Pleural Disease

Pleural Effusions & Pleural Interventions

Highlights ultrasound-first evaluation, manometry use, tube size selection, IPC versus pleurodesis decisions, complication management, and trapped lung considerations.

Thoracentesis • Malignant effusions • Pleural ultrasoundReading time · 32mWord count · 4,348

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Exam mapping & scope

This chapter maps to the AABIP/CAQ domains covering the diagnostic approach to pleural effusions and the full spectrum of pleural procedures: thoracic ultrasound (TUS), diagnostic and therapeutic thoracentesis (including pleural manometry), image-guided pleural catheter/needle interventions, chest tube selection and management, intrapleural therapy for pleural infection, malignant pleural effusion (MPE) management pathways (IPC vs. pleurodesis), and medical thoracoscopy (MT). Emphasis is placed on exam-relevant decision-making, stepwise technique, complication avoidance, and the evolving evidence base.

Focus this round

Safety thresholds
Algorithmic management
Complication rescue

High-yield pearls

Ultrasound is the standard of care for thoracentesis and tube placement; it significantly reduces pneumothorax rates and “dry taps.”
Light’s criteria remain first-line to classify exudates; however, borderline values reduce accuracy—always use clinical context and ancillary tests.
Large-volume thoracentesis is safe when guided by symptoms and pleural pressures. Stop if Ppl falls below approximately -20 cm H₂O or if the patient develops chest pain or relentless cough.
Do not routinely obtain a post-tap CXR. Reserve imaging for clinical concerns (air aspiration, difficult procedure, prior radiation, symptoms, etc.).
Small-bore (≤14F) chest tubes suffice for most effusions and pneumothoraces; they are better tolerated and placed via the Seldinger technique.
When to favor large-bore: Unstable hemothorax/trauma, massive air leak, or immediate post-thoracic surgery (due to flow and clogging considerations).
Suction is not routine for pneumothorax management; water seal often suffices and may reduce fistula propagation.
Pleural infection: Start antibiotics + small-bore tube early. Escalate to intrapleural tPA/DNase if drainage stalls; refer for surgery if the patient is a non-responder.

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