Pleural effusion

Question 1

Mx of antiplt & anticoag before pleural procedure

Answer 1

Warfarin - stop 5d before & INR ≤1.5
DOAC - stop 24-48h before, resume after 24h
Clopidogrel/ Prasugrel - stop 5d before
Ticagrelor - stop 7d before
Aspirin - can continue

Question 2

Indications for IPC removal

Answer 2

1) Evidence of successful IPC-related pleurodesis:
- drainage <50mls in 3 consecutive occasions
- absence of Sx suggestive of fluid accumulation
- absence of fluid accumulation on imaging

2) Intractable pain
3) Irrepairable damage to IPC
4) Irreversible IPC blockage
5) Skin/pleural infection not resolved with Abx

Question 3

Care for IPC

Answer 3

1) remove closing suture at 7-10d, and holding suture at 21d
2) No bathing/swimming until removal of both sutures
3) Maintain dry dressing after showering with waterproof dressing, and change dressing when it’s wet
4) daily drainage to increase rate of pleurodesis, or if not possible, as frequently as tolerated.
5) Stop drainage when pt dev CP or persistent coughs

Question 4

Indications for IPC

Answer 4

1) MPE

2) Transudative effusion:
- unlikely to have IPC-related pleurodesis
- REDUCE trial: no change re breathlessness despite much more drainage in IPC group (17L vs 3L in 12w)
- IPC has more adverse effects
- Thus IPC is indicated when >3 aspirations needed despite optimisation of underlying cause (e.g. cardiac/ renal/ liver dysfunction)

3) Empyema
- when failed/ not suitable for surgical Mx

Question 5

Contraindication for IPC

Answer 5

1) Inability to tolerate IPC
2) No support to Mx IPC as output
3) Significant cellulitis at proposed insertion site
4) Malignant infiltration of the skin
5) Pleural infection with on-going sepsis
6) Life expectancy less than few weeks

Question 6

How to manage Re-expansion Pulmonary Oedema (RPO)

Answer 6

RPO is rare but potentially life-threatening complication –> hypoxemia and new diffuse alveolar infiltrates.

Mx of RPO:
- ABCD
- in pleural effusion, clamp the drain or stop therapeutic aspiration
- commence O2 according to target SpO2
- Urgent CXR to Ax drain position & complications
- KIV ICU referral
- KIV CPAP (in pneumothorax, need to open the drain), HFNC, HFM
- Opioids, diuretics but not much evidence

Question 7

Pleural effusions work-up