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Pleural effusion

What's new

Updated 2023 AAFP guidelines for the diagnosis and management of pleural effusion.

Background

Overview

Definition
Pleural effusion is a disease characterized by pathologic accumulation of fluid in the pleural space.
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Pathophysiology
Common causes of pleural effusions include congestive HF, pneumonia, malignancy, and PE.
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Epidemiology
The incidence of pleural effusion in the US is estimated at 400 cases per 100,000 person-years.
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Disease course
Accumulation of fluid in the pleural space with resultant pleural irritation and compression atelectasis results in clinical manifestations of dyspnea, pleuritic pain, and dry cough.
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Prognosis and risk of recurrence
In hospitalized patients, pleural effusion is associated with 30-day and 1-year mortality of 15% and 32%, respectively.
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Guidelines

Key sources

The following summarized guidelines for the evaluation and management of pleural effusion are prepared by our editorial team based on guidelines from the American Academy of Family Physicians (AAFP 2023), the British Thoracic Society (BTS 2023,2017), the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB 2022), the Society of Thoracic Surgeons (STS/STR/ATS 2018), and the Society of ...
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Diagnostic investigations

General principles: as per BTS 2023 guidelines, interpret imaging findings of a unilateral pleural effusion in the context of clinical history and knowledge of pleural fluid characteristics.
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  • Chest ultrasound

  • Chest CT/PET

  • Serum biomarkers

Diagnostic procedures

Diagnostic thoracentesis: as per AAFP 2023 guidelines, perform diagnostic thoracentesis for new-onset, unilateral, and larger than minimal pleural effusions in the absence of clinically evident HF, cirrhosis, or kidney failure appropriately responsive to therapy. Perform therapeutic thoracentesis to relieve symptoms.
B
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  • Pleural fluid culture

  • Pleural fluid cytology

  • Pleural fluid biomarkers

  • Pleural biopsy

Respiratory support

Supplemental oxygen: as per BTS 2017 guidelines, target an oxygen saturation of 94-98% in patients with pleural effusions, or 88-92% if the patient is at risk of hypercapnic respiratory failure.
B

Specific circumstances

Patients with malignant pleural effusion, diagnostic imaging: as per BTS 2023 guidelines, consider obtaining an ultrasound at presentation to support the diagnosis of pleural malignancy, particularly in the context of a pleural effusion, where appropriate sonographic skills are present.
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More topics in this section

  • Patients with malignant pleural effusion (general principles of management)

  • Patients with malignant pleural effusion (thoracentesis)

  • Patients with malignant pleural effusion (indwelling pleural catheter)

  • Patients with malignant pleural effusion (pleurodesis)

  • Patients with malignant pleural effusion (intrapleural fibrinolytics)

  • Patients with malignant pleural effusion (intrapleural chemotherapy)

  • Patients with malignant pleural effusion (surgery)

Follow-up and surveillance

Follow-up
As per BTS 2023 guidelines:
Consider obtaining follow-up CT to exclude occult malignancy in patients presenting with pleural infection and having ongoing symptoms or other clinically concerning features.
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Consider obtaining follow-up CT to exclude occult malignancy in patients presenting with pleural thickening and unexplained unilateral pleural effusion unless a clear diagnosis is reached by other means (such as biopsy).
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