Nonmalignant Pleural Effusions

Abstract

Although the potential causes of nonmalignant pleural effusions are many, the management of a few, including complicated pleural infections and refractory heart failure and hepatic hydrothoraces, can be challenging and requires the assistance of interventional pulmonologists. A pragmatic approach to complicated parapneumonic effusions or empyemas is the insertion of a small-bore chest tube (e.g., 14–16 Fr) through which fibrinolytics (e.g., urokinase and alteplase) and DNase are administered in combination. Therapeutic thoracenteses are usually reserved for small to moderate effusions that are expected to be completely aspirated at a single time, whereas video-assisted thoracic surgery should be considered after failure of intrapleural enzyme therapy. Refractory cardiac and liver-induced pleural effusions portend a poor prognosis. In cases of heart failure–related effusions, therapeutic thoracentesis is the first-line palliative therapy. However, if it is frequently needed, an indwelling pleural catheter (IPC) is recommended. In patients with hepatic hydrothorax, repeated therapeutic thoracenteses are commonly performed while a multidisciplinary decision on the most appropriate definitive management is taken. The percutaneous creation of a portosystemic shunt may be used as a bridge to liver transplantation or as a potential definitive therapy in nontransplant candidates. In general, an IPC should be avoided because of the high risk of complications, particularly infections, that may jeopardize candidacy for liver transplantation. Even so, in noncandidates for liver transplant or surgical correction of diaphragmatic defects, IPC is a therapeutic option as valid as serial thoracenteses.

Expert Review on Contemporary Management of Common Benign Pleural Effusions

“…120 However, if pleurodesis events occurring as the result of the normalization of portal pressure by a successful liver transplantation are excluded, the rate of autopleurodesis decreases markedly (<20%). 6 In addition, to have an IPC in place for such a long period of time increases the risk of IPC-related infections (813%), 6,120 which may have a negative effect on liver transplantation candidacy. Therefore, while in nontransplantable patients IPC may be an acceptable palliative measure, in transplant candidates its indication is questionable and requires individual decisions based on a multidisciplinary discussion.…”

“…12 However, a therapeutic thoracentesis (TT) can be performed for immediate symptomatic relief in subjects with moderate to large PEs (usually three or more intercostal spaces on TUS or two intercostal spaces in association with intense dyspnea and/or diaphragmatic dysfunction). 6 An analysis of PF helps to confirm the cardiac nature of a PE. 26 Cardiac PEs meet the Light's transudative criteria in 72% of the cases.…”

“…placed on medical therapies, since the indication of invasive pleural procedures for these entities have recently been discussed in detail. 6 Other benign PEs, such as parapneumonics or postsurgical, are separately covered in this Pleural Series in Seminars in Respiratory and Critical Care Medicine and elsewhere. [7][8][9] Heart Failure-Related Effusions…”

Acute kidney injury in hospitalized patients with nonmalignant pleural effusions: a retrospective cohort study

“…It affects more than 3,000 people per million population each year [ 1 ]. Nonmalignant pleural effusions (NMPE) are usually associated with organ dysfunction such as pneumonia and heart failure [ 2 ].…”