1. Surgical Management
of Pleural Effusion

2. Thoracentesis
• A procedure to remove excess fluid in the pleural space
• Indications:
– Diagnostic: to classify effusion as exudative or transudative
– Therapeutic: palliation of dyspnea (not more than 1.5L in
one sitting)
• Diagnostic sampling allows the collection of liquid for
microbiologic and cytologic studies

3. Thoracentesis
• video

4. Effusion due to Heart Failure
• most common cause of pleural effusion
• a diagnostic thoracentesis is done if:
– the effusions are not bilateral and comparable in size
– the patient is febrile
– the patient has pleuritic chest pain to verify that the effusion is
transudative
• Otherwise the patient's heart failure is treated
• If the effusion persists despite therapy, a diagnostic thoracentesis should
be done
• A pleural fluid N-terminal pro-brain natriuretic peptide (NT-proBNP)
>1500 pg/mL is diagnostic of an effusion secondary to congestive heart
failure

5. Parapneumonic Effusions
• most common cause of exudative pleural effusion (bacterial
pneumonias, lung abscess, bronchiectasis)
• The presence of free pleural fluid can be demonstrated with a lateral
decubitus radiograph, CT of the chest, or ultrasound
• If the free fluid separates the lung from the chest wall by >10 mm, a
therapeutic thoracentesis should be performed
• A procedure more invasive than thoracentesis is needed if the
following factors are present:
– Loculated pleural fluid
– Pleural fluid pH <7.20
– Pleural fluid glucose <3.3 mmol/L (<60 mg/dL)
– Positive Gram stain or culture of the pleural fluid
– Presence of gross pus in the pleural space

6. Parapneumonic Effusion
• If the fluid recurs after the initial therapeutic thoracentesis and if
any of these characteristics are present - a repeat thoracentesis
• If the fluid cannot be completely removed with the therapeutic
thoracentesis,
– insert a chest tube and instill a fibrinolytic agent (e.g., tissue
plasminogen activator, 10 mg)
– perform a thoracoscopy with the breakdown of adhesions
– Decortication (if these measures are ineffective)

7. Malignant Pleural Effusions
• 2nd most common type of exudative pleural effusion (lung carcinoma,
breast carcinoma, & lymphoma)
• Diagnosis: cytology of the pleural fluid
• If cytology is negative, thoracoscopy is done if malignancy is suspected
• Pleural abrasion should be performed to effect a pleurodesis
• Pleural abrasion: a scourer is used to scrape off the surface of parietal
pleura
• An alternative to thoracoscopy : CT- or ultrasound-guided needle
biopsy of pleural thickening or nodules
• Patients with a malignant pleural effusion are treated symptomatically
• Dyspnea if present and is relieved with a therapeutic thoracentesis,
one of the following procedures should be considered:
– insertion of a small indwelling catheter or
– tube thoracostomy with the instillation of a sclerosing agent such as
doxycycline, 500 mg

8. Chylothorax
• Occurs when thoracic duct is disrupted and chyle
accumulates in the pleural space.
• Causes: trauma (thoracic surgery), mediastinal tumors
• Thoracentesis shows milky fluid, and biochemical
analysis reveals a triglyceride level that exceeds 1.2
mmol/L (110 mg/dL)
• Treatment: insertion of a chest tube plus the
administration of octreotide
• If these measures fail, a pleuroperitoneal shunt should
be placed
• An alternative treatment is ligation of the thoracic duct

9. Hemothorax
• Diagnostic thoracentesis shows bloody pleural fluid,
• Hematocrit :if >1/2 of that in the peripheral blood, the
patient is considered to have a hemothorax
• Causes: trauma, rupture of a blood vessel or tumor
• Treatment: tube thoracostomy ( helps quantify
bleeding)
• If the bleeding emanates from a laceration of the
pleura, apposition of the two pleural surfaces is likely
to stop the bleeding.
• If the pleural hemorrhage exceeds 200 mL/h, perform
thoracoscopy or thoracotomy