Pleural effusions are very significant since they are invariably secondary to an important underlying condition. Fluid collections within the pleural space are rarely apparent clinically or by radiography until they amount to about 500 ml. Indications for draining a pleural effusion emergently are usually limited to three settings: an effusion suspected of being infected, a suspected hemorrhagic effusion, and a high suspicion that the fluid in the pleural space is causing ventilatory compromise. Thoracentesis should not be attempted unless more than 1 cm of fluid layers out on lateral decubitus chest radiography or can be safely localized by other means. When considering drainage of pleural fluid, it is important to consider whether the diagnosis made from the fluid is going to change current treatment. This is important because thoracentesis performed on critically ill patients in the intensive care unit has significant risks. The critically ill patient may be too unstable to position properly or may be ventilator dependent. If the pleural fluid cannot be well localized, thoracentesis should not be attempted.
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