In his interview, interventional pulmonologist, Dr. Christopher Kapp explains how he diagnoses pleural effusions and provides patients with personalized treatment options.
Managing Parapneumonic Effusions
Key Points:
- Place a 14F chest tube for diagnostic sampling and source control
- Start antibiotics promptly, including anerobic coverage. 3. Start tPA/ dornase per MIST-2 Trial.
- MIST-2: combination tPA/dornase improved drainage, reduced surgery referrals, and shortened hospital length of stay; no mortality benefit
- tPA / dornase caveats: ineffective in cases of lung entrapment or thick pleural rind; poses bleeding risk in anticoagulated patients.
Management of Malignant Pleural Effusions
Key Points:
- Pleural thickening greater than 1cm or nodularity on ultrasound is highly suspicious for malignant pleural effusion.
- Collect at least 50 cc during the first thoracentesis for comprehensive testing.
- Depending on the rapidity of fluid reaccumulation post drainage, next steps to consider: serial thoracenteses, tunneled catheter placement, or pleurodesis.
- If the lung does not fully re-expand, pleurodesis is not feasible.
Interpreting Pleural Fluid Cholesterol
Key Points:
- Cholesterol greater than 40 is consistent and less than 25 is highly inconsistent with exudative effusions.
- Pleural fluid cholesterol can help diagnose pleural effusions where the etiology is uncertain.
- Milky pleural fluid isn’t always chylous—high cholesterol and low triglycerides indicates a pseudochylothorax.
Pleurodesis Pain Control
Key Points:
- Collaborate with oncology and palliative care to manage pain in patients with malignant pleural effusions.
- Consider pre-procedural bupivacaine, NSAIDs (if tolerated), and short-term opioids when necessary to manage pleurodesis-related pain.
- Lidocaine patches and other topical treatments are efficacious for localized pleuritic pain.
Full Podcast
Tags: interventional pulmonology, pleural effusion, pulmonology, thoracentesis