Pleural Effusion

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Pleural Effusion

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Pleural effusion
-DDx includes: Parapneumonic effusion vs malignant effusion vs hepatic hydrothorax vs CHF vs empyema vs cirrhosis vs nephrotic syndrome.
-Thoracentesis ordered, limit to 1500ml volume aspirate to decrease risk of re-expansion.
-Ordered fluid pH, fluid protein, albumin and LDH, fluid glucose, fluid triglyceride, fluid cell count differential, fluid gram stain and culture, fluid cytology, amylase, and adenosine deaminase.
-Order CBC, BMP, BNP.
-Will initiate broad spectrum antibiotics with anaerobic coverage.
-Will follow if transudate vs exudate using light’s criteria.
-If exudate, but in setting of diuretic use, likely discordant exudate.
-May need thoracoscopy and/or bronch, if cytology negative exudate.
-If complex pleural effusion/empyema in the setting of pneumonia, will consult for chest tube insertion for drainage. AVOID chest tube if suspicious for hepatic hydrothorax. Consult hepatologist/ transplant team if cirrhotic.
-Thoracoscopic decortication or debridement + intrapleural fibrinolytics and DNAse may be used to improve drainage. Consult pulmonologist or CT surgery for co-management.
-Monitor and exclude for esophageal rupture and rheumatoid arthritis, if low pH.
-Will order a CT scan, if risk of malignancy remains elevated.
-Will monitor and exclude for PE/renal vein thrombosis, if nephrotic.
-Will consider pulmonary LAM, if chylothorax in premenopausal woman.
-Pleurodesis w/wo talc per surgery, if requiring frequent drainage. 
-Chest physical therapy and serial CXR as needed.
-Pain control and supplemental O2, if needed.
-Monitor for sepsis and trapped lung.
-Prognosis guarded if malignant effusion, < 24months.