Pleural Effusion

In a patient with pneumonia or otherwise unexplained sepsis, investigate a concurrent pleural effusion for pleural infection. This branch is time-sensitive because a complicated parapneumonic effusion or empyema may require drainage escalation in addition to antimicrobial treatment. jtcvsjtcvsAATS EXPERT CONSENSUS GUIDELINES: EMPYEMA

When diagnostic thoracentesis is performed, send paired pleural-fluid and serum total protein and LDH to classify the effusion, and obtain pleural-fluid glucose, pH measured on a blood-gas analyzer, cell count with differential, microbiologic studies, and cytology when infection or malignancy is plausible. Routine fluid assessment commonly includes protein, LDH, glucose, cytology, and microbiology. ScienceDirect+1ScienceDirectThe use of non-routine pleural fluid analysis in the diagnosis of pleural effusion - ScienceDirectpublications aapPleural Fluid | Pediatrics In Review

Use thoracic ultrasound to identify septations or fibrin strands and to assess whether a collection is complex or loculated; these findings, together with clinical infection and adverse pleural-fluid chemistry, increase concern for inadequate drainage. In one pleural-infection protocol, poor drainage was defined as chest-tube output of 150 mL or less after 24 hours, with complex effusion defined sonographically by fibrin strands or septations. cdn clinicaltrialscdn clinicaltrialsLABEL CONTROLLED TRIAL OF PLEURAL IRRIGATIO

Classify pleural fluid as exudative when any Light criterion is met: pleural-fluid to serum total-protein ratio greater than 0.5, pleural-fluid to serum LDH ratio greater than 0.6, or pleural-fluid LDH greater than two-thirds the upper reference limit for serum LDH. If none is met, classify as transudative. NatureNatureEffects of Light’s criteria on the diagnostic accuracy of pleural fluid carcinoembryonic antigen concentrations for malignant pleural effusion | Scientific Reports

Do not treat a Light classification as immutable when results are near a threshold. In paired specimens with pleural-fluid protein 25 to 35 g/L, classification across three analytical platforms was discordant in 18%; variation was attributed principally to assay behavior for LDH in pleural fluid. BMJBMJThe impact of between analytical platform variability on the classification of pleural effusions into exudate or transudate using Light's criteria | Journal of Clinical Pathology

Reassess an apparent exudate in a patient receiving diuretics for heart failure, cirrhosis, or renal hydrothorax. Light’s criteria may misclassify 20% to 30% of transudates as exudates in diuretic-treated patients; a serum-pleural albumin gradient is among proposed adjunctive approaches in that situation. WHOWHOEvaluation of Serum and Pleural Levels of Angiopoietin-1 ...

For suspected malignant pleural effusion, establish the diagnosis by malignant cells in pleural fluid or pleural biopsy. If cytology is negative but clinical suspicion persists, proceed to pleural biopsy rather than accepting a paramalignant explanation without excluding pleural malignancy; repeated fluid cytology and pleural biopsy have been useful diagnostic approaches for malignant effusions. Nature+1NatureEffects of Light’s criteria on the diagnostic accuracy of pleural fluid carcinoembryonic antigen concentrations for malignant pleural effusion | Scientific ReportsWHOWHO EMRO - Etiology of pleural effusion among adults in the State of Qatar: a 1-year hospital-based study

For suspected tuberculous pleuritis, pursue mycobacterial culture or nucleic-acid testing of pleural fluid and obtain pleural tissue when needed. Tuberculous pleural effusion can be established by positive Mycobacterium tuberculosis culture or nucleic-acid amplification testing, granulomatous pleural inflammation after exclusion of other granulomatous disorders, or compatible clinical and imaging resolution after empiric antituberculosis therapy when direct confirmation is unavailable. Nature+1NatureDevelopment and validation of a predictive model for tuberculous pleural effusion with high adenosine deaminase | Scientific ReportsWHOWHO EMRO - Etiology of pleural effusion among adults in the State of Qatar: a 1-year hospital-based study

In an exudative lymphocyte-predominant effusion, add flow cytometry when lymphoma is a realistic possibility. In an amylase-rich effusion, evaluate for acute pancreatitis and pancreaticopleural fistula; the latter may produce pleural-fluid amylase greater than 100,000 IU/L. ScienceDirectScienceDirectThe Value of Pleural Fluid Analysis - ScienceDirect

Use pleural-fluid cell burden and biochemical extremes as prioritization tools. Nucleated-cell counts above 10,000/µL occur most often with parapneumonic effusion, acute pancreatitis, subdiaphragmatic hepatic or splenic abscess, and splenic infarction; this pattern should prompt an anatomic search for the corresponding thoracic or subdiaphragmatic process. ScienceDirectScienceDirectThe Value of Pleural Fluid Analysis - ScienceDirect

For pleural infection, insert and monitor a chest drain when infected fluid requires evacuation, then reassess drainage and residual collection. When initial chest-tube drainage has ceased but a residual collection remains, consider combination intrapleural tPA and DNase. BMJBMJBritish Thoracic Society Guideline for pleural disease

Use the randomized-trial-based regimen of tPA 10 mg intrapleurally twice daily plus DNase 5 mg intrapleurally twice daily for 3 days. A lower-dose regimen of tPA 5 mg twice daily plus DNase 5 mg twice daily for 3 days may be used when necessary; reduced tPA doses may be considered when bleeding risk is higher, including therapeutic anticoagulation that cannot be temporarily stopped. Obtain consent before treatment. BMJBMJBritish Thoracic Society Guideline for pleural disease

Do not use tPA alone, DNase alone, or streptokinase for pleural infection. If tPA/DNase and surgery are unsuitable, saline irrigation is an alternative consideration. BMJBMJBritish Thoracic Society Guideline for pleural disease

Escalate early to thoracic surgery when drainage remains inadequate and the effusion is organized or pleural thickening is substantial, because full recovery and lung re-expansion are less likely without surgery in these patterns. Exact surgical timing and selection remain unsettled because randomized trials have not defined an optimal threshold; local multidisciplinary review should explicitly weigh operative fitness, pleural organization, and response to drainage or intrapleural therapy. BMJBMJManaging pleural infections: a nationwide survey of ...

For recurrent symptomatic malignant pleural effusion, select an indwelling pleural catheter when the lung remains trapped after fluid evacuation, pleurodesis has failed, or the patient has poor performance status or comorbidity that makes pleurodesis unsuitable. Outpatient intermittent drainage through a tunneled catheter can relieve dyspnea in these settings. ScienceDirectScienceDirectHome-management of malignant pleural effusion with an indwelling pleural catheter: Ten years experience - ScienceDirect

Avoid talc pleurodesis when the lung does not re-expand after evacuation or when chest-tube drainage remains greater than 300 mL/day, because these conditions predict pleurodesis failure. Talc slurry through a chest tube and talc insufflation at thoracoscopy are effective options when pleurodesis is otherwise feasible. ScienceDirectScienceDirectHome-management of malignant pleural effusion with an indwelling pleural catheter: Ten years experience - ScienceDirect

When catheter removal is a patient priority, recommend daily indwelling-catheter drainage because it produces higher pleurodesis rates than symptom-guided or alternate-day drainage. Daily drainage is not required solely for symptom relief. BMJBMJBritish Thoracic Society Guideline for pleural disease