Evidence-based On-call

Pleural effusion

Therapy

Malignancy

Insert a chest drain and perform pleurodesis in recurrent cases ^a

Perform pleurodesis once ^d after the chest tube is draining < 150 ml of fluid per day ^d and a chest X-ray shows no remaining fluid ^d. The effect of rotating the patient immediately after insertion of the sclerosant on successful pleurodesis is unclear.

An alternative is surgical pleurodesis using thoracoscopy ^a , using talc ^b

Use any of the following when performing medical pleurodesis:

tetracycline ^b and bleomycin ^a
doxycycline ^b
minocycline ^b
mepacrine ^a
Pain and fever are common following pleurodesis ^b, so give prophylactic analgesis ^d - options include opiates ^dand intrathecal local anaesthesia ^d

Parapneumonic effusion

Drain a parapneumonic effusion if it is purulent or loculated

Insert a chest drain ^a
Instill streptokinase ^a or urokinase ^d (e.g. 250 000 units streptokinase in 20 ml daily)

Refer patients for surgery if drainage is unsuccessful. ^c

Tuberculosis

Give antituberculous chemotherapy. ^a If TB is prevalent, consider empiric treatment in patients where no clear cause can be found. ^d

Insert a chest drain ^d

There is no clear role for steroids, once the effusion has been drained ^d