Less Is More: A Collaborative, Non-Operative Approach to Care for a Patient With 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. Published online January 27, 2023. doi:10.25270/con.2023.01.000007

Received June 30, 2022. Acccepted October 31, 2022.

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).