What is the diagnosis and treatment for pleural effusion?

From the Guidelines

Pleural effusion management should prioritize a systematic approach to investigation, starting with a careful history and physical examination, followed by thoracic ultrasound (TUS) to guide further diagnostic and therapeutic interventions, as recommended by the most recent British Thoracic Society guideline for pleural disease 1. The management of pleural effusion depends on the underlying cause and severity of the condition. For symptomatic effusions, thoracentesis is often the initial procedure to drain fluid and provide relief. If the effusion is due to infection (empyema), antibiotics are necessary, typically starting with broad-spectrum coverage. For malignant effusions, options include therapeutic thoracentesis, pleurodesis using talc or doxycycline, or placement of an indwelling pleural catheter. Some key points to consider in the management of pleural effusion include:

• The use of diuretics like furosemide for effusions caused by heart failure or volume overload
• The role of corticosteroids in inflammatory effusions
• The need for dietary modifications and sometimes octreotide in chylous effusions
• The importance of addressing the underlying cause in recurrent effusions The pathophysiology of fluid accumulation in pleural effusion varies according to underlying aetiologies, and a systematic approach to investigation is necessary to establish a diagnosis and facilitate treatment, as outlined in the British Thoracic Society guideline for pleural disease 1. Key considerations in the investigation of pleural effusion include:
• A careful history and physical examination to elucidate the likely cause
• The use of thoracic ultrasound (TUS) to guide further diagnostic and therapeutic interventions
• The importance of considering drug history and occupational history, including asbestos exposure
• The role of CT scans in further investigation, particularly when malignancy is suspected.

From the Research

Definition and Presentation of Pleural Effusion

• Pleural effusion is an excessive accumulation of fluid in the pleural space, which can pose a diagnostic dilemma due to its potential relation to various disorders of the lung, pleura, or systemic conditions 2.
• Patients commonly present with dyspnea, dry cough, and pleuritic chest pain, with the etiology of pleural effusion remaining unclear in nearly 20% of cases 2.

Diagnostic Approach

• Thoracocentesis should be performed for new and unexplained pleural effusions to determine the etiology and to distinguish between transudate and exudate 2, 3.
• Laboratory testing, including chemical and microbiological studies, cytological analysis, and immunohistochemistry, can provide further information about the etiology of the disease process 2, 3.
• Point-of-care ultrasound can detect small effusions, features of complicated effusion, and guide thoracentesis to reduce complications 3.
• Computed tomography of the chest can exclude other causes of dyspnea and suggest complicated parapneumonic or malignant effusion 3.

Etiology and Treatment

• The leading causes of pleural effusion in adults are heart failure, infection, malignancy, and pulmonary embolism 3, 4.
• Transudative effusions are usually managed by treating the underlying medical disorder, while exudative effusions require treatment based on the underlying etiology 2, 4.
• Malignant effusions are usually drained to palliate symptoms and may require pleurodesis to prevent recurrence 2, 4.
• Lung ultrasound-guided therapeutic thoracentesis can provide immediate and substantial symptomatic relief in patients with refractory heart failure 5.

Management and Complications

• Pleural biopsy is recommended for evaluation and exclusion of various etiologies, such as tuberculosis or malignant disease 2.
• Empyemas need to be treated with appropriate antibiotics and intercostal drainage, and surgery may be needed in selected cases where drainage procedure fails to produce improvement or to restore lung function and for closure of bronchopleural fistula 2.
• The proper treatment of pleural effusion can be determined only after meticulous differential diagnosis, and the range of therapeutic options has recently become much wider 4.