In this episode of Hospital Medicine Unplugged, we sprint through pleural effusions—scan smart, tap safer, and match treatment to mechanism so your patients breathe easier with fewer procedures.
We open with the do-firsts: confirm the effusion and triage the “why.” Go POCUS-first (size, septations, safe pocket), use CXR for laterality, save CT for complexity. Tap if it’s new, unexplained, unilateral, febrile/suspected infection or cancer, or large/symptomatic. Send a full panel: protein, LDH, pH, glucose, cell count/diff, Gram/culture, cytology; add ADA/TB PCR when TB’s on the table. Call it with Light’s criteria; if diuretics muddy the waters, use serum–pleural albumin gradient >1.2 g/dL or NT-proBNP when HF is likely.
Drainage decisions—match the mechanism:
• Transudates: Treat the cause. – Heart failure: GDMT (diuretics, ARNI, β-blocker, MRA, SGLT2i); tap for dyspnea if needed. – Cirrhosis (hepatic hydrothorax): Na restriction + diuretics; avoid nonselective β-blockers; refractory → serial taps or IPC (avoid in transplant candidates); consider TIPS as bridge to transplant. – Nephrotic/renal: Volume control; repeat taps if symptomatic. • Exudates: Treat the pleura/lung. – Parapneumonic/empyema: Antibiotics early. Drain if pH <7.2, low glucose, high LDH, pus/positive Gram, or loculations. Use small-bore US-guided tube; add tPA + DNase for loculations; escalate to VATS if failing. – TB effusion: Expect paucibacillary fluid; support with NAATs; treat per standard regimen. – Malignant pleural effusion (MPE): Start with a large-volume tap to confirm symptom benefit and test re-expansion. Choose talc pleurodesis (inpatient) or IPC (ambulatory). Nonexpandable (trapped) lung → IPC; pleurodesis won’t take.
Procedure pearls (make it boring-safe): US guidance for every tap; remove up to ~1.5 L per session or stop for cough/chest tightness; no routine post-tap CXR unless symptoms/air aspirated. Watch for pneumothorax, bleeding, infection, and re-expansion pulmonary edema.
ICU plays: in vented, hypoxemic patients, drain when PaO₂/FiO₂ <200 and estimated effusion >~500 mL—oxygenation usually improves; pneumothorax risk is low but real.
Complications you don’t want to miss: loculated collections needing fibrinolytics/surgery, trapped lung (think IPC, not pleurodesis), procedure-related air/bleeding/infection, and recurrent effusions that tank QoL.
We close with the system moves: a pleural-effusion bundle that (1) makes POCUS the default for diagnosis and marking; (2) fires a “new/unilateral/unexplained” tap trigger with the full lab set + cytology; (3) auto-adds albumin gradient/NT-proBNP when diuretics or HF suspected; (4) runs a parapneumonic pathway (abx → drain → tPA/DNase → VATS); (5) runs an MPE pathway (test re-expansion → pleurodesis or IPC; IPC for trapped lung); (6) builds a cirrhosis track (Na restriction, diuretics, no NSBB, early TIPS/transplant consult); (7) mandates US-guided procedures and post-tap safety checks; (8) standardizes IPC care/education and follow-up.
Fast, ultrasound-led, and decision-forward—everything your team needs to tap smart, treat smarter, and keep patients off the yo-yo of repeat admissions.
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