Spirometry Does Not Remove Septations in Pleural Fluid
Spirometry is a pulmonary function test that measures lung volumes and airflow—it has no therapeutic role in removing septations from pleural effusions. This appears to be a fundamental misunderstanding of what spirometry does versus what treats loculated pleural collections.
What Spirometry Actually Does
- Spirometry is a diagnostic test that measures forced vital capacity (FVC), forced expiratory volume (FEV1), and other lung function parameters 1
- In patients with pleural effusion, spirometry demonstrates restrictive patterns with reduced lung volumes, but performing the test does not alter the effusion or its septations 1
- Spirometry may show the functional impact of pleural effusion on lung mechanics, but it is purely diagnostic, not therapeutic 1
What Actually Removes Septations
The evidence-based treatments for septated pleural effusions involve mechanical drainage and fibrinolytic therapy, not pulmonary function testing.
Imaging to Identify Septations
- Ultrasound is superior to CT for visualizing fibrinous septations, with 81-88% sensitivity and 83-96% specificity 2
- Septations are better visualized on ultrasound than on CT scans 3
Treatment Options for Septated Effusions
Intrapleural Fibrinolytic Therapy:
- Intrapleural fibrinolytics can be considered in highly selected symptomatic patients with malignant pleural effusion and septated effusion to improve breathlessness 3
- Fibrinolytic agents work by lysing fibrinous strands, clearing lymphatic pores, and restoring normal pleural fluid dynamics 2
- Alteplase, urokinase, and streptokinase are the available fibrinolytic options 2
- These agents result in greater radiological lung expansion, higher daily drainage volumes, and shorter hospital stays 2
Drainage Procedures:
- Ultrasound-guided pleural aspiration should be used as a safe and accurate method of obtaining fluid if the effusion is small or loculated 3
- Small-bore chest tubes (10-14 French) are equally effective as large-bore tubes but less uncomfortable 4
- Indwelling pleural catheters (IPCs) are effective for malignant effusions with septations, though fibrinolytics may be needed if drainage is inadequate 3
Surgical Options:
- Video-Assisted Thoracoscopic Surgery (VATS) allows septations to be broken up under direct vision 2
- Surgery can be considered for palliation in selected patients with significantly septated malignant pleural effusion and good performance status 3
- Decortication may be needed for organized empyema with trapped lung 4
Critical Distinction
Septations are physical fibrinous strands within the pleural space that require mechanical disruption (surgery) or chemical lysis (fibrinolytics) to remove—no breathing maneuver or pulmonary function test can accomplish this. 3, 2