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Medication

Medication Summary

Pharmacologic management of pleural effusion depends on the condition’s etiology. For example, medical management includes nitrates and diuretics for congestive heart failure 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 when these conditions are suspected.

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. Antimicrobial 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 pre-existing conditions.

Class Summary

Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting.

Ampicillin and sulbactam (Unasyn)

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This combination of ampicillin and a beta-lactamase inhibitor interferes with bacterial cell wall synthesis during active replication, causing bactericidal activity against susceptible organisms. It is an alternative to amoxicillin when the patient is unable to take medication orally.

Ampicillin/sulbactam covers skin, enteric flora, and anaerobes. It is not ideal for nosocomial pathogens.

Imipenem and cilastatin (Primaxin)

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This drug combination is used for the treatment of multiple organism infections for which other agents do not have wide-spectrum coverage or are contraindicated due to their potential toxicity.

Piperacillin and tazobactam sodium (Zosyn)

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This consists of antipseudomonal penicillin plus a beta-lactamase inhibitor. It inhibits biosynthesis of the cell wall mucopeptide and is effective during the active multiplication stage.

Clindamycin (Cleocin)

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Clindamycin is a lincosamide for the treatment of serious skin and soft-tissue staphylococcal infections. It is also effective against aerobic and anaerobic streptococci (except enterococci). Clindamycin inhibits bacterial growth, possibly by blocking dissociation of peptidyl transfer ribonucleic acid (tRNA) from ribosomes, arresting RNA-dependent protein synthesis.

Piperacillin

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Piperacillin inhibits biosynthesis of cell-wall mucopeptides and the active multiplication stage; it has antipseudomonal activity.

Class Summary

These agents are used for their ability to decrease preload.

Nitroglycerin (Nitrostat, Nitro-Bid, Nitro-Dur, Nitrolingual)

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Nitroglycerin is a first-line therapy for patients who are not hypotensive. It provides excellent and reliable preload reduction. Higher doses provide mild afterload reduction. Nitroglycerin has a rapid onset and offset (both within minutes), allowing rapid clinical effects and rapid discontinuation of effects in adverse clinical situations.

Class Summary

Loop diuretics decrease plasma volume and edema by causing diuresis.

Furosemide (Lasix)

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Furosemide increases the excretion of water by interfering with the chloride-binding cotransport system, which, in turn, inhibits sodium and chloride reabsorption in the ascending loop of Henle and distal renal tubule.

Class Summary

Anticoagulants prevent recurrent or ongoing thromboembolic disorders by inhibiting thrombogenesis.

Heparin

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Heparin augments the activity of antithrombin III and prevents the conversion of fibrinogen to fibrin. It does not actively lyse but is able to inhibit further thrombogenesis. Heparin prevents reaccumulation of a clot after spontaneous fibrinolysis. When unfractionated heparin is used, the activated partial thromboplastin time (aPTT) should not be checked until 6 hours after the initial heparin bolus because an extremely high or low value during this time should not provoke any action.

Questions

Diaz-Guzman E, Dweik RA. Diagnosis and management of pleural effusions: a practical approach. Compr Ther. 2007 Winter. 33(4):237-46. [QxMD MEDLINE Link].
Noppen M. Normal volume and cellular contents of pleural fluid. Curr Opin Pulm Med. 2001 Jul. 7(4):180-2. [QxMD MEDLINE Link].
Sahn SA. The differential diagnosis of pleural effusions. West J Med. 1982 Aug. 137(2):99-108. [QxMD MEDLINE Link]. [Full Text].
Sahn SA. Pleural effusions of extravascular origin. Clin Chest Med. 2006 Jun. 27(2):285-308. [QxMD MEDLINE Link].
Light RW. The undiagnosed pleural effusion. Clin Chest Med. 2006 Jun. 27(2):309-19. [QxMD MEDLINE Link].
Culotta R, Taylor D. Diseases of the pleura. Ali J, Summer WR, Levitzky MG, eds. Pulmonary Pathophysiology. 2nd ed. New York: Lange Medical Books/McGraw-Hill; 2005. 194-212.
Askegard-Giesmann JR, Caniano DA, Kenney BD. Rare but serious complications of central line insertion. Semin Pediatr Surg. 2009 May. 18(2):73-83. [QxMD MEDLINE Link].
Garcia-Vidal C, Carratalà J. Early and late treatment failure in community-acquired pneumonia. Semin Respir Crit Care Med. 2009 Apr. 30(2):154-60. [QxMD MEDLINE Link].
Heffner JE. Diagnosis and management of malignant pleural effusions. Respirology. 2008 Jan. 13(1):5-20. [QxMD MEDLINE Link].
Bouros D, Pneumatikos I, Tzouvelekis A. Pleural involvement in systemic autoimmune disorders. Respiration. 2008. 75(4):361-71. [QxMD MEDLINE Link].
Depascale R, Del Frate G, Gasparotto M, Manfrè V, Gatto M, Iaccarino L, et al. Diagnosis and management of lung involvement in systemic lupus erythematosus and Sjögren's syndrome: a literature review. Ther Adv Musculoskelet Dis. 2021. 13:1759720X211040696. [QxMD MEDLINE Link].
Albakri M, Ahmad M, Mohamed MFH. Rapidly recurring massive pleural effusion as the initial presentation of sarcoidosis: A case report. Medicine (Baltimore). 2021 Feb 12. 100 (6):e24027. [QxMD MEDLINE Link].
Tanaka M, Yamanoi K, Kitamura S, Horikawa N, Chigusa Y, Horie A, et al. A 36 kg Giant Ovarian Fibroma with Meigs Syndrome: A Case Report and Literature Review of Extremely Giant Ovarian Tumor. Case Rep Obstet Gynecol. 2021. 2021:1076855. [QxMD MEDLINE Link].
Vidal A, Wachter C, Kohl Schwartz A, Dhakal C. A rare presentation of isolated right-sided pleural effusion in the context of ovarian hyperstimulation syndrome: A case report. Case Rep Womens Health. 2021 Oct. 32:e00347. [QxMD MEDLINE Link].
Sahn SA. The value of pleural fluid analysis. Am J Med Sci. 2008 Jan. 335(1):7-15. [QxMD MEDLINE Link].
Beers SL, Abramo TJ. Pleural effusions. Pediatr Emerg Care. 2007 May. 23(5):330-4; quiz 335-8. [QxMD MEDLINE Link].
Yinon Y, Kelly E, Ryan G. Fetal pleural effusions. Best Pract Res Clin Obstet Gynaecol. 2008 Feb. 22(1):77-96. [QxMD MEDLINE Link].
Burrows CM, Mathews WC, Colt HG. Predicting survival in patients with recurrent symptomatic malignant pleural effusions: an assessment of the prognostic values of physiologic, morphologic, and quality of life measures of extent of disease. Chest. 2000 Jan. 117(1):73-8. [QxMD MEDLINE Link].
Meriggi F. Malignant Pleural Effusion: Still A Long Way To Go. Rev Recent Clin Trials. 2018 Dec 3. [QxMD MEDLINE Link].
Musani AI. Treatment options for malignant pleural effusion. Curr Opin Pulm Med. 2009 Jul. 15(4):380-7. [QxMD MEDLINE Link].
[Guideline] Roberts ME, Neville E, Berrisford RG, Antunes G, Ali NJ, BTS Pleural Disease Guideline Group. Management of a malignant pleural effusion: British Thoracic Society Pleural Disease Guideline 2010. Thorax. 2010 Aug. 65 Suppl 2:ii32-40. [QxMD MEDLINE Link].
Khaleeq G, Musani AI. Emerging paradigms in the management of malignant pleural effusions. Respir Med. 2008 Jul. 102(7):939-48. [QxMD MEDLINE Link].
Froudarakis ME. Diagnostic work-up of pleural effusions. Respiration. 2008. 75(1):4-13. [QxMD MEDLINE Link].
Wong CL, Holroyd-Leduc J, Straus SE. Does this patient have a pleural effusion?. JAMA. 2009 Jan 21. 301(3):309-17. [QxMD MEDLINE Link].
Kalantri S, Joshi R, Lokhande T, Singh A, Morgan M, Colford JM Jr, et al. Accuracy and reliability of physical signs in the diagnosis of pleural effusion. Respir Med. 2007 Mar. 101(3):431-8. [QxMD MEDLINE Link].
Saraya T, Light RW, Takizawa H, Goto H. Black pleural effusion. Am J Med. 2013 Jul. 126(7):641.e1-6. [QxMD MEDLINE Link].
Light RW, Macgregor MI, Luchsinger PC, Ball WC Jr. Pleural effusions: the diagnostic separation of transudates and exudates. Ann Intern Med. 1972 Oct. 77(4):507-13. [QxMD MEDLINE Link].
Heffner JE, Brown LK, Barbieri CA. Diagnostic value of tests that discriminate between exudative and transudative pleural effusions. Primary Study Investigators. Chest. 1997 Apr. 111(4):970-80. [QxMD MEDLINE Link].
Light RW. Use of pleural fluid N-terminal-pro-brain natriuretic peptide and brain natriuretic peptide in diagnosing pleural effusion due to congestive heart failure. Chest. 2009 Sep. 136(3):656-8. [QxMD MEDLINE Link].
Romero-Candeira S, Fernandez C, Martin C, Sanchez-Paya J, Hernandez L. Influence of diuretics on the concentration of proteins and other components of pleural transudates in patients with heart failure. Am J Med. 2001 Jun 15. 110(9):681-6. [QxMD MEDLINE Link].
Burgess LJ. Biochemical analysis of pleural, peritoneal and pericardial effusions. Clin Chim Acta. 2004 May. 343(1-2):61-84. [QxMD MEDLINE Link].
Kolditz M, Halank M, Schiemanck CS, Schmeisser A, Hoffken G. High diagnostic accuracy of NT-proBNP for cardiac origin of pleural effusions. Eur Respir J. 2006 Jul. 28(1):144-50. [QxMD MEDLINE Link].
Porcel JM, Martinez-Alonso M, Cao G, Bielsa S, Sopena A, Esquerda A. Biomarkers of heart failure in pleural fluid. Chest. 2009 Sep. 136(3):671-7. [QxMD MEDLINE Link].
Wilcox ME, Chong CA, Stanbrook MB, Tricco AC, Wong C, Straus SE. Does this patient have an exudative pleural effusion? The Rational Clinical Examination systematic review. JAMA. 2014 Jun 18. 311(23):2422-31. [QxMD MEDLINE Link].
Menzies SM, Rahman NM, Wrightson JM, et al. Blood culture bottle culture of pleural fluid in pleural infection. Thorax. 2011 Aug. 66(8):658-62. [QxMD MEDLINE Link].
Abouzgheib W, Bartter T, Dagher H, Pratter M, Klump W. A prospective study of the volume of pleural fluid required for accurate diagnosis of malignant pleural effusion. Chest. 2009 Apr. 135(4):999-1001. [QxMD MEDLINE Link].
Swiderek J, Morcos S, Donthireddy V, et al. Prospective study to determine the volume of pleural fluid required to diagnose malignancy. Chest. 2010 Jan. 137(1):68-73. [QxMD MEDLINE Link].
Sakuraba M, Masuda K, Hebisawa A, Sagara Y, Komatsu H. Pleural effusion adenosine deaminase (ADA) level and occult tuberculous pleurisy. Ann Thorac Cardiovasc Surg. 2009 Oct. 15(5):294-6. [QxMD MEDLINE Link].
Gurung P, Goldblatt M, Huggins JT, et al. Pleural Fluid Analysis, Radiographic, Sonographic and Echocardiographic Characteristics of Hepatic Hydrothorax. Chest. 2011 Jan 27. [QxMD MEDLINE Link].
Patel PA, Ernst FR, Gunnarsson CL. Ultrasonography guidance reduces complications and costs associated with thoracentesis procedures. J Clin Ultrasound. 2012 Mar-Apr. 40(3):135-41. [QxMD MEDLINE Link].
Mercaldi CJ, Lanes SF. Ultrasound guidance decreases complications and improves the cost of care among patients undergoing thoracentesis and paracentesis. Chest. 2013 Feb 1. 143(2):532-8. [QxMD MEDLINE Link].
Duncan DR, Morgenthaler TI, Ryu JH, Daniels CE. Reducing iatrogenic risk in thoracentesis: establishing best practice via experiential training in a zero-risk environment. Chest. 2009 May. 135(5):1315-20. [QxMD MEDLINE Link].
Feller-Kopman D. Therapeutic thoracentesis: the role of ultrasound and pleural manometry. Curr Opin Pulm Med. 2007 Jul. 13(4):312-8. [QxMD MEDLINE Link].
Zarogoulidis K, Zarogoulidis P, Darwiche K, et al. Malignant pleural effusion and algorithm management. J Thorac Dis. 2013 Sep. 5 Suppl 4:S413-9. [QxMD MEDLINE Link]. [Full Text].
Metintas M, Ak G, Dundar E, et al. Medical thoracoscopy vs CT scan-guided Abrams pleural needle biopsy for diagnosis of patients with pleural effusions: a randomized, controlled trial. Chest. 2010 Jun. 137(6):1362-8. [QxMD MEDLINE Link].
Goligher EC, Leis JA, Fowler RA, et al. Utility and safety of draining pleural effusions in mechanically ventilated patients: a systematic review and meta-analysis. Crit Care. 2011 Feb 2. 15(1):R46. [QxMD MEDLINE Link].
Shebl E, Paul M. Parapneumonic, Pleural Effusions And Empyema Thoracis. 2018 Jan. [QxMD MEDLINE Link]. [Full Text].
Colice GL, Curtis A, Deslauriers J, et al. Medical and surgical treatment of parapneumonic effusions : an evidence-based guideline. Chest. 2000 Oct. 118(4):1158-71. [QxMD MEDLINE Link].
Efthymiou CA, Masudi T, Thorpe JA, Papagiannopoulos K. Malignant pleural effusion in the presence of trapped lung. Five-year experience of PleurX tunnelled catheters. Interact Cardiovasc Thorac Surg. 2009 Dec. 9(6):961-4. [QxMD MEDLINE Link].
Fysh ET, Waterer GW, Kendall P, Bremner P, Dina S, Geelhoed E, et al. Indwelling Pleural Catheters Reduce Inpatient Days over Pleurodesis for Malignant Pleural Effusion. Chest. 2012 Mar 8. [QxMD MEDLINE Link].
Feller-Kopman D, Parker MJ, Schwartzstein RM. Assessment of pleural pressure in the evaluation of pleural effusions. Chest. 2009 Jan. 135(1):201-9. [QxMD MEDLINE Link].
Cafarotti S, Dall'Armi V, Cusumano G, et al. Small-bore wire-guided chest drains: safety, tolerability, and effectiveness in pneumothorax, malignant effusions, and pleural empyema. J Thorac Cardiovasc Surg. 2011 Mar. 141(3):683-7. [QxMD MEDLINE Link].
Safiyeh M, Huang D. New strategies to manage complicated pleural effusions. Crit Care. 2012 May 22. 16(3):312. [QxMD MEDLINE Link].
West SD, Davies RJ, Lee YC. Pleurodesis for malignant pleural effusions: current controversies and variations in practices. Curr Opin Pulm Med. 2004 Jul. 10(4):305-10. [QxMD MEDLINE Link].
Shaw P, Agarwal R. Pleurodesis for malignant pleural effusions. Cochrane Database Syst Rev. 2004. CD002916. [QxMD MEDLINE Link].
Rodriguez-Panadero F, Romero-Romero B. Management of malignant pleural effusions. Curr Opin Pulm Med. 2011 Jul. 17(4):269-73. [QxMD MEDLINE Link].
Putnam JB Jr, Walsh GL, Swisher SG, et al. Outpatient management of malignant pleural effusion by a chronic indwelling pleural catheter. Ann Thorac Surg. 2000 Feb. 69(2):369-75. [QxMD MEDLINE Link].
Tan C, Sedrakyan A, Browne J, Swift S, Treasure T. The evidence on the effectiveness of management for malignant pleural effusion: a systematic review. Eur J Cardiothorac Surg. 2006 May. 29(5):829-38. [QxMD MEDLINE Link].
Dresler CM, Olak J, Herndon JE 2nd, et al. Phase III intergroup study of talc poudrage vs talc slurry sclerosis for malignant pleural effusion. Chest. 2005 Mar. 127(3):909-15. [QxMD MEDLINE Link].
Van Meter ME, McKee KY, Kohlwes RJ. Efficacy and safety of tunneled pleural catheters in adults with malignant pleural effusions: a systematic review. J Gen Intern Med. 2011 Jan. 26(1):70-6. [QxMD MEDLINE Link]. [Full Text].
Davies HE, Mishra EK, Kahan BC, et al. Effect of an indwelling pleural catheter vs chest tube and talc pleurodesis for relieving dyspnea in patients with malignant pleural effusion: the TIME2 randomized controlled trial. JAMA. 2012 Jun 13. 307(22):2383-9. [QxMD MEDLINE Link].
Puri V, Pyrdeck TL, Crabtree TD, et al. Treatment of malignant pleural effusion: a cost-effectiveness analysis. Ann Thorac Surg. 2012 Aug. 94(2):374-9; discussion 379-80. [QxMD MEDLINE Link]. [Full Text].
Reddy C, Ernst A, Lamb C, Feller-Kopman D. Rapid pleurodesis for malignant pleural effusions: a pilot study. Chest. 2011 Jun. 139(6):1419-23. [QxMD MEDLINE Link].
Freeman RK, Ascioti AJ, Mahidhara RS. A propensity-matched comparison of pleurodesis or tunneled pleural catheter in patients undergoing diagnostic thoracoscopy for malignancy. Ann Thorac Surg. 2013 Jul. 96(1):259-63: discussion 263-4. [QxMD MEDLINE Link].
[Guideline] Hooper C, Lee YC, Maskell N, BTS Pleural Guideline Group. Investigation of a unilateral pleural effusion in adults: British Thoracic Society Pleural Disease Guideline 2010. Thorax. 2010 Aug. 65 Suppl 2:ii4-17. [QxMD MEDLINE Link].
[Guideline] Simoff MJ, Lally B, Slade MG, Goldberg WG, Lee P, Michaud GC, et al. Symptom management in patients with lung cancer: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2013 May. 143 (5 Suppl):e455S-97S. [QxMD MEDLINE Link].

Media Gallery

Large right-sided pleural effusion. This effusion was malignant.
Left-sided pleural effusion.
Left lateral decubitus film displaying freely layering left-sided pleural effusion.
Lung entrapment with right hydropneumothorax and pleural drain in place.
Massive right pleural effusion resulting in mediastinal shift to the left.
Right-sided pleural effusion after partial drainage showing improved left mediastinal shift.
Bilateral pleural effusions with loss of bilateral costophrenic sulci (meniscus sign). Anteroposterior, upright chest radiograph. Image courtesy of Allen R. Thomas, MD.
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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Author

Kamran Boka, MD, MS Attending Physician in Pulmonary and Critical Care Medicine, StatCare

Kamran Boka, MD, MS is a member of the following medical societies: American College of Critical Care Medicine, Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Chief Editor

Guy W Soo Hoo, MD, MPH Professor of Clinical Medicine, University of California, Los Angeles, David Geffen School of Medicine; Director, Medical Intensive Care Unit, Chief, Pulmonary, Critical Care and Sleep Section, West Los Angeles VA Healthcare Center, Veteran Affairs Greater Los Angeles Healthcare System

Guy W Soo Hoo, MD, MPH is a member of the following medical societies: American Association for Respiratory Care, American College of Chest Physicians, American College of Physicians, American Thoracic Society, California Thoracic Society, Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Additional Contributors

Jeffrey Rubins, MD Professor of Medicine, University of Minnesota Medical School; Director, Palliative Medicine, Hennepin County Medical Center

Jeffrey Rubins, MD is a member of the following medical societies: American Academy of Hospice and Palliative Medicine, American College of Chest Physicians

Disclosure: Nothing to disclose.

Acknowledgements

Harold L Manning, MD 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.

Stephen P Peters, MD, PhD, FACP, FAAAAI, FCCP, FCPP Professor of Genomics and Personalized Medicine Research, Internal Medicine, and Pediatrics, Associate Director, Center for Genomics and Personalized Medicine Research, Director of Research, Section on Pulmonary, Critical Care, Allergy and Immunologic Diseases, Wake Forest University School of Medicine

Stephen P Peters, MD, PhD, FACP, FAAAAI, FCCP, FCPP 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

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Pleural Effusion Medication

Medication Summary

Antibiotics, Other

Class Summary

Ampicillin and sulbactam (Unasyn)

Ampicillin and sulbactam (Unasyn)

Imipenem and cilastatin (Primaxin)

Imipenem and cilastatin (Primaxin)

Piperacillin and tazobactam sodium (Zosyn)

Piperacillin and tazobactam sodium (Zosyn)

Clindamycin (Cleocin)

Clindamycin (Cleocin)

Piperacillin

Piperacillin

Vasodilators

Class Summary

Nitroglycerin (Nitrostat, Nitro-Bid, Nitro-Dur, Nitrolingual)

Nitroglycerin (Nitrostat, Nitro-Bid, Nitro-Dur, Nitrolingual)

Diuretics

Class Summary

Furosemide (Lasix)

Furosemide (Lasix)

Anticoagulants, Hematologic

Class Summary

Heparin

Heparin

Pleural Effusion Medication

Medication Summary

Antibiotics, Other

Class Summary

Ampicillin and sulbactam (Unasyn)

Imipenem and cilastatin (Primaxin)

Piperacillin and tazobactam sodium (Zosyn)

Clindamycin (Cleocin)

Piperacillin

Vasodilators

Class Summary

Nitroglycerin (Nitrostat, Nitro-Bid, Nitro-Dur, Nitrolingual)

Diuretics

Class Summary

Furosemide (Lasix)

Anticoagulants, Hematologic

Class Summary

Heparin

References

Tables

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