1. Treatment for Pleural
Effusions
Candice Reyes, MS III

2. Overview
• Pleural fluid is produced at 0.01 mL/kg/body
weight/hour; a normal volume in the pleural
space is 5–15 mL
• Transudative effusions occur in the absence
of pleural disease; 90% of cases result from
congestive heart failure
• Exudative effusions are most commonly due
to pneumonia (parapneumonic effusions)
and malignancy (malignant effusions)

3. Overview
• Analysis of pleural fluid allows for identification of
the pathophysiologic process leading to
accumulation of pleural fluid
– Increased production due to increased hydrostatic or
decreased oncotic pressures (transudates)
– Increased production due to abnormal capillary
permeability (exudates)
– Decreased lymphatic clearance of fluid (exudates)
– Infection in the pleural space (empyema)
– Bleeding into the pleural space (hemothorax)
• A definitive diagnosis is made through cytology or
identification of causative organism in 25% of cases
• In 50–60% of cases, classification of the effusion
leads to a presumptive diagnosis

4. Signs and Symptoms
• Dyspnea, cough, or chest pain with respirations
• Symptoms are more common in patients with
underlying cardiopulmonary disease
• Large effusions are more likely to be
symptomatic
• Bronchial breath sounds and egophony above
the effusion are caused by compressive
atelectasis
• Massive effusions may cause contralateral shift
of the trachea and bulging of intercostal spaces
• A pleural friction rub indicates infarction or
pleuritis

5. Differential
• Atelectasis
• Chronic pleural thickening
• Lobar consolidation
• Subdiaphragmatic process

6. Medications
• Appropriate Antibiotics for pleural
infections

7. Surgery
• Thoracotomy may be required in
hemothorax to control hemorrhage,
remove clot, and treat complications
• Chest tube insertions
– Rarely indicated for transudates
– May be useful in malignant effusions
– Indicated for some complicated
parapneumonic effusions and empyema

8. Therapeutic Procedures
• Pleurodesis involves placing an irritant into the
pleural space to obliterate it by producing
adhesions; side effects are pain and fever;
premedication is necessary
– Doxycycline is 70–75% effective
– Talc is 90% effective
– Rarely indicated for transudates
– Often used for recurrent malignant effusions
• Intrapleural fibrinolysis
– Streptokinase, 250,000 units or urokinase 100,000
units in 100 mL of saline can improve drainage of
empyema or complicated parapneumonic effusions
with loculations

9. Transudative effusions
• Treatment is directed at the underlying
cause
• Therapeutic thoracentesis may offer
only transient relief from dyspnea
• Tube thoracostomy and pleurodesis are
rarely indicated

10. Malignant Effusions
• Systemic therapy may address the underlying
malignancy
• Repeated thoracentesis or chest tube insertion
(tube thoracostomy) may be needed as local
therapy to relieve symptoms related to the effusion
itself
• Pleurodesis can reduce reaccumulation of fluid
• Alternative strategy is indwelling pleural catheter
(eg, Pleurex)
– Facilitates home drainage for suitable ambulatory
patients
– Provides relief while avoiding hospitalization
– Has about 40% rate of spontaneous pleurodesis

11. Parapneumonic effusions
• Simple effusions (free-flowing, sterile) will
resolve with treatment of the pneumonia and
do not require drainage
• Complicated effusions should be drained via
chest tube if fluid analysis reveals pH < 7.2 or
glucose < 60 mg/dL; drainage should be
considered for pH 7.2–7.3 or LDH > 1000
mg/dL
• Empyema should be drained via chest tube

12. Hemothorax
• If small-volume and stable, observation
is adequate
• All other cases should be treated with
immediate drainage via a large-bore
chest tube