When a pleural effusion is diagnosed, it is necessary to determine whether it is recurrent or of new onset, or if there is a history of trauma ( Fig 1). If there is a history of trauma a chest tube is indicated. The most important aspect of a new-onset pleural effusion is determination of the cause. This can usually be done by a thorough history, but diagnostic thoracentesis is often needed.
Fig. 1 Management of a new-onset pleural effusion: CHF, congestive heart falure; PRN, as required.
Based on findings from the thoracentesis, the treatment of the effusion may vary. If purulent fluid is aspirated at thoracentesis, a chest tube should be placed immediately to drain the empyema. However, a free-flowing parapneumonic effusion with a pleural fluid pH of 7.3 or above, glucose content above 60 mg/dl, and lactate dehydrogenase content below 1000 IU/l can usually be treated with antibiotics alone. If the parapneumonic effusion has pH below 7.1, glucose content below
40 mg/dl, and lactate dehydrogenase content above 1000 IU/l, early tube thoracostomy is advisable ( Sahns 1993). In the patient with a multiloculated pleural effusion aggressive drainage and decortication is needed, usually via thoracotomy. If the fluid in the pleural space is secondary to congestive heart failure, medical treatment will usually suffice. However, if the patient is symptomatic, repeat thoracentesis may be necessary. If the effusion is determined to be sympathetic, treating the underlying cause usually resolves the effusion. Discomfort in patients with symptomatic new-onset malignant pleural effusions can often be relieved with thoracentesis. If thoracentesis is not successful, chest tube insertion and possible pleurodesis should be performed. If this is unsuccessful, the malignant effusion should be treated as a recurrent symptomatic effusion (Fig. 2).
Fig. 2 Management of recurrent pleural effusion: VATS, video-assisted thorascopic surgery.
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