Less Is More: A Collaborative, Non-Operative Approach to Care for a Patient With Pleural Effusion

Case Report Insights: For an in-depth look at the Photoclinic case report below and an interview with the authors, visit https://www.consultant360.com/videos/collaborative-and-holistic-approach-patient-care-pleural-effusion

AFFILIATION:
¹Department of Family Medicine, Morehouse School of Medicine, Atlanta, GA

CITATION:
Mobolaji A, Omole F. Less is more: a collaborative, non-operative approach to care for a patient with pleural effusion. Consultant. 2023;63(7):e6. doi:10.25270/con.2023.01.000007

Received June 30, 2022. Acccepted October 31, 2022. Published online January 27, 2023.

DISCLOSURES:
The authors report no relevant financial relationships.

ACKNOWLEDGEMENTS:
The authors would would like to acknowledge Morohunfolu Akinusi, MD, for pulmonary consultation and collaborative medical decision making.

CORRESPONDENCE:
Folashade Omole, MD, FAAFP, Department of Family Medicine, Morehouse School of Medicine, 720 Westview Drive, SW. Atlanta, GA 30310 (fomole@msm.edu)

Introduction. Clinical decision-making should be a collaborative effort between the physician and the patient. Whenever possible, physicians should apply a holistic approach to patient management, including the presentation of minimally invasive treatment options for the patient. We present an illustrative case involving a well-defined but less frequently used therapeutic option to help a patient avoid major surgery.

Case description. A 68-year-old woman presented to the emergency room with pleuritic left-sided chest pain associated with shortness of breath and a productive cough with clear sputum but no hemoptysis. The patient also noted a fever and unquantified weight loss.

Patient history. The patient denied any prior history of chronic or acute lung disease and reported a positive history of substance use, including an approximately 50 pack-year of tobacco smoking.

Physical examination. The patient is ill appearing with mild respiratory distress. The patient’s cardiovascular examination findings were within normal limits, without heart murmurs. Pulmonary findings revealed shallow breath sounds that were diminished at lower bases and poor inspiratory efforts due to pain. The patient had conversational dyspnea and tachypnea. Her oxygen saturation dropped to 83% during the encounter,  so she was placed on 3L (32% fraction of inspired oxygen) via a nasal cannula with improved response, which increased to 96%. There was tenderness anteriorly and along left lower ribs to palpation.

Laboratory Testing.  

Table 1. Initial workup.

Diagnostic testing. A single frontal view of the chest revealed borderline cardiomegaly. There are atheromatous calcifications, prominent interstitial markings, which are likely chronic, a left-sided effusion, and atelectasis. No significant effusion is seen on the right. There is no acute osseous abnormality (Figure 1).

Figure 1. Chest X-ray on admission.

Diagnostic thoracentesis revealed findings indicative of an exudate. Pleural fluid cytology was negative for malignancy. On day 2 of admission, a chest computed tomography (CT) scan showed worsening of the left pleural effusion. (Figure 2). Subsequent therapeutic thoracentesis did not improve the patient’s condition, due to less than 5 cc of drainage despite the large size of the effusion seen on CT. The patient remained hypoxic, and a pulmonary consult was initiated for chest tube placement and management. Interventional radiology specialists placed a chest tube with about 30 cc thick fluid drainage, but clinical and radiographic abnormalities persisted. Thoracic surgery specialist input was considered for managing the loculated fluid with possible video-assisted thoracoscopic surgery (VATS). In consultation with the pulmonologist, the decision was made to use a less invasive approach to drain the loculated effusion through intrapleural thrombolytic therapy. (Figure 3).

Figure 2. The patient’s chest CT prior to tissue plasminogen activator (tPA) is shown.

Figure 3. Chest X-ray after tPA instillation.

Treatment and management. Once we determined the etiology of the pleural effusion, we based our treatment on managing the underlying cause. For patients with complex parapneumonic effusions, chest tube drainage is usually indicated along with antibiotics. This was how we initially approached treating our patient.

If the patient does not respond to appropriate antibiotics, and there is not adequate drainage from a well-positioned chest tube as expected, then thoracoscopic decortication or debridement may be needed. This was a consideration for our patient. Instillation of intrapleural fibrinolytics and DNAse may also be used to improve drainage after chest tube placement when no major drainage is noted or, when there is persistence of abnormal pleural fluid. This approach could also be used in patients who are not surgical candidates.¹

In all cases, treatment should focus on patient-centered goals of therapy, which include sustained symptom relief, improvement in quality of life, acceptability of an intervention, affordability, and preference for less invasive procedures.

Albeit a secondary goal, cost-effective medical care should be the prerogative of clinical providers when choosing the type of care and recommendations made in all settings.

For our patient, we sought the advice of other specialists including pulmonologists, intervention radiologists, pharmacists, and the coordinating medical team.

Patient outcome. With a multidisciplinary team approach, it was agreed, in lieu of VATS, to offer intrapleural thrombolytic therapy. The patient received intrapleural tPA x 1 dose, resulting in increased pleural fluid drainage, symptomatic relief, and radiographic resolution. She was subsequently discharged home in stable condition and a post hospital discharge follow-up phone call revealed continued improvement. She was lost to continued follow-up 1 month later. 

Discussion. Pleural effusion is the abnormal accumulation of pleural fluid in the pleural space due to an imbalance between excessive pleural fluid formation and pleural fluid absorption.¹ The most common causes of pleural effusion are pneumonia, other infections, congestive heart failure, and malignancy. Based on modified Light's criteria, pleural effusions are classified as transudate or exudate.²

Pleural fluid can be considered an exudate if it meets one of the following criteria:

1. Pleural fluid protein/serum protein ratio more than 0.5
2. Pleural fluid lactate dehydrogenase (LDH)/serum LDH ratio of more than 0.6
3. Pleural fluid LDH is more than two-thirds of the upper limits of normal laboratory value for serum LDH

In the absence of any of these criteria, pleural fluid is considered a transudate. Conditions that alter the hydrostatic or oncotic pressures in the pleural space like congestive left heart failure, nephrotic syndrome, liver cirrhosis, hypoalbuminemia leading to malnutrition and with the initiation of peritoneal dialysis are common causes of transudates.²

Some of the common causes of exudates includes infections like pneumonia, which was the case with our patient, tuberculosis infection, malignancy, inflammatory disorders like pancreatitis, lupus, rheumatoid arthritis, post-cardiac injury syndrome, chylothorax (due to lymphatic obstruction), hemothorax (blood in pleural space) and benign asbestos pleural effusion.²

Less common causes are pulmonary embolism which could be a transudate or exudate, medication-induced such as methotrexate, amiodarone, phenytoin, dasatinib, usually exudate, post-radiotherapy (exudate), esophageal rupture (exudate) and ovarian hyperstimulation syndrome (exudate).²

Conclusion. We encourage collaborative, multidisciplinary, holistic care whenever possible. Dedicated and appropriate team effort often obviates the need for complicated approaches to patient care, which can lead to adverse or suboptimal outcomes.