What is the treatment for pleurisy?

Treatment of Pleurisy

The treatment of pleurisy depends critically on the underlying cause: for simple viral pleurisy, use NSAIDs for pain control; for pleural infection (empyema/complicated parapneumonic effusion), immediately start antibiotics and drain with a small-bore chest tube (≤14F); for tuberculous pleurisy, use standard 6-month anti-TB therapy without routine steroids. 1, 2, 3

Initial Assessment and Risk Stratification

Before treating pleurisy, exclude life-threatening causes including pulmonary embolism, myocardial infarction, pericarditis, pneumothorax, and pneumonia through history, physical examination, chest radiography, and ECG. 4 Once these are ruled out, determine if the pleurisy is:

• Simple (dry) pleurisy - inflammation without significant effusion
• Pleural infection - complicated parapneumonic effusion or empyema
• Tuberculous pleurisy - requiring specific anti-TB treatment
• Other causes - malignancy, autoimmune disease, etc.

Treatment of Simple Pleurisy

For uncomplicated pleurisy without significant effusion:

• NSAIDs are the mainstay of pain management 4
• Treat the underlying cause (e.g., viral infection typically self-limited) 4, 5
• Small effusions (<10mm rim on imaging) can be managed with antibiotics alone if infection is suspected 2, 3

Treatment of Pleural Infection (Empyema/Complicated Parapneumonic Effusion)

Immediate Antibiotic Therapy

All patients with pleural infection must receive antibiotics as soon as the condition is identified. 2

For community-acquired pleural infection:

• First-line: Cefuroxime 1.5g IV three times daily + metronidazole 400mg orally three times daily 2
• Alternative: Benzyl penicillin 1.2g IV four times daily + ciprofloxacin 400mg IV twice daily 2
• Oral option: Amoxicillin-clavulanate 1g/125mg three times daily 2, 3

For hospital-acquired pleural infection:

• First-line: Piperacillin-tazobactam 4.5g IV four times daily 2
• Alternative: Ceftazidime 2g IV three times daily 2
• For severe cases: Meropenem 1g IV three times daily ± metronidazole 400mg orally three times daily 2

Key antibiotic principles:

• Beta-lactams show good pleural space penetration 2
• Avoid aminoglycosides - poor penetration and inactivation in acidic pleural fluid 2
• Adjust based on pleural fluid culture results when available 2
• Duration: 2-4 weeks depending on clinical response and drainage adequacy 2

Drainage Strategy

Initial drainage should use a small-bore chest tube (14F or smaller) to minimize patient discomfort while maintaining effectiveness. 1

Chest tube management principles:

• Never use substantial force or a trocar for insertion 1
• Perform chest radiograph after insertion 1
• Connect to unidirectional flow drainage system (underwater seal) kept below chest level 1
• Never clamp a bubbling chest drain 1
• Check for obstruction if drainage suddenly ceases 1
• Remove when clinical resolution occurs 1

Intrapleural Fibrinolytic Therapy

When initial chest tube drainage ceases but leaves residual pleural collection, consider combination TPA and DNAse. 1

Dosing regimen:

• TPA 10mg twice daily + DNAse 5mg twice daily for 3 days (based on RCT data) 1
• Alternative: TPA 5mg twice daily + DNAse 5mg twice daily for 3 days (based on retrospective data) 1
• Reduce TPA dose in patients with higher bleeding risk (e.g., on anticoagulation) 1
• Obtain patient consent due to bleeding risk 1

Evidence for fibrinolytics:

• Combination TPA + DNAse reduces hospital stay, persistent fevers, and improves radiographic resolution 1
• Single agent TPA or DNAse should NOT be used - ineffective 1
• Streptokinase should NOT be used - no benefit and increases complications 1
• Urokinase reduces need for surgery and hospital stay (primarily studied in children) 1

Surgical Intervention

Refer early to thoracic surgery if chest tube drainage, antibiotics, and fibrinolytics fail. 1

Indications for surgery:

• Persistent sepsis with persistent pleural collection despite drainage and antibiotics 1
• Failure of sepsis to resolve within 7 days 1
• Organized empyema in symptomatic patients 1

Surgical approach:

• VATS should be preferred over thoracotomy - shorter hospital stay (2.3 days), less postoperative pain, fewer complications, and slightly lower mortality 1
• Early surgical drainage should NOT routinely replace initial medical management 1

Supportive Care

• Ensure adequate nutritional support from diagnosis - poor nutrition associated with worse outcomes 1
• Provide appropriate analgesia, especially with chest drain in place 1
• Give antipyretics 1
• Do NOT perform chest physiotherapy - not beneficial 1
• Encourage early mobilization and exercise 1

Treatment of Tuberculous Pleurisy

Use standard 6-month anti-tuberculosis regimen (INH, RIF, PZA, EMB for 2 months, then INH and RIF for 4 months). 3

Adjunctive corticosteroids should NOT be used routinely for tuberculous pleurisy. 3

Tuberculous empyema requires drainage (often surgical) plus anti-TB chemotherapy with typically prolonged duration. 3

Monitoring and Follow-up

• Reassess at 48-72 hours for clinical improvement (fever resolution, improved respiratory status) 2, 3
• Monitor effusion size if clinical improvement not occurring 2
• Consider VATS if no improvement after 2-3 days of chest tube drainage and fibrinolytic therapy 2
• Remove chest tube when drainage <1 mL/kg/24 hours and no air leak 2
• Follow until complete recovery and chest radiograph returns to near normal 1
• Consider underlying diagnoses (immunodeficiency, cystic fibrosis) if appropriate 1

Common Pitfalls to Avoid

• Do not delay antibiotics while awaiting culture results in suspected pleural infection 2
• Do not use large-bore chest tubes - no advantage over small-bore and increases pain 1
• Do not use single-agent fibrinolytics - ineffective 1
• Do not ignore nutritional status - critical for recovery 1
• Do not clamp bubbling chest drains - risk of tension pneumothorax 1