmatic defects 1
• Rest period of 3-4 weeks after surgical repair before reinitiating PD 1

Critical Pitfalls to Avoid

• Do not delay chest tube drainage—delay increases morbidity, hospital stay, and possibly mortality 1
• Do not treat enlarging or respiratory-compromising effusions with antibiotics alone 1
• Do not use repeated thoracocentesis for significant pleural infection—insert a drain at the outset 1
• Do not use aminoglycosides intrapleurally or systemically for pleural infection 1, 6
• Do not use single-agent fibrinolytics—only the TPA/DNase combination is effective 1
• Do not use streptokinase—it increases complications 1
• Ensure adequate nutritional support from diagnosis—hypoalbuminemia is associated with poor outcomes 1

Monitoring and Drain Removal

Monitor for clinical improvement 5:

• Resolution of fever and improved respiratory status 5
• Remove chest tube when drainage is <1 mL/kg/24 hours and no air leak 5
• Reassess effusion size if no clinical improvement 5