Assessing patients with pleural effusions in the emergency department (ED) can be challenging and nuanced. This is largely due to the lack of guidelines around pleural effusions in the ED. In part one we focused on imaging, diagnosis, and management of parapneumonic effusions. In this second part, we will look at malignant and CHF-related effusions, management, and ways to optimize the ED thoracentesis procedure.
Malignant Pleural Effusions
Case 2- Ms. MPE is a 70-year-old female presenting to the ED with progressive dyspnea for the past 2 months, but has been worse over the past week. She has no fever or infectious symptoms. She has a history of breast cancer. She has a moderate unilateral effusion and POCUS features of an exudative effusion. You suspect a malignant pleural effusion.
Radiopedia.org Pleural Effusion.
Jones 2009, updated Sharma 2024
Malignant pleural effusions are the second leading cause of exudative effusions. The most common causes of pleural malignancy are lung and breast cancer. Approximately 50% of the patients with lung cancer will develop an effusion.
Depending on the specific clinical situation, performing a CT chest as part of the work-up for the initial presentation of a pleural effusion is generally recommended, particularly in the following scenarios:
- A suspected malignant pleural effusion: CT can help in revealing underlying abnormalities such as pleural masses.
- Unclear chronicity of the effusion: a CT can identify features of a trapped lung.
- Atypical POCUS features.
The information obtained from a CT can also help with safe planning of a thoracentesis.
In this case of Ms. MPE, there is a high pretest probability for a malignant pleural effusion given her new pleural effusion and history of breast cancer. A CT chest is performed which shows some pleural thickening but no overlying pleural mass. A thoracentesis is performed in the ED. For the pleural fluid analysis, in addition to the tests discussed previously, it is also important to send the fluid for cytology (both formalin and cyto-rich samples).
Therapeautic Thoracentesis
When indicated, therapeutic thoracentesis is ideally done in the ED setting to improve a patient’s dyspnea and work of breathing. This procedure can also impact disposition and help expert consultants (respirology, oncology) in guiding further management.
The goal of a therapeutic thoracentesis in these cases is to remove enough fluid to relieve symptoms (but not to completely drain all pleural fluid). Drainage should be considered when there are significant symptoms and there is at least a moderate-sized effusion (this would be an interpleural distance of approximately >30-50mm).
Depending on the center of practice, as an alternative to a therapeutic thoracentesis in the ED, a referral can be sent to interventional pulmonology or general respirology if the patient is asymptomatic or minimally symptomatic. This is ONLY an option if there is no competing diagnoses or concern for infected parapneumonic effusion, and should be discussed with a specialist first.
For this case of Ms. MPE, a diagnostic and therapeutic thoracentesis are performed in the ED and 500mL of fluid is removed. Her symptoms improve with the procedure and the fluid is sent for cytology. If a patient’s symptoms improve with an ED-performed thoracentesis, they can be discharged home with close specialist follow-up (generally respirology or interventional pulmonology) for:
- Cytology results
- Pleural biopsy
- Additional imaging
Malignant Pleural Effusion – Definitive Therapy
Malignant pleural effusions often recur after initial aspiration. Treatment tends to focus on palliation of symptoms. Definitive management by specialists can involve:
- Ambulatory recurrent aspiration
- Home-based management with indwelling pleural catheters
- Chest tube with talc slurry pleurodesis
Malignant Pleural Effusion – Take Home Points
- Consider a CT chest to help with diagnosis and planning of a thoracentesis procedure.
- Send pleural fluid for analysis and include cytology.
- A therapeutic thoracentesis is within our scope in the ED. Consider this for moderate-to-large symptomatic pleural effusions. This can impact patient disposition and treatment.
- Patients with suspected malignant pleural effusions will need a specialist referral for further work-up and management.
Chronic Pleural Effusions
Radiopedia.org Trapped lung. Weerakkody and Elfeky 2012
With chronic pleural effusions, there is often the development of something called a non-expandable lung, or specifically a trapped lung. A trapped lung involves the formation of a fibrous membrane over the pleura from a chronic inflammatory process. This can be seen in diseases such as a previous CABG or an established pleural malignancy. For chronic, unchanged pleural effusions, pleural drainage should not be performed in the ED, as the lung will not re-expand.
For a trapped lung, if a thoracentesis is done, there will be a pneumothorax after the procedure until pleural fluid fills up or re-accumulates in the pleural space. Patients with a chronic effusion can have a lot of discomfort during the thoracentesis procedure because there is now a negative pressure space causing tension on the mediastinal structures. It is also important to note that any shortness of breath will not improve with fluid drainage.
A CT chest can be useful in these clinical situations if there is a known chronic effusion or the chronicity of an effusion is uncertain, to assess for certain findings that would suggest the lung won’t re-expand. Patients with chronic pleural effusion can be referred for further management. There is no role for therapeutic drainage for a chronic effusion in the ED, unless there is concern for pleural infection or an increase in the size of the effusion.
Congestive Heart Failure
Case 3 – Ms. CHF is a 70-year-old female, known for two previous myocardial infarctions with four drug-eluting stents placed in the last 10 years. She presents with one month of progressive exertional dyspnea. Her cardiac POCUS shows moderately reduced LV function and bilateral B-lines. She has small-to-moderately sized bilateral pleural effusions.
Congestive heart failure (CHF) is the most common cause of a transudative pleural effusion. Effusions from heart failure are most often bilateral and are typically small to moderate in size. POCUS often shows simple, anechoic fluid. As reflected in the current BTS guidelines (Roberts et al. 2023), further diagnostic workup, such as a CT or pleural fluid analysis, is not needed unless there is clinical uncertainty, including:
- Fever
- Pleuritic chest pain
- Largely unequal effusions
CHF Pleural Effusion – Treatment
Treatment for these transudative effusions is directed at optimizing the management of the underlying system – in this case, heart failure. It has been thoroughly demonstrated that patients with an initial response to diuretic treatment have near-resolution of their effusions. If a patient with heart failure presents with significant dyspnea, or symptoms persist despite typical treatment in the ED, they may benefit from pleural fluid drainage and thoracentesis should be considered. This may help to facilitate a patient’s disposition.
An important note…
Further work-up is needed for a patient with a chronic effusion or history of CHF with any change in symptoms. For example, if the patient Ms. CHF presents with pleural effusion(s) and:
- A fever and cough
- An increase in the size of a known effusion
- Now a new unilateral effusion
A diagnostic thoracentesis is indicated in these scenarios for further assessment (if there is an amenable pocket). Drainage of the pleural fluid can also be considered, but only to target relief of symptoms (not to completely drain the fluid).
Thoracentesis
Complications
1. Pneumothorax
There are three main mechanisms of a post-thoracentesis pneumothorax:
- Iatrogenic
- A non-expandable lung as outlined above.
- Entrainment of air into the pleural cavity during a procedure
The true incidence of clinically significant postprocedural pneumothorax is difficult to establish. It has been thoroughly demonstrated that ultrasound reduces the incidence of pneumothorax. A large, observational cohort study in 2013 that reviewed 60,000 thoracenteses reported an overall risk of pneumothorax of 2.7%. After adjustment, it demonstrated that the use of ultrasound reduced the risk of post-procedure pneumothorax by 19% (Mercaldi et al. 2013). Thoracentesis must be performed with ultrasound in the ED.
2. Re-expansion Pulmonary Edema
Re-expansion pulmonary edema (RPE) is a rare but potentially critical complication of thoracentesis. It involves the development of pulmonary edema after a period of lung collapse followed by rapid re-inflation of the lung. It can be associated with thoracentesis when large amounts of pleural fluid are withdrawn quickly. The true incidence is not well-established but is likely low. The largest case series reported that symptomatic RPE occurred in 1% of patients undergoing thoracentesis (Feller-Kopman et al. 2007).
The maximum volume that should be safely drained during a single procedure is a subject of debate. Evidence supports minimal complication rates when draining less than 1.5L. Typically in the ED, 1L is a safe conservative maximum volume. Remember the goal is to target an improvement in symptoms. Irrespective of the volume, the procedure should be stopped if the patient develops chest pain, cough or worsening breathlessness, as these symptoms might signal impending RPE or a non-expandable lung.
Small-bore Chest Tube
Aside from infected parapneumonic effusions, there is no clear guideline for when to insert a small-bore chest tube versus performing a thoracentesis in the ED. The general recommendations here are largely based on speaking with experts. A small-bore chest tube should be considered in the following situations:
- Hydropneumothorax
- For a patient with a large effusion, especially if they are quite symptomatic and/or in respiratory distress.
Patients with a larger effusion and respiratory distress likely need a larger volume of fluid removed. Placing the chest tube obviates the need for a repeat procedure to remove additional fluid at a later time.
Optimizing your Thoracentesis Procedure
Consider watching this video by Sonosite for a real-time explanation of the thoracentesis procedure. Sonosite: Ultrasound Guidance for Thoracentesis. 2010. (Screenshots from the video are included below).
The optimal position is to have the patient seated upright and leaning forward slightly. Ultrasound (guidance or landmarking) is essential for thoracentesis and the key to reducing the risk of complications. A phased-array probe should be used initially to landmark and find the largest pocket of fluid. All the relevant landmarks: chest wall, pleura, lung, diaphragm, and liver/ spleen should all be identified.
Sonosite 2010: Ultrasound Guidance for Thoracentesis.
Sonosite 2010: Ultrasound Guidance for Thoracentesis.
The needle site of insertion should be aimed at least 1-2 intercostal spaces below the highest level of the pleural effusion on inspiration. It is important to remember the liver and spleen rise during exhalation. Several respiratory cycles should be observed to ensure that no intervening lung or diaphragm could move near or into the proposed needle path. A few rib spaces should be examined to select the best site. The best site is that with the maximal intrapleural distance at the base of the lung.
Sonosite 2010: Ultrasound Guidance for Thoracentesis.
M-mode on ultrasound can be considered as an adjunct at this stage for two reasons:
- To confirm the lung is moving freely within the effusion, and
- To assess and measure the depth of the fluid pocket during a respiratory cycle.
A linear probe can be used next and placed between the two selected ribs to measure and confirm the pleural effusion depth. It is important to ensure that the site with the maximum distance between the visceral and parietal pleura at the lung base has been selected. Although there is no clear guideline, a minimum safe distance/depth for a diagnostic thoracentesis can be considered at least 20-30mm.
Sonosite 2010: Ultrasound Guidance for Thoracentesis.
Drainage Devices
The drainage device is another procedural consideration for a therapeutic thoracentesis. Multiple options exist, and include gravity, hand syringe, and vacuum bottle drainage. There is no consensus for one method over the other. Vacuum containers are frequently used safely for thoracenteses, by emergency and respirology physicians.
Bonus Thoracentesis Procedure Points
- When removing the catheter from the pleural space, instruct the patient to hum continuously to expel any air present
- Always obtain a post-procedure chest x-ray or use POCUS to rule-out a pneumothorax
- For a therapeutic thoracentesis, always use an over-the-needle catheter with a safety, spring-loaded obturator and one-way valve, as available. With these systems, the safety catheter extends beyond the needle tip once the pleural space is entered, reducing the risk of lung puncture.
The alternative for a diagnostic thoracentesis is an angiocatheter.
Safe-T-centesis™ Drainage System by BD
Final Take-Home Points
- POCUS should be used to characterize and size pleural effusions and reduce the risk of procedural complications.
- Thoracentesis should be performed in the ED when clinically indicated for a new effusion with an amenable pocket. This can change a patient’s clinical course.
- Consider a therapeutic thoracentesis for a moderate-large symptomatic effusion
- Consider a chest tube for a large effusion with significant symptoms/ respiratory distress
- For parapneumonic effusions:
- The majority are not significant or are uncomplicated and resolve with antibiotics alone
- The indications for a surgical consultation and consideration of a small-bore chest tube:
- pH < 7.2
- Loculated effusions
- Frank pus
- Empyema on CT
- For malignant pleural effusions:
- Send cytology with the pleural fluid analysis
- Consider a CT in the ED, especially if considering therapeutically draining the pleural fluid
- Follow-up with appropriate specialists is needed
*The POCUS images in this post were captured and shared by:
Dr. Rajiv Thavanathan, MD FRCPC, Emergency Physician, Department of Emergency Medicine, The Ottawa Hospital, Assistant Program Director | Area of Focused Competency POCUS.
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