Seminars in respiratory and critical care medicine
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Infection of the pleural space is an ancient and common clinical problem, the incidence which is on the rise. Advances in therapy now present clinicians of varying disciplines with an array of therapeutic options ranging from thoracentesis and chest tube drainage (with or without intrapleural fibrinolytic therapies) to video-assisted thoracic surgery (VATS) or thoracotomy. A framework is provided to guide decision making, which involves weighing multiple factors (clinical history and presentation, imaging characteristics, comorbidities); multidisciplinary collaboration and active management are needed as the clinical course over a few days determines subsequent refinement. ⋯ Antibiotics alone are rarely successful and can be justified only in specific circumstances. Early drainage with or without intrapleural fibrinolytics is usually required. This is successful in most patients; however, when surgical decortication is needed, clear benefit and low physiologic impact are more likely with early intervention, expeditious escalation of interventions, and care at a center experienced with VATS.
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Pleural effusions are commonly encountered and have a significant impact on the respiratory system. The reported effect of thoracentesis on physiologic parameters including oxygenation, lung volumes, and respiratory mechanics is variable likely owing to studies with a small, heterogeneous population of patients. Most patients who are short of breath from pleural effusion experience relief following drainage due to improvement in the length-tension relationship of the respiratory muscles. ⋯ Recent advances in methods of measuring pleural pressure provide a greater understanding of the impact of pleural effusion on pleural pressure and changes in pleural pressure with thoracentesis; however, there has been no demonstrated benefit of routine monitoring of pleural pressure to reduce complications from thoracentesis. Manometry does allow for the identification of patients with unexpandable lung which is useful when determining options for pleural palliation. The following article will review the pathophysiological effects of pleural effusion and thoracentesis.