Pleural Disease

Pleural effusions are common in patients admitted to the intensive care unit (ICU), with heart failure/fluid overload and proinflammatory conditions such as parapneumonic or malignant effusion being common causes. Failure of oxygenation, prolonged mechanical ventilation, prolonged ICU stay, and increased mortality have all been reported to be associated with pleural effusions. The presence of a pleural effusion should be suspected and investigated in the context of severe pneumonia, unexplained sepsis, unexplained or refractory hypoxaemia, deteriorating respiratory function, or difficulty weaning from mechanical ventilation. Point-of-care thoracic ultrasound has been shown to be superior to supine chest radiographs for the identification of pleural effusions in ICU. Drainage of a pleural effusion may improve oxygenation and potentially reduce dependency on ventilatory support. However, high-quality data to inform thresholds on effusion size or ventilatory parameters above which patients will benefit from pleural drainage is lacking. Chest drains below 16F are likely to be adequate for most indications, with the exception of significant haemothorax and post-trauma or instrumentation. Randomized trials are urgently required to inform clinical treatment guidelines of this common condition with significant associated adverse outcomes. The optimal selection of clinically important patient-reported outcome measures for such studies is required.