Medical Care:

Transudative effusions usually are managed by treating the underlying medical disorder. However, whether transudates or exudates, drain large pleural effusions if they are causing severe respiratory symptoms, even if the cause is understood and disease-specific treatment is available. The management of exudative effusions depends on the underlying etiology of the effusion. Pneumonia, malignancy, or TB causes the majority of exudative pleural effusions, or effusions are deemed idiopathic. Drain complicated parapneumonic effusions and empyemas to avoid fibrosing pleuritis. Malignant effusions usually are drained to palliate symptoms and might require pleurodesis to prevent recurrence.

• Although causing only a small proportion of all pleural effusions, a number of medications, including the following, are associated with exudative pleural effusions: medications causing drug-induced lupus syndrome (procainamide, hydralazine, quinidine), nitrofurantoin, dantrolene, methysergide, procarbazine, and methotrexate.

• Recognition of these iatrogenic causes of pleural effusions will avoid unnecessary additional diagnostic procedures and will lead to definitive therapy, which is discontinuation of the medication.

• Of the common causes for exudative pleural effusions, parapneumonic effusions have the highest diagnostic priority. Even in the face of antibiotic therapy, infected pleural effusions can rapidly coagulate and organize to form fibrous peels that might require surgical decortication. Thus, quickly assess pleural fluid characteristics predictive of a complicated course to identify para-pneumonic effusions that require urgent tube drainage, which are seen more commonly in indolent anaerobic pneumonias than in typical community-acquired pneumonia.

• Indications for urgent drainage of parapneumonic effusions include the following: frankly purulent fluid, pleural fluid pH less than 7.2, loculated effusions, and bacteria on Gram stain or culture.

• Patients with parapneumonic effusions who do not meet criteria for immediate tube drainage should improve clinically within 1 week with appropriate antibiotic treatment.

• Radiographically reassess patients with parapneumonic effusions who do not improve or deteriorate clinically.

• Malignant pleural effusions usually signify incurable disease with considerable morbidity and a dismal mean survival of less than 1 year.

• Drainage of large malignant effusions might relieve dyspnea caused by distortion of the diaphragm and chest wall produced by the effusion.

• Pleural sclerosis also might be necessary to prevent recurrence of symptomatic effusions.

• TB pleuritis typically is self-limited. However, because 65% of patients with primary TB pleuritis reactivate their disease within 5 years, empiric anti-TB treatment usually is begun pending culture results when sufficient clinical suspicion is present, such as an unexplained exudative or lymphocytic effusion in a patient with a positive PPD.