eMedicine Specialties > Pulmonology > Pleural Disorders

Pleural Effusion: Treatment & Medication

Author: Jeffrey Rubins, MD, Director of Clinical Operations, Professor, Department of Internal Medicine, Division of Pulmonary Medicine, Minneapolis Veterans Affairs Medical Center, University of Minnesota Medical School
Contributor Information and Disclosures

Updated: Jun 5, 2008

Treatment

Medical Care

Transudative effusions are usually managed by treating the underlying medical disorder. However, whether transudates or exudates, drain large pleural effusions if they are causing severe respiratory symptoms, even if the cause is understood and disease-specific treatment is available. The management of exudative effusions depends on the underlying etiology of the effusion. Pneumonia, malignancy, or TB causes most exudative pleural effusions, or effusions are deemed idiopathic. Drain complicated parapneumonic effusions and empyemas to avoid fibrosing pleuritis. Malignant effusions are usually drained to palliate symptoms and may require pleurodesis to prevent recurrence.

Although medications cause only a small proportion of all pleural effusions, they are associated with exudative pleural effusions.  

  • Implicated drugs include medications that cause drug-induced lupus syndrome (eg, procainamide, hydralazine, quinidine), nitrofurantoin, dantrolene, methysergide, procarbazine, and methotrexate.
  • Recognition of these iatrogenic causes of pleural effusion avoids unnecessary additional diagnostic procedures and leads to definitive therapy, which is discontinuation of the medication.

Of the common causes for exudative pleural effusions, parapneumonic effusions have the highest diagnostic priority. Even in the face of antibiotic therapy, infected pleural effusions can rapidly coagulate and organize to form fibrous peels that might require surgical decortication. Therefore, quickly assess pleural fluid characteristics predictive of a complicated course to identify parapneumonic effusions that require urgent tube drainage, which are observed more commonly in indolent anaerobic pneumonias than in typical community-acquired pneumonia.  

  • Indications for urgent drainage of parapneumonic effusions include (1) frankly purulent fluid, (2) pleural fluid pH less than 7.2, (3) loculated effusions, and (4) bacteria on Gram stain or culture.
  • Patients with parapneumonic effusions who do not meet criteria for immediate tube drainage should improve clinically within 1 week with appropriate antibiotic treatment.
  • Radiographically reassess patients with parapneumonic effusions who do not improve or who deteriorate clinically.

Malignant pleural effusions usually signify incurable disease with considerable morbidity and a dismal mean survival of less than 1 year. Drainage of large malignant effusions might relieve dyspnea caused by distortion of the diaphragm and chest wall produced by the effusion. Pleural sclerosis also might be necessary to prevent recurrence of symptomatic effusions. 

TB pleuritis typically is self-limited. However, because 65% of patients with primary TB pleuritis reactivate their disease within 5 years, empiric anti-TB treatment is usually begun pending culture results when sufficient clinical suspicion is present, such as an unexplained exudative or lymphocytic effusion in a patient with a positive PPD finding.

Chylous effusions are usually managed by dietary and surgical modalities discussed below. However, studies suggest that somatostatin analogues also may help in reducing efflux of chyle into the pleural space.

Surgical Care

Surgical intervention is most often required for parapneumonic effusions that cannot be drained adequately by needle or small-bore catheters, and surgery might be required for diagnosis and sclerosis of exudative effusions.

  • Video-assisted thoracoscopy with the patient under local or general anesthesia allows direct visualization and biopsy of the pleura for diagnosis of exudative effusions.
  • Pleural sclerosis by insufflating talc directly onto the pleural surface using video-assisted thoracoscopy is an alternative to using talc slurries.
  • Decortication is usually needed to remove a thick, inelastic pleural peel that restricts ventilation and produces progressive or refractory dyspnea. In patients with chronic, organizing parapneumonic pleural effusions, technically demanding operations might be required to drain loculated pleural fluid and to obliterate the pleural space.
  • Surgically implanted pleuroperitoneal shunts are another treatment option for recurrent symptomatic effusions, most often in the setting of malignancy, but they are also used for management of chylous effusions. However, the shunts are prone to malfunction over time and can require surgical revision.
  • In unusual cases, surgery might be required to close diaphragmatic defects (thereby preventing recurrent accumulation of pleural effusions in patients with ascites) and to ligate the thoracic duct to prevent reaccumulation of chylous effusions.

Consultations

A pulmonologist can be consulted for assistance with high-risk diagnostic thoracentesis, depending on the experience of the clinician. Drainage of complicated effusions usually requires consultation with a pulmonologist, interventional radiologist, or thoracic surgeon, depending on the location of the effusion and the clinical situation.

Diet

Restrictions of fat intake might help in the management of chylous effusions, although management remains controversial. Ongoing drainage of these effusions can rapidly deplete patients of fat and protein stores. Limiting oral fat intake might slow the accumulation of chylous effusions in some patients. Hyperalimentation or total parenteral nutrition can preserve nutritional stores and limit accumulation of the chylous effusion but probably should be restricted to patients in whom definitive therapy for the underlying cause of the chylous effusion is possible.

More on Pleural Effusion

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Differential Diagnoses & Workup: Pleural Effusion
Treatment & Medication: Pleural Effusion
Follow-up: Pleural Effusion
Multimedia: Pleural Effusion
References
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References

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Further Reading

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Keywords

pleural effusion, pleuritis, pleurisy, serous pleurisy, wet pleurisy, congestive heart failure, lung malignancy, lung infections, pulmonary infection, pulmonary emboli, pulmonary embolus, lung emboli, lung embolus, esophageal rupture, pneumothorax, thoracentesis

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Contributor Information and Disclosures

Author

Jeffrey Rubins, MD, Director of Clinical Operations, Professor, Department of Internal Medicine, Division of Pulmonary Medicine, Minneapolis Veterans Affairs Medical Center, University of Minnesota Medical School
Jeffrey Rubins, MD is a member of the following medical societies: American College of Chest Physicians
Disclosure: Nothing to disclose.

Medical Editor

Stephen P Peters, MD, PhD, Professor, Department of Medicine, Wake Forest University
Stephen P Peters, MD, PhD is a member of the following medical societies: American Academy of Allergy Asthma and Immunology, American Association of Immunologists, American College of Chest Physicians, American College of Physicians, American Federation for Medical Research, American Thoracic Society, and Sigma Xi
Disclosure: See below for list of all activities None None

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Harold L Manning, MD, Associate Professor, Departments of Medicine, Anesthesiology and Physiology, Section of Pulmonary and Critical Care Medicine, Dartmouth Medical School
Harold L Manning, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, and American Thoracic Society
Disclosure: Nothing to disclose.

CME Editor

Timothy D Rice, MD, Associate Professor, Departments of Internal Medicine and Pediatrics and Adolescent Medicine, Saint Louis University School of Medicine
Timothy D Rice, MD is a member of the following medical societies: American Academy of Pediatrics and American College of Physicians
Disclosure: Nothing to disclose.

Chief Editor

Zab Mosenifar, MD, Director, Division of Pulmonary and Critical Care Medicine, Director, Women's Guild Pulmonary Disease Institute, Executive Vice Chair, Department of Medicine, Cedars Sinai Medical Center; Professor of Medicine, David Geffen School of Medicine at UCLA
Zab Mosenifar, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, American Federation for Medical Research, and American Thoracic Society
Disclosure: Nothing to disclose.

 
 
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