Effusion, Pneumothorax & Pleural Disease

• Light's criteria distinguish exudate from transudate; a parapneumonic effusion with pH <7.2 → drain it.
• Tension pneumothorax demands immediate decompression; spontaneous cases get aspiration or a small-bore drain.
• Malignant effusions need therapeutic drainage, with an indwelling pleural catheter now often first-line for recurrence (pleurodesis the alternative).
• Guiding every thoracentesis with ultrasound reduces pneumothorax.
• Selected primary spontaneous pneumothorax can be managed ambulatorily with a one-way valve.

Workup of the Undiagnosed Effusion

• Effusion — pleural
• PE suspected?
• PE-protocol CT
• CT positive?
• Rx for PE
• Continue the workup below
• Effusion features suggesting a benign exudate?
• Lateral decubitus x-ray
• CHF+?
• Observe
• Lateral decubitus x-ray
• Fluid layering >1 cm on decubitus view?
• → Thoracentesis
• Observe
• Five processes account for 90% of pleural effusions

Workup and Care of Pleural Fluid Following Thoracentesis

• Thoracentesis — inspect fluid appearance
• Fluid purulent or bloody?
• If purulent → EMPYEMA → chest tube
• Bloody → pleural fluid hematocrit >50% of peripheral blood → HEMOTHORAX → chest tube
• Other appearance → does fluid analysis meet Light's or Heffner's criteria?
• Exudate per Light's/Heffner's criteria?
• CHF/cirrhosis present?
• Serum–pleural albumin gradient above 1.2?
• TRANSUDATE → observe
• EXUDATE →
• EXUDATE → further workup
• TRANSUDATE → watch

Care of Parapneumonic Effusions

• Parapneumonic effusion identified
• >1 cm thick on lateral decubitus chest x-ray?
• → Thoracentesis
• Fulfills Table 16.7 criteria (complicated parapneumonic effusion)?
• Antibiotics with tube thoracostomy
• Improving?
• Pull the chest tube once infection signs resolve, drainage <150 mL/day, minimal effusion on chest x-ray
• If loculated, consider fibrinolytics, thoracoscopy, or thoracotomy
• Antibiotics ± repeated thoracentesis
• Observe

Care of Recurrent Malignant Effusions

• Malignant effusion → thoracentesis
• Symptoms improved?
• Recurs within <3 weeks?
• Discuss pleurodesis vs PleurX catheter placement with the patient
• Follow clinically
• Another cause of SOB (e.g., pulmonary embolism, pericardial effusion)?
• Treat the underlying cause of dyspnea
• Treat dyspnea symptomatically (narcotics to blunt breathlessness)
• Per BTS Pleural Disease Guideline 2023: an indwelling pleural catheter is often first-line for recurrent malignant effusion; pleurodesis is the alternative

Care of Pneumothorax

• Pneumothorax suspected at initial evaluation
• Unstable patient or suspected tension?
• Give high-flow supplemental oxygen and perform immediate needle thoracostomy
• Tube thoracostomy
• Confirm with chest x-ray
• Stable, with only a small pneumothorax (<2 cm rim on CXR)?
• Observe — ambulatory management with a one-way valve is an option for primary spontaneous cases
• Tube thoracostomy