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Management of pleural effusion and haemothorax 

Management of pleural effusion and haemothorax
Chapter:
Management of pleural effusion and haemothorax
Author(s):

Davide Chiumello

and Silvia Coppola

DOI:
10.1093/med/9780199600830.003.0125
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date: 01 December 2020

Key points

  • The management of pleural effusion depends on type, stage, and underlying diseases.

  • Primary treatment of non-malignant pleural effusions is directed to the underlying cause of pleural effusion.

  • Parapneumonic effusions should be sampled by thoracentesis. A pleural fluid pH <7.2 is the single most powerful indicator to predict a need for chest tube drainage.

  • The rate of re-accumulation of pleural effusion, the patient’s prognosis and the severity of symptoms should guide the management of malignant pleural effusions.

  • Thoracotomy is the procedure of choice for chest surgical exploration when massive haemothorax or persistent bleeding is present.

Introduction

The goal in the management of pleural effusions is to provide symptomatic relief removing fluid from pleural space and to treat underlying diseases. The management options depend on the type of pleural effusion, stage in the evolution, and underlying disease.

Diagnostic approach

Chest radiography remains the most important technique for the initial diagnosis of pleural effusion.

If an effusion is suspected, ultrasonography (US) should be performed since it is more reliable for detecting small pleural effusions in critical care setting. The major advantage of US over radiography is its ability to differentiate between free and loculated pleural effusion, then it is useful to guide thoracentesis. Computed tomography (CT) can be used to evaluate complex situations, where the anatomy cannot be fully assessed by radiography or US. Although history, physical examination, and radiographic studies may provide important clues to the cause of a pleural effusion diagnostic thoracentesis should be always performed [1,2,3].

The main step is to determine whether the fluid is a transudate or an exudate, using Light’s Criteria [1]‌. If it is exudative, more diagnostic tests are required to determine the cause of the local disease—differential cell counts, smears and cultures for organisms, measurement of glucose and amylase levels, cytological analysis, and testing for a pleural fluid marker of tuberculosis. Generally, a transudate is considered as uncomplicated effusion that can be managed by conservative treatment or antibiotics alone. An exudative effusion or a large amount of loculated effusion, that is considered complicated effusion, should be managed by drainage. Complicated effusions include empyema, malignant effusion and haemothorax [2,4].

Management

Refractory non-malignant effusions

These effusions can be transudative (congestive heart failure, cirrhosis, nephrosis) or exudative (pancreatitis, connective tissue disease, endocrine dysfunction), uncomplicated or complicated.

Patients who have symptoms due to a pleural effusion that is refractory to primary treatment are candidates for additional therapies. Dyspnoea is the most common symptom that necessitates additional therapy.

Before proceeding with more invasive therapy, trapped lung should be excluded. Trapped lung refers to a fibrous pleural peel that encases the visceral pleura, while the visceral and parietal pleura are widely separated.

Bilateral symmetrical pleural effusions in a patient with congestive heart failure without fever or chest pain should be treated with diuretics before thoracentesis. However, if pleural effusion persists for more than 3 days, thoracentesis should be performed.

Repeated therapeutic thoracentesis are appropriate when the effusion re-accumulates slowly enough that repeated procedures do not become burdensome to the patient.

Additional management options for patients with non-malignant pleural effusions include in-dwelling pleural catheter for intermittent external drainage, pleuroperitoneal shunts for internal drainage, or surgical pleurectomy. These techniques have been applied in patients with non-malignant pleural effusions [3,4].

Parapneumonic effusions

Patients with severe pneumonia often develop parapneumonic effusions, with sometimes progression to empyema.

Parapneumonic pleural effusions are divided in three types:

  • An uncomplicated effusion occurs when lung interstitial fluid increases and moves across the adjacent visceral pleural membrane.

  • Complicated effusions occur when there is persistent bacterial invasion of the pleural space.

  • An empyema is defined as the presence of pus in the pleural space [3]‌.

A positive culture is not required for diagnosis since anaerobic organisms are difficult to culture or sampling is often performed after a patient has received antibiotics. Blood cultures should be performed in all patients with suspected pleural infection, although they are positive in only 14% of these patients. The usual presentation includes fever, cough, dyspnoea, chest pain, purulent sputum, leukocytosis, and new alveolar infiltrate on chest radiograph.

Radiographic and ultrasound imaging play a key role in the evaluation of parapneumonic effusions and empyema.

Optimal evaluation of empyema or loculated effusions requires chest CT scan with intravenous contrast because the pleural microbubbles may suggest that the fluid collection will be more resistant to chest tube drainage. It is clinically impossible to differentiate the presence of a complicated parapneumonic effusion requiring chest tube drainage from a simple effusion that may be resolved with antibiotics alone [5]‌.

Pleural fluid sampling remains the most reliable diagnostic test to guide management and is recommended in all patients with a pleural effusion >10 mm depth associated to pneumonic illness or recent chest trauma or surgery. Small effusions (thickness <10 mm) usually resolve with antibiotics alone.

Pleural fluid pH should be assessed in all non-purulent effusions when pleural infection is suspected. A pleural fluid pH <7.2 is demonstrated as the single most powerful predictor for the need of chest tube drainage. Where pleural fluid pH measurement is not available, glucose and lactic dehydrogenases (LDH) should be measured: a pleural fluid glucose level <50 mg/dL may be used as an alternative marker to indicate a need for chest drain insertion [6,7].

According to the British Thoracic society, the indications for pleural fluid drainage in pleural infection are:

  • A frankly purulent or turbid/cloudy pleural fluid or a loculated pleural collection

  • The presence of organisms identified by Gram stain

  • Pleural fluid pH <7.2 in patients with suspected pleural infection

  • Poor clinical progress during treatment with antibiotics alone [6]‌.

When the effusion is free-flowing, as demonstrated by lateral decubitus views or US and thoracentesis shows a non-purulent exudate with a glucose level greater than 60 mg/dL, LDH less than 1000 IU/L, and pH >7.20, the patient has a high likelihood of pleural fluid resolution with antibiotics alone over 7–14 days (uncomplicated effusion) [7,8].

Table 125.1 shows the risk of poor outcome in patients with parapneumonic effusions based on the volume of pleural effusion, pleural fluid bacteriology and pleural fluid pH, developed by an expert panel. The panel’s consensus opinion suggests drainage for patients with moderate or high risk of poor outcome [7]‌.

Table 125.1 Parapneumonic effusion characteristics and outcome

Volume of effusion

Bacteriology

Effusion pH

Outcome

From minimal to moderate free flowing effusion more than 10 mm, but <½ hemithorax

Unknown or negative culture and Gram stain results

Unknown or ≥7.20

Very low or low risk of poor outcome

Large, free flowing (≥½ hemithorax), loculated effusion

Positive culture or Gram stain or pus

<7.20

Moderate–high risk of poor outcome

For the moderate/high risk of poor outcome is sufficient that just only one of the three characteristics is present [7]‌.

Data from Colice GL et al., (2000) ‘Medical and Surgical Treatment of Parapneumonic Effusions An Evidence-Based Guideline’, Chest, 118, pp. 1158–71.

The choice of antibiotic should be based on the bacteriology. Virtually all antibiotics adequately penetrate the pleural space except aminoglycosides that may be inactivated at low pleural fluid pH. Empiric therapy should cover anaerobic organisms and include clindamycin, beta-lactam plus beta-lactamase inhibitors, and carbapenems. It is recommended that antibiotic therapy be continued until there is radiographic resolution of fluid, generally for 2–4 weeks following defervescence.

In addition to appropriate antibiotic therapy, some complicated parapneumonic effusions and all empyemas require drainage for resolution. Failure to improve after tube thoracostomy drainage may indicate that antibiotic coverage is not adequate or that a loculated area of empyema has developed.

Early thoracic surgical consultation is appropriate, as many patients require thoracoscopic, or open debridement and drainage. Proper management includes the sterilization of the empyema with appropriate systemic antibiotics (at least 4–6 weeks), the complete pleural fluid drainage, and the obliteration of the empyema cavity by adequate lung expansion.

Options for surgical solutions include open decortication and open thoracostomy. For patients who do not have good drainage of empyema from a well-placed chest tube, an intrapleural administration of fibrinolytic therapy is suggested. Continued failure of adequate pleural drainage should prompt thoracoscopy or thoracotomy to lyse adhesions, to completely drain the pleural space and optimize chest tube placement. The choice between thoracoscopic debridement and decortication depends on several factors; those favouring decortication include more adhesions, greater visceral pleural thickness and larger empyema cavity size [4,7,8].

Malignant effusions

Malignancy is the most common cause of exudative pleural effusions in patients aged >60 years [4]‌.

Malignant pleural effusion implies disseminated disease and median survival depends upon the site and stage of the primary tumour. The decision to treat a malignant effusion depends upon the presence of symptoms and the underlying tumour type. Asymptomatic malignant pleural effusions (up to 25%) do not need to be treated as long as they attain a steady state and remain asymptomatic. Some tumour types may respond to chemotherapy with resolution of the effusion [9]‌.

Symptomatic patients should initially undergo therapeutic thoracentesis to drain the fluid. The rate of re-accumulation of pleural effusion, patient’s prognosis, and the severity of patient’s symptoms should guide the therapy. Patients whose malignant pleural effusion re-accumulates slowly (longer than 1 month) may be managed with therapeutic thoracentesis. Repeat pleural aspiration is recommended for the palliation of breathlessness in patients with a life expectancy <3 months [9,10].

A more aggressive intervention may be required if malignant pleural effusions recur rapidly (less than 1 month). Options include in-dwelling pleural catheter drainage, pleurodesis, pleurectomy, and pleuroperitoneal shunt. Placement of an in-dwelling pleural catheter for drainage is indicated when there is an irremediable lung entrapment or an endobronchial obstruction by tumour. This option is ideal when length of hospitalization has to be kept to a minimum because of the short duration of survival. Pleurodesis is a reasonable alternative for patients with an expected survival of few months. This therapy can be carried out in a single definitive procedure without the potential inconvenience of a long-term drainage catheter. In selected patients with trapped lung and large effusions refractory to chemical pleurodesis, pleuroperitoneal shunting is an acceptable palliative option [9,11].

A summary of the main different approaches to the management of malignant pleural effusions is shown in Table 125.2.

Table 125.2 Different options of management of malignant pleural effusions

Options

Clinical condition

Observation

Asymptomatic effusions (most will progress and require therapy)

Therapeutic thoracentesis

Relief of dyspnoea (most effusions can recur unless underlying tumour responds to chemo- or radiotherapy)

Chest catheter drainage

Most effusions will recur after catheter removal

Chest catheter drainage with chemical pleurodesis

Uncontrolled and recurrent symptomatic malignant effusions. 90% of patients seem to respond to talc pleurodesis

Thoracoscopy with talc insufflation

Uncontrolled and recurrent symptomatic malignant effusions. In more than 90% of patients effusion seem to be controlled

Pleurectomy

In patients who have failed chemical pleurodesis, but with reasonably long expected survival

Long-term in-dwelling pleural catheter

Symptomatic relief in patients who cannot tolerate a general anaesthesia or are not candidates for video thoracoscopy

Pleuroperitoneal shunt

When other options have failed

Haemothorax

Haemothorax needs to be differentiated from a haemorrhagic pleural effusion, as the latter can result from only few drops of blood in serous pleural fluid.

The definition of haemothorax is a pleural fluid to blood haematocrit ratio greater than 50%. Routine radiology cannot distinguish blood from other pleural effusions. CT scan helps to identify the precise location of blood. Massive haemothorax is diagnosed when 2 L drain from the chest. Blood removed from a probable haemothorax should be examined to establish its haematocrit and to exclude infection [12].

When a haemothorax is suspected, the essential management, together with appropriate resuscitation, is intercostal drainage. The only exception is the presence of clinical and radiological signs suggestive of aortic dissection or transection, because intercostal drainage can lead to rapid exsanguination.

Intercostal drainage in haemothorax achieves two objectives—to drain the pleural space allowing expansion of the lung and to allow assessment of rates of blood loss. The latter, along with the general clinical state of patient dictates further management.

Chest drains should be large enough to permit some clots to be evacuated (28–30G minimum) and should be placed at the base of the hemithorax. The ideal insertion point is the 6th intercostal space in the mid-axillary line. Lower spaces should be avoided; contraction of the hemithorax is frequently present because of pain and/or pulmonary collapse, and selection of too low space may cause iatrogenic intra-abdominal injury.

Chest tube drainage allows the monitoring of bleeding rate, may potentially tamponade bleeding, and evacuate the pleural space, thus decreasing the risk of developing empyema or a subsequent fibrothorax.

If pleural effusion persists despite tube thoracostomy, a diagnosis of clotted or retained haemothorax is made. The ideal management of clotted haemothorax is a matter of controversy. The placement of additional chest tubes can be ineffective because of the presence of clotted blood and loculations. Although thoracotomy is an effective procedure in the management of clotted haemothorax, video-assisted thoracoscopic surgery (VATS) is currently preferred to open thoracotomy [13].

One easily available and effective alternative to VATS is the use of intrapleural fibrinolysis. Recently, intrapleural streptokinase, has been shown to decrease pleural thickening and adhesion in experimental clotted haemothorax. However, more human trials are needed to confirm this finding [14].

Thoracotomy is the procedure of choice for surgical exploration of the chest when massive haemothorax or persistent bleeding is present.

Generally, indications for emergency or urgent thoracotomy in haemothorax are:

  • Haemodynamic instability despite adequate resuscitation.

  • Initial drainage >1500 mL.

  • Continued bleeding >200 mL/hour for 3 consecutive hours.

  • Continued bleeding >1500 mL/day.

  • Radiographic evidence of significant retained clot (>1/3 of pleural space) [13,15].

Drainage techniques

Thoracentesis

Thoracentesis is the basic procedure not only to differentiate transudate from exudate, but also to remove the fluid in a patient with a large volume of effusion for symptomatic relief. The most common indication of diagnostic thoracentesis is fluid in the pleural space more than 10 mm in thickness on lateral decubitus chest radiograph with unknown aetiology [1,2,16]

Complications of thoracentesis include pneumothorax, haemothorax, re-expansion pulmonary oedema, and organ laceration. In general, removal of <1500 mL pleural effusion is recommended to avoid the risk of re-expansion pulmonary oedema.

Thoracentesis must be performed with care in mechanically-ventilated patients, because positive pressure ventilation increases the risk of tension pneumothorax. Thoracentesis as therapeutic procedure, may reduce respiratory distress in patients with large effusions [16].

However, Doelken et al. evaluated the effects of thoracentesis on respiratory function in mechanically-ventilated patients and did not find any significant changes in peak or plateau airway pressure or compliance of respiratory system after the procedure [17]. After fluid removal from the pleural space, changes in pulmonary gas volume and size of the thoracic cavity depend on the lung compliance compared with the chest wall compliance—the more compliant the lung is, the greater will be the increase in gas volume [16].

Thoracostomy drainage

Tube thoracostomy allows a continuous and large volume drainage of air or liquid from pleural space.

Specific indications include haemothorax, penetrating chest trauma, complicated parapneumonic effusion or empyema, chylothorax, and pleurodesis of symptomatic pleural effusions. In symptomatic or clinically unstable patients, there is no absolute contraindication to chest tube placement. The need for prophylatctic antibiotics depends upon the clinical circumstances. The tube should be removed as soon as it is safe to do so. For the pleural effusions, the indications to remove the tube are when the lung is fully expanded or when the daily fluid output is less than about 100–300 mL/day. Pleurodesis should be considered for patients with uncontrolled and recurrent symptomatic malignant effusions via a tube thoracostomy or during thoracoscopy to produce a chemical serositis and subsequent fibrosis of the pleura. Pleural sclerosis should be attempted only if the lung expands fully after fluid removal. Pleurodesis failure is usually the result of suboptimal technique or inappropriate patient selection [2,4,18].

Surgical therapy

Video-assisted thoracoscopic surgery is very useful in managing incompletely drained parapneumonic effusions and clotted haemothorax. With thoracoscopy, the loculi in the pleura can be disrupted, the pleural space can be completely drained, and the chest tube can be optimally placed [4]‌.

Radical total or subtotal pleurectomy and decortications should be reserved for patients who have failed chemical pleurodesis. Appropriate candidates must be good surgical candidates and have a reasonably long expected survival, as total radical pleurectomy/decortications is a major surgical procedure associated with some mortality [4,18].

Pleuroperitoneal shunts and in-dwelling external catheters

Pleuroperitoneal shunting is a rarely-used option for patients who have lung entrapment, malignant chylothorax, or failed pleurodesis.

In-dwelling catheters provide symptomatic relief in patients with malignant pleural effusions, who either cannot tolerate general anaesthesia or have a trapped lung that is not amenable to video-assisted thoracoscopy. The catheter is placed in the intrapleural space under local anaesthesia and drains externally when effusions are symptomatic. This drainage technique has the disadvantage of ongoing protein losses and increased risk of infection, and because of these side effects it is not used for non-malignant effusions [19].

Acknowledgements

The authors acknowledge R. Phillip Dellinger MD, Camden, USA for his guidance in the preparation of this manuscript.

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