What is the recommended treatment for a loculated pleural effusion in an adult?

Treatment of Loculated Pleural Effusion

Patients with loculated pleural effusions require early chest tube drainage with a small-bore catheter (10-14F), and if simple drainage fails after 48 hours, intrapleural fibrinolytic therapy should be administered to break down septations and improve fluid clearance. 1, 2

Initial Assessment and Imaging

• Use ultrasound as the primary imaging modality to identify septations, with sensitivity of 81-88% and specificity of 83-96%, which significantly outperforms CT scanning (71% sensitivity, 72% specificity). 2
• Reserve CT imaging for mediastinal loculations or fissure involvement where ultrasound is limited by overlying lung. 1, 2
• All pleural interventions should be performed under ultrasound guidance to reduce complications and increase diagnostic yield. 2

Drainage Strategy

• Insert small-bore catheters (10-14F) as first-line drainage, as they achieve equivalent pleurodesis success rates (~80%) compared to large-bore tubes while causing significantly less patient discomfort. 1, 2
• Connect catheters to underwater seal drainage initially without suction; apply high-volume, low-pressure suction (-10 to -20 cm H₂O) only after 48 hours if the collection persists. 1
• Control drainage rate at approximately 500 mL/hour and avoid evacuating more than 1-1.5 L in a single session to minimize re-expansion pulmonary edema. 2
• Stop aspiration immediately if the patient develops chest discomfort, persistent cough, or vasovagal symptoms. 2

Intrapleural Fibrinolytic Therapy

When to initiate fibrinolytics:

• Administer intrapleural fibrinolytics if simple drainage fails after 48 hours, particularly when thick fluid or fibrinous debris prevents adequate evacuation. 1, 2
• The presence of loculation on imaging is associated with poorer outcomes and warrants earlier intervention. 3

Dosing regimens:

• Urokinase: 100,000 IU once daily for 3 days, with 1-2 hour dwell time before reopening the chest tube. 4, 5, 6
• Streptokinase: 250,000 IU twice daily for 3 days. 4
• Alteplase (tissue plasminogen activator): Can be used as an alternative, particularly in North America where urokinase may not be available. 2

Expected outcomes:

• Increased pleural fluid drainage occurs in 93-100% of treated patients. 2, 4
• Hospital stay shortens from mean 8.7 days with drainage alone to 6.2 days with fibrinolytic therapy. 1, 4
• Radiographic improvement (>40% reduction in pleural opacity) is seen in 85% of patients versus 35% with placebo. 2
• Complete resolution is achieved in approximately 85-90% of cases, avoiding surgical intervention. 2

Monitoring response:

• Reassess at 5-8 days after initiating therapy, looking for resolution of fever and sepsis, increased daily drainage output, and radiographic improvement. 4
• Measure D-dimer levels before and after treatment to monitor pleural fibrinolytic activity. 5, 6

Antibiotic Therapy for Infected Effusions

• All infected loculated effusions require appropriate antibiotics alongside drainage. 2
• For community-acquired culture-negative pleural infection: Cefuroxime 1.5 g IV three times daily plus metronidazole 400 mg oral three times daily. 3
• Alternative regimens include benzylpenicillin plus ciprofloxacin. 1

Specialist Involvement

• A respiratory physician or thoracic surgeon should be involved in the care of all patients requiring chest tube drainage for pleural infection, as early specialist involvement reduces delays to drainage and associated morbidity. 3, 2
• Refer to respiratory physician or thoracic surgeon within 48 hours if the effusion fails to respond to initial drainage. 1

Surgical Intervention

• Consider Video-Assisted Thoracoscopic Surgery (VATS) if medical management fails after approximately 7 days, as it allows septations to be broken up under direct vision with similar outcomes to chest tube drainage with fibrinolytics. 1, 2
• Medical or surgical thoracoscopy is the preferred surgical approach for definitive management of persistent loculations. 1

Special Considerations for Malignant Effusions

• Use an indwelling pleural catheter (IPC) as first-line therapy for symptomatic malignant pleural effusions with loculation, as it allows ongoing drainage without requiring complete lung expansion. 2
• IPCs are preferred over chemical pleurodesis in loculated malignant effusions, as pleurodesis will be ineffective if loculations prevent lung re-expansion. 2
• Intrapleural fibrinolytics can be administered through IPCs to improve drainage in symptomatic loculations (93% success rate), though they do not improve clinical outcomes like dyspnea or pleurodesis success rates in malignant effusions. 2
• In medically inoperable cancer patients, urokinase treatment is associated with longer median survival (69 days vs 48 days) and shorter hospital stays. 2

Critical Safety Considerations

• Never clamp a bubbling chest tube, as this can convert a simple pneumothorax into life-threatening tension pneumothorax. 1
• Bleeding complications occur in only 2-8.5% of patients receiving fibrinolytic therapy. 2
• Patients receiving streptokinase must be given a streptokinase exposure card and should receive urokinase or tissue plasminogen activator for any future systemic indications due to antibody formation. 4
• Give intrapleural lignocaine 3 mg/kg (maximum 250 mg) prior to sclerosant administration to reduce procedural pain. 2

Common Pitfalls to Avoid

• Do not delay chest tube drainage in loculated effusions, as loculation is associated with longer hospital stays and more complicated courses. 3, 2
• Do not attempt pleurodesis in patients with non-expandable lung due to loculations, as it will fail. 2
• Do not rely solely on CT for detection of septations when ultrasound is available, as ultrasound is superior. 2
• Do not perform pleural interventions in asymptomatic patients with malignant pleural effusion. 2