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Pleural Effusion: Treatment & Medication
Updated: Nov 13, 2009
- Overview
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Treatment
Prehospital Care
Most commonly, a pleural effusion is an incidental finding in a stable patient. Prehospital interventions are generally limited to patients who are in respiratory distress or are hemodynamically unstable.
- As with any other life-threatening condition, initial management is directed at ensuring adequate oxygenation and ventilation.
- Oxygen should be administered to all unstable patients.
- After airway stabilization, the patient's circulatory status should be assessed and supported as indicated.
Emergency Department Care
On the basis of presentation in the ED, patients with pleural effusions may be stable, requiring hospital admission; stable, not requiring hospital admission; or unstable. Generally, any patient who requires thoracentesis in the ED should be admitted to the hospital.
- Stable patients who do not require admission include those in whom the clinical circumstances clearly explain the effusion and/or prior investigations of the cause were performed, effusions are typical of the disease and are asymptomatic, and diagnostic or therapeutic thoracentesis is not required.
- In such patients, thoracentesis is not indicated emergently and can be deferred. Therapy for the specific cause, if indicated, should be initiated. If the patient does not improve after a few days, diagnostic thoracentesis should be performed. This assumes that the patient is reliable, has a stable social situation, and has a physician with whom to follow-up.
- Stable patients requiring admission include those with no prior history of pleural effusion, patients with parapneumonic effusions who do not appear to be septic, and patients with a prior history of pleural effusion whose condition has deteriorated.
- Although these patients are not in acute respiratory distress, diagnostic thoracentesis is warranted. This need not be performed in the ED if it can be performed promptly by the accepting inpatient service. When the cause of the pleural effusion is obvious, appropriate medical therapy should be initiated in the ED.
- Simple parapneumonic effusions have potential to become complicated effusions or empyemas. Antimicrobial therapy alone is not sufficient for complicated parapneumonic effusions or empyemas. These patients require prompt tube thoracostomy and antibiotics.
- Unstable patients include those in septic shock, respiratory distress, or with hemodynamic compromise due to the effusion. The initial treatment focus should be on stabilizing the airway and circulation. Patients with dyspnea or severe respiratory distress should placed on the gurney in an upright position, as this will increase tidal volume, decrease the work of breathing, and may improve symptoms of congestive heart failure and/or pulmonary edema. Life-threatening traumatic or medical conditions (eg, tension hydropneumothorax, massive effusion with contralateral mediastinal shift, pulmonary embolism, esophageal perforation, traumatic rupture of the thoracic duct, strangulated diaphragmatic hernia) must be ruled out. These patients require immediate diagnostic and therapeutic thoracentesis.
- Tube thoracostomy should be performed on patients with hemothorax, pneumothorax, or empyema.
- The chest tube tip should be directed postero-inferiorly to drain blood or pus and superiorly in the setting of pneumothorax. Other conditions, such as complicated parapneumonic effusion, chylothorax, or malignant pleural effusion, may require chest tube placement for definitive treatment. However, this decision should be made in collaboration with the admitting service.
- For suspected parapneumonic effusions, appropriate antibiotics should be administered in the ED, including coverage for anaerobic organisms.
Consultations
Depending on the patient's clinical condition and local consultation practices, the primary care provider, a pulmonologist, or, if indicated, a medical or surgical intensivist or general surgeon, may be consulted.
Medication
- Because the most common causes of pleural effusion that may treated in the ED are congestive heart failure (CHF), infection, and pulmonary embolism, medical management includes nitrates and diuretics for CHF and pulmonary edema, antibiotics for parapneumonic effusion and empyema, and anticoagulation for pulmonary embolism.
- In patients with parapneumonic effusions, empyemas, and effusions associated with esophageal perforation and intra-abdominal abscesses, antibiotics should be administered early in the ED course. Antibiotic selection should be based on the suspected causative microorganisms and the overall clinical picture. Considerations include the patient's age, comorbidities, duration of the illness, setting (community vs nursing home), and local organism sensitivities. Various effective single agents and combination antimicrobial therapies exist. Coverage should generally include anaerobic organisms. Options may include clindamycin, extended-spectrum penicillins, and imipenem. Depending on the patient's clinical condition, infectious disease consultation may be appropriate.
- Particular attention must be given to potential drug interactions, adverse effects, and preexisting conditions.
Antibiotics
Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting.
Ampicillin and sulbactam (Unasyn)
Drug combination of beta-lactamase inhibitor with ampicillin. Interferes with bacterial cell wall synthesis during active replication, causing bactericidal activity against susceptible organisms. Alternative to amoxicillin when unable to take medication orally.
Covers skin, enteric flora, and anaerobes. Not ideal for nosocomial pathogens.
Adult
1.5 (1 g ampicillin + 0.5 g sulbactam) to 3 g (2 g ampicillin + 1 g sulbactam) IV/IM q 6-8h; not to exceed 4 g/d sulbactam or 8 g/d ampicillin
Pediatric
<3 months: Not established
3 months to 12 years: 100-200 mg ampicillin/kg/d (150-300 mg Unasyn) IV divided q6h
>12-years: Administer as in adults; not to exceed 4 g/d sulbactam or 8 g/d ampicillin
Probenecid and disulfiram elevate ampicillin levels; allopurinol decreases ampicillin effects and has additive effects on ampicillin rash; may decrease effects of oral contraceptives
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in renal failure; evaluate rash and differentiate from hypersensitivity reaction
Imipenem and cilastatin (Primaxin)
For treatment of multiple organism infections in which other agents do not have wide spectrum coverage or are contraindicated due to potential for toxicity.
Adult
Base initial dose on severity of infection, and administer in equally divided doses; dose may range from 250 to 500 mg q6h IV for a maximum of 3-4 g/d
Alternatively, 500-750 mg q12h IM or intra-abdominally
Pediatric
Infants >3 months and children <12 years: 15-25 mg/kg/dose IV q6h
Fully susceptible organisms: Not to exceed 2 g/d
Infections with moderately susceptible organisms: Not to exceed 4 g/d
>12 years: Administer as in adults
Coadministration with cyclosporine may increase CNS side effects of both agents; coadministration with ganciclovir may result in generalized seizures
Documented hypersensitivity; known hypersensitivity to amide local anesthetics; children with CNS infections (increased seizure risk); children <30 kg with renal impairment (lack of data)
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Adjust dose in renal insufficiency (adult adjustments)
CrCl (mL/min) 80-50: 0.5 g q6-8h
CrCl 50-10: 0.5 g q8-12h
Hemodialysis (HD): 0.25-0.5 g after HD, then q12h
Adjust dose in renal insufficiency; avoid use in children <12 y with CNS infections
Caution with history of seizures, hypersensitivity to penicillins, cephalosporins, or other beta lactam antibiotics
Piperacillin and tazobactam sodium (Zosyn)
Antipseudomonal penicillin plus beta-lactamase inhibitor. Inhibits biosynthesis of cell wall mucopeptide and is effective during stage of active multiplication.
Adult
3/0.375 g (piperacillin 3 g and tazobactam 0.375 g) IV q6h
Pediatric
<12 years: Not established
>12 years: Administer as in adults
Tetracyclines may decrease effects of piperacillin; high concentrations of piperacillin may physically inactivate aminoglycosides if administered in same IV line; effects when administered concurrently with aminoglycosides are synergistic; probenecid may increase penicillin levels; high-dose parenteral penicillins may result in increased risk of bleeding
Documented hypersensitivity; severe pneumonia, bacteremia, pericarditis, emphysema, meningitis and purulent or septic arthritis should not be treated with an oral penicillin during the acute stage
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Perform CBCs prior to initiation of therapy and at least weekly during therapy; monitor for liver function abnormalities by measuring AST and ALT levels during therapy; exercise caution in patients diagnosed with hepatic insufficiencies; perform urinalysis, and BUN and creatinine determinations during therapy and adjust dose if values become elevated; monitor blood levels to avoid possible neurotoxic reactions
Clindamycin (Cleocin)
Lincosamide for treatment of serious skin and soft-tissue staphylococcal infections. Also effective against aerobic and anaerobic streptococci (except enterococci). Inhibits bacterial growth, possibly by blocking dissociation of peptidyl tRNA from ribosomes, arresting RNA-dependent protein synthesis.
Adult
450-900 mg IV q8h
Pediatric
Not established
Increases duration of neuromuscular blockade induced by tubocurarine and pancuronium; erythromycin may antagonize effects; antidiarrheals may delay absorption
Documented hypersensitivity; regional enteritis; ulcerative colitis; hepatic impairment; antibiotic-associated colitis
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in severe hepatic dysfunction; no adjustment necessary in renal insufficiency; associated with severe and possibly fatal colitis; can cause pseudomembranous enterocolitis secondary to Clostridium difficile infection
Piperacillin
Inhibits biosynthesis of cell wall mucopeptides and stage of active multiplication; has antipseudomonal activity.
Adult
2-3 g/dose IV/IM q6-12h; not to exceed 2 g with IM injection
Serious infection: 3-4 g/dose q4-6h; not to exceed 24 g/d
Pediatric
200-300 mg/kg/d IV/IM divided q4-6h
Tetracyclines may decrease effects; piperacillin at high concentrations may physically inactivate aminoglycosides; probenecid may increase levels of piperacillin; coadministration with aminoglycosides has synergistic effects
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in renal impairment and in history of seizures
Antianginal agents
These agents are used for their ability to decrease preload.
Nitroglycerin (Nitrostat, Nitro-Bid, Nitro-Dur, NitroQuick)
First-line therapy for patients who are not hypotensive. Provides excellent and reliable preload reduction. Higher doses provide mild afterload reduction. Has a rapid onset and offset (both within minutes), allowing rapid clinical effects and rapid discontinuation of effects in adverse clinical situations.
Adult
Topical: Apply topically 1/2-2" q6h
Transdermal: 0.3-0.6 mg/h qd
Intravenous: 0.2-10 mcg/kg/min IV infusion; titrate by 10 mcg/min increments until desired hemodynamic effect is achieved or until maximally tolerated dose is reached
Spray: Single spray (0.4 mg), which is equivalent to a single 150 mcg sublingual; dose may be repeated q3-5min as hemodynamics permit, up to a maximum of 1.2 mg
Pediatric
Not established
Aspirin may increase nitrate serum concentrations; marked symptomatic orthostatic hypotension may occur with coadministration of calcium channel blockers (dose adjustment of either agent may be necessary)
Documented hypersensitivity; severe anemia, shock, postural hypotension, head trauma, closed-angle glaucoma, or cerebral hemorrhage
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in coronary artery disease, and low systolic blood pressure
Diuretics
Loop diuretics decrease plasma volume and edema by causing diuresis.
Furosemide (Lasix)
Increases excretion of water by interfering with chloride-binding cotransport system, which, in turn, inhibits sodium and chloride reabsorption in ascending loop of Henle and distal renal tubule.
Adult
20-40 mg/d IV; then 80 mg within 2 h prn
Pediatric
1 mg/kg/dose IV slowly q6-12h with close supervision; not to exceed 6 mg/kg/dose; do not administer more frequently than q6h
Metformin decreases concentrations; interferes with hypoglycemic effect of antidiabetic agents and antagonizes muscle relaxing effect of tubocurarine; auditory toxicity appears to be increased with coadministration of aminoglycosides; hearing loss of varying degrees may occur; anticoagulant activity of warfarin may be enhanced when taken concurrently; increased plasma lithium levels and toxicity are possible when taken concurrently
Documented hypersensitivity; hepatic coma; anuria; severe electrolyte (K, Mg, Na) depletion
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Frequently determine serum electrolyte, CO2, glucose, creatinine, uric acid, calcium, and BUN levels during the first few months of therapy and periodically thereafter; observe for blood dyscrasias and liver or kidney damage
Anticoagulant
Prevent recurrent or ongoing thromboembolic disorders by inhibiting thrombogenesis.
Heparin
Augments activity of antithrombin III and prevents conversion of fibrinogen to fibrin. Does not actively lyse but is able to inhibit further thrombogenesis. Prevents reaccumulation of clot after spontaneous fibrinolysis. When unfractionated heparin is used, the aPTT should not be checked until 6 h after the initial heparin bolus because an extremely high or low value during this time should not provoke any action.
Adult
Initial bolus: 120-140 U/kg IV or approximately 10,000 U/70 kg; adjust dose according to desired aPTT
Initial infusion: 20 U/kg/h IV; adjust dose according to desired aPTT
If the aPTT is low (<1.5-times control value), rebolus with 5000 U and increase the drip by 10%
If aPTT is high (>2.5-times control value), decrease drip by 10%
If aPTT is extremely high (>100 s), hold drip for 1 h and decrease drip by 10%
Pediatric
Loading dose: 100 U/kg/h IV
Maintenance infusion: 15-25 U/kg/h IV
Increase dose by 2-4 U/kg/h q6-8h prn using aPTT results
Digoxin, nicotine, tetracycline, and antihistamines may decrease effects; NSAIDs, ASA, dextran, dipyridamole, and hydroxychloroquine may increase heparin toxicity
Documented hypersensitivity; subacute bacterial endocarditis, active bleeding, history of heparin-induced thrombocytopenia
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
In neonates, preservative-free heparin is recommended to avoid possible toxicity (gasping syndrome) by benzyl alcohol; caution in severe hypotension and shock; monitor for bleeding in peptic ulcer disease, menstruation, increased capillary permeability, and when giving IM injections
More on Pleural Effusion |
| Overview: Pleural Effusion |
| Differential Diagnoses & Workup: Pleural Effusion |
 Treatment & Medication: Pleural Effusion |
| Follow-up: Pleural Effusion |
| Multimedia: Pleural Effusion |
| References |
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Further Reading
Keywords
pleural effusion, fluid in chest, fluid in lungs, pleural effusion diagnosis, pleural effusion causes, pleural effusion treatment, pleural fluid, thoracentesis, congestive heart failure, pulmonary embolism, hydrothorax, hemothorax, chylothorax, pyothorax, empyema, pneumothorax
