Guidelines
Guidelines Summary
In 2010, the British Thoracic Society issued an update to its 2003 evidence-based pleural disease management guidelines. [65] The guidelines address both investigation of a unilateral pleural effusion and management of malignant pleural effusion. [21, 65]
In 2013, the American College of Chest Physicians updated its evidence-based clinical practice guidelines for the management of lung cancer, and these guidelines included recommendations for the treatment of malignant pleural effusions. [66]
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Pleural Effusion Investigation Guidelines
The key British Thoracic Society guideline recommendations for the investigation of a unilateral pleural effusion include the following [65] :
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Bedside ultrasound guidance improves success rate, reduces complications (including pneumothorax), significantly increases the likelihood of successful pleural fluid aspiration, and reduces the risk of organ puncture (level B).
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Ultrasound detects pleural fluid septations with greater sensitivity than CT scanning (level C).
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Pleural fluid should always be sent for protein, lactate dehydrogenase (LDH), Gram stain, cytology and microbiological culture (level C).
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Light’s criteria should be used to distinguish between a pleural fluid exudate and transudate. In order to apply Light’s criteria, the total protein and LDH values should be measured in both blood and pleural fluid (level B).
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Pleural fluid cell proportions are helpful in narrowing the differential diagnosis but are not disease-specific (level C).
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Pleural malignancy, cardiac failure, and tuberculosis are common specific causes of lymphocyte-predominant effusions (level C).
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In nonpurulent effusions, when pleural infection is suspected, pleural fluid pH should be measured providing that appropriate collection technique can be observed and a blood gas analyzer is available (level B).
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Inclusion of air or local anaesthetic in samples should be avoided as they may significantly alter the pH results (level B).
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Tube drainage is required in a parapneumonic effusion with a pH of less than7.2 (level B).
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Malignant effusions can be diagnosed based on pleural fluid cytology results in about 60% of cases (level B).
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Immunocytochemistry should be used to differentiate between malignant cell types and can be very important in guiding oncological therapy (level C).
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CT scans should be performed with contrast enhancement and before complete drainage of pleural fluid (level C).
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CT scans can be useful in distinguishing malignant from benign pleural thickening and should be performed in all undiagnosed exudative pleural effusions (level C).
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A CT scan should be requested for complicated pleural infection when initial tube drainage has been unsuccessful and surgery is to be considered (level C).
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When investigating an undiagnosed effusion in which malignancy is suspected and areas of pleural nodularity are shown on contrast-enhanced CT, an image-guided cutting needle is the percutaneous pleural biopsy method of choice (level A).
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Thoracoscopy is the investigation of choice in exudative pleural effusions in which a diagnostic pleural aspiration is inconclusive and malignancy is suspected (level C).
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Routine diagnostic bronchoscopy should not be performed for undiagnosed pleural effusion (level C).
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Bronchoscopy should be considered in the presence of hemoptysis or clinical or radiographic features suggestive of bronchial obstruction (level C).
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Malignant Pleural Effusion Guidelines
The key recommendations from the British Thoracic Society for the management of malignant pleural effusion include the following [21] :
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If the patient is asymptomatic with a known tumor type, observation is recommended (level C).
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Pleural effusion treated with aspiration is not recommended if life expectancy is greater than a month because of high rate of recurrence (level A).
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Other than in patients with a very short life expectancy, small-bore chest tubes followed by pleurodesis are preferred to recurrent aspiration.
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Intercostal drainage should be followed by pleurodesis to prevent recurrence unless the lung is significantly trapped (level A).
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Small-bore (10-14F) intercostal catheters should be the initial choice for effusion drainage and pleurodesis (level A).
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Large pleural effusions should be drained in a controlled fashion to reduce the risk of reexpansion pulmonary edema (level C).
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Once effusion drainage and lung reexpansion have been radiographically confirmed, pleurodesis should not be delayed (level B).
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Lidocaine (3 mg/kg; not to exceed 250 mg) should be administered intrapleurally just prior to sclerosant administration (level B).
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Premedication should be considered to alleviate anxiety and pain associated with pleurodesis (level C).
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Talc is the most effective sclerosant available for pleurodesis (level A).
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Talc pleurodesis is equally effective when administered as a slurry or by insufflation (level B).
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Bleomycin is an alternative sclerosant with a modest efficacy rate (level B).
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Patient rotation is not necessary after intrapleural instillation of sclerosant (level A).
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In patients with good performance status, thoracoscopy is recommended for diagnosis of suspected malignant pleural effusion and for drainage and pleurodesis of a known malignant pleural effusion (level B).
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Thoracoscopic talc poudrage should be considered for the control of recurrent malignant pleural effusion (level B).
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Ambulatory indwelling pleural catheters are effective in controlling recurrent and symptomatic malignant effusions in selected patents (level B).
American College of Chest Physicians guideline recommendations for the treatment of malignant pleural effusions include the following [66] :
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In patients with a symptomatic recurrent malignant pleural effusion with a re-expandable lung, tunneled pleural catheter (TPC) or chemical pleurodesis (grade 1C) is recommended. Serial thoracentesis can be considered in patients with a limited life expectancy.
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In patients with a symptomatic recurrent malignant pleural effusion with lung trapping, TCP for symptomatic relief and improvement in quality of life (grade 1C) is recommended.
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In patients with a suspected malignant pleural effusion in whom the diagnosis of stage IV disease is not confirmed, thoracoscopy instead of a TPC is recommended, owing to its diagnostic as well as therapeutic benefit (grade 1C).
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Graded talc is the pleural sclerosant of choice, owing to its efficacy and safety profile (grade 1C).
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Thoracoscopy with talc poudrage is recommended instead of talc slurry through a bedside chest tube for pleurodesis (if there are no contraindications to thoracoscopy) (grade 1C).
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Media Gallery
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Large right-sided pleural effusion. This effusion was malignant.
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Left-sided pleural effusion.
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Left lateral decubitus film displaying freely layering left-sided pleural effusion.
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Lung entrapment with right hydropneumothorax and pleural drain in place.
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Massive right pleural effusion resulting in mediastinal shift to the left.
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Right-sided pleural effusion after partial drainage showing improved left mediastinal shift.
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Bilateral pleural effusions with loss of bilateral costophrenic sulci (meniscus sign). Anteroposterior, upright chest radiograph. Image courtesy of Allen R. Thomas, MD.
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Isolated, left-sided pleural effusion with visualized loss of left, lateral costophrenic sulcus. Posteroanterior upright chest radiograph. Image courtesy of Allen R. Thomas, MD.
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- Overview
- Presentation
- DDx
- Workup
- Approach Considerations
- Distinguishing Transudates From Exudates
- Pleural Fluid LDH, Glucose, and pH
- Pleural Fluid Cell Count Differential
- Pleural Fluid Culture and Cytology
- Additional Laboratory Tests
- CT Scanning and Ultrasonography
- Chest Radiography
- Diagnostic Thoracentesis
- Idiopathic Exudative Effusions
- Biopsy
- Show All
- Treatment
- Guidelines
- Medication
- Questions & Answers
- Media Gallery
- References
