eMedicine Specialties > Emergency Medicine > Pulmonary

Pleural Effusion: Treatment & Medication

Author: Fredrick Melik Abrahamian, DO, FACEP, Associate Professor of Medicine, University of California at Los Angeles School of Medicine; Director of Education for Emergency Medicine Residency Program, Consulting Staff, Department of Emergency Medicine, Olive View-University of California at Los Angeles Medical Center
Contributor Information and Disclosures

Updated: Jan 14, 2008

Treatment

Prehospital Care

Most commonly, a pleural effusion is an incidental finding in a stable patient. Emergency medical services are required more often by patients with a toxic condition, respiratory distress, or cardiovascular instability.

• As with any other life-threatening condition, direct initial management toward stabilization of the airway to ensure adequate oxygenation and ventilation. Administer supplemental oxygen to all unstable patients.
• After airway stabilization, address and support the patient's circulatory status.
• For any unstable patient, time is a critical factor. Patients in unstable condition require prompt evaluation by an emergency physician because ultimate treatments required for stabilization are not available in the prehospital setting.
• Upon arrival in the ED, disclosure of physical findings (eg, deviation of the trachea, distended neck veins, absence of breath sounds, muffled heart sounds, peripheral edema, ascites, subcutaneous emphysema) is important.

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 is admitted to the hospital. When a patient is stable hemodynamically, time may be available to investigate the patient's past medical history. Previous hospitalization and outpatient records and radiographs can be invaluable.

• 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 or asymptomatic, and diagnostic or therapeutic thoracentesis is not required. Such patients include the following: patients with effusions due to viral pleurisy, with a free pleural fluid level thinner than 10 mm on a lateral decubitus radiograph; asymptomatic patients with pleural effusions associated with systemic diseases such as congestive heart failure, renal disease, and hepatic cirrhosis; patients with small (free pleural fluid level <10 mm on the lateral decubitus radiograph) pleural effusions after recent (<3 d) thoracic or abdominal surgery; and patients with asymptomatic effusions immediately postpartum.
  • In such patients, thoracentesis is not indicated and can be deferred. Therapy for the specific cause, if indicated, should be initiated, and no improvement occurs after a few days, diagnostic thoracentesis should be performed.
  • Consultation with the patient's primary physician or pulmonologist may be appropriate. Consider the patient's financial circumstances and ability to follow up on an outpatient basis. If early follow-up seems unlikely at an outpatient clinic or with a specialist, clearly instruct the patient to return to the ED for reevaluation in 2-3 days or sooner, if necessary. Document that the patient understands the importance of compliance with the treatment regimen and follow-up.
• Stable patients requiring admission include most patients with pleural effusion thicker than 10 mm on the lateral decubitus radiograph. Such patients include the following: patients with no prior history of pleural effusions, patients with parapneumonic effusions who do not appear to have a toxic condition, and patients with a prior history of pleural effusions who have a change in their usual symptoms or effusion. Often, these patients do not require a monitored bed and can be admitted to a regular floor.
  • Although these patients are not in acute respiratory distress, diagnostic thoracentesis is imperative. Thoracentesis need not be performed in the ED if the accepting physician will perform it soon. When the cause of pleural effusion is obvious, initiate appropriate medical therapy (diuretics, antibiotics) in the ED.
  • Simple parapneumonic effusions have a great potential to become complicated effusions or empyemas. Antimicrobial therapy alone is not sufficient for complicated parapneumonic effusions or empyemas; they require tube thoracostomy and antibiotics. The distinction of simple and complicated parapneumonic effusion can be made only after the pleural fluid characteristics are assessed. For parapneumonic effusions, if possible, antibiotics should be instituted after diagnostic thoracentesis during which pleural fluid is analyzed with appropriate microbiologic studies. However, if a delay in thoracentesis is anticipated, antibiotic treatment takes precedence and is preferred to be initiated in the ED.
• Unstable patients include those in severe sepsis/septic shock, respiratory distress, or cardiovascular compromise due to the effusion. The initial treatment focus should be stabilizing the airway and circulation. Patients with dyspnea or severe respiratory distress should sit, because the seated position increases tidal volume, decreases 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.
  • Chest tube placement is an appropriate initial diagnostic and therapeutic modality when a hemothoracic mechanism exists. Hemothorax, pneumothorax, and drainage of thick pus at initial diagnostic thoracentesis are the only clear indications for chest tube placement in the ED.
  • Direct the chest tube tip posteroinferiorly with draining blood or pus and superiorly with draining air. Other conditions, such as complicated parapneumonic effusion, chylothorax, or malignant pleural effusion, may require chest tube placement for definitive treatment; however, a pulmonologist should make this decision after reviewing radiographic and diagnostic findings.
  • The criteria to place a chest tube when pleural fluid has a pH less than 7.00 and/or when the glucose level is less than 40 m/dL applies only to parapneumonic effusions. Pleural fluid in conditions such as rheumatoid effusions, malignant effusions, and TB may have similar characteristics, but these conditions do not require tube thoracostomy. The decision to place a chest tube in a patient with positive Gram staining results, a pleural fluid pH less than 7.0, or a glucose level less than 40 m/dL should be made after consulting a pulmonologist.
  • Infected pleural fluid with bronchopleural fistula is considered a medical emergency. Suspect bronchopleural fistula when a patient with pleural effusion produces a larger amount of sputum (especially when lying in one position) than that expected from associated pulmonary disease.
  • The presence of an air-fluid level in the pleural space on upright radiographs suggests bronchopleural fistula. Patients with this require immediate diagnostic thoracentesis, antibiotics, and pulmonary consultation.
  • For suspected parapneumonic effusions, initiate antibiotics in the ED. The choice of antibiotics should be based on clinical factors and consistent with guidelines for the treatment of pneumonia.
  • In any patient with chest trauma (penetrating or nonpenetrating), hemothorax should be suspected. Maintain a high index of suspicion for concomitant pneumothorax with blunt or penetrating traumatic hemothorax. Traumatic hemothorax is an indication for the insertion of a large-bore (36-40F) chest tube.
  • If initial radiographic findings are negative for pneumothorax or hemothorax, a follow-up chest radiograph should be obtained 3-6 hours after the accident. These patients require admission for monitoring. Early consultation with the ICU or surgical teams is an essential part of treatment.

• All patients with pleural effusions require thorough evaluation in the ED.
  • Ascites should be excluded in patients with pleural effusion. A history of chronic alcohol or drug use, hepatitis, or pelvic neoplasm should heighten suspicion for ascites. In women with undiagnosed pleural effusion and ascites, a pelvic examination is required to exclude large ovarian or uterine masses (Meigs syndrome). When ascites is present, paracentesis with thoracentesis is important for diagnosis (similarity of pleural and peritoneal fluid characteristics indicates a common diagnosis of hydrothorax, which almost always is an extension of peritoneal fluid) and treatment. (Management of pleural effusions associated with ascites is directed primarily toward control of ascites.)
  • Maintain a high index of suspicion for concomitant infection. Certain conditions, such as rheumatoid arthritis, congestive heart failure, hepatic cirrhosis, esophageal rupture, and immunocompromise, have a predilection for infection. When patients with these conditions require thoracentesis, Gram staining and culturing of the pleural fluid is important. Gram staining always should be performed by using the sediment of the centrifuged pleural fluid; this method increases sensitivity. With Gram staining, positive findings can provide useful information for initial antibiotic selection in the ED. Negative results do not rule out infection; the ultimate diagnosis depends on culture findings.

Consultations

Consult the general primary care provider, a pulmonologist, or, if indicated, a medical or surgical intensivist or general surgeon, depending on the patient's clinical condition and local consultation practices.

Medication

Antibiotics (eg, for parapneumonic effusions) and diuretics (eg, for effusions associated with CHF) are commonly used in the initial management of pleural effusions in the ED. The selection of drugs in each class depends on the cause of the effusion and its clinical presentation. Particular attention must be given to potential drug interactions, adverse effects, and preexisting conditions.

Antibiotics

Expeditiously initiate empiric systemic antibiotic coverage for parapneumonic effusions, empyemas, and effusions associated with esophageal perforation and intra-abdominal abscesses in the ED. Base initial antibiotic selection on the microorganisms presumed present and the overall clinical picture. Considerations include the patient's age, comorbid conditions, duration of the illness (acute vs chronic), setting (community vs nursing home), and prevalence of resistance.

Generally for parapneumonic effusions, initial antibiotics used in the ED should be based on clinical factors and consistent with guidelines for treatment of pneumonia. Various effective single and combination antimicrobial therapies exist. A combination therapy may include a third-generation cephalosporin, such as ceftriaxone and a macrolide, or, alternatively, monotherapy with a new-generation antipneumococcal fluoroquinolone. If the patient is immunosuppressed or has structural lung disease (eg, bronchiectasis), a cephalosporin with enhanced antipseudomonal activity, such as ceftazidime (Fortaz), is recommended.

For a patient with a community-acquired infection who presents in severe sepsis/septic shock, combination antimicrobial therapy may include vancomycin, a third-generation cephalosporin such as ceftriaxone, and a new-generation antipneumococcal fluoroquinolone (eg, moxifloxacin or levofloxacin). Anaerobic coverage (eg, clindamycin) should also be added for patients with subacute/chronic infections or for those with necrotizing infection, abscess, or empyema.

Ceftriaxone (Rocephin)

Third-generation cephalosporin with broad-spectrum, gram-negative activity; lower efficacy against gram-positive organisms; higher efficacy against resistant organisms. Arrests bacterial growth by binding to one or more penicillin-binding proteins.

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.

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.

Spironolactone (Aldactone)

For management of edema resulting from excessive aldosterone excretion. Competes with aldosterone for receptor sites in distal renal tubules, increasing water excretion while retaining potassium and hydrogen ions.

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