Introduction

Pleurisy is the inflammation of the pleura, the tissue lining the lung. Pleurisy is also called pleuritis, it causes a sharp and stabbing localized chest pain which may get worse while coughing or sneezing. The inflammation can be caused by a viral or bacterial infection or other illnesses that cause damage to the lung. The severity of pleurisy varies from mild to very serious depending on the cause of the inflammation and its complications.¹

The main symptom of pleurisy is chest pain which can be described as a stabbing or knife-like feeling that comes from a specific place. It can be accompanied by fever, shortness of breath, cough, and fatigue. The NHS recommends asking for an urgent consultation if you experienced one of the following:² 

• Sharp chest pain when coughing or breathing
• Sharp chest pain that doesn’t get better
• Regular shortness of breath
• Coughing up spots of blood

Treating pleurisy depends on the underlying cause and symptom relief, it’s crucial to get the proper management because pleurisy can be a sign of something more serious like pneumonia. Moreover, an interprofessional approach from the healthcare team is required to prevent complications and improve lung function.³ We will discuss in this article the different possible options for the treatment and management of pleurisy.

Medications

Non-steroidal anti-inflammatory drugs (NSAIDs) and analgesics

Pleurisy caused by a viral infection usually goes away on its own. The healthcare provider recommends medications such as non-steroidal anti-inflammatory Drugs (NSAIDs) and analgesics to relieve pain and inflammation, like Ibuprofen, Celecoxib, and Acetaminophen.⁴

Steroids

Steroids may be given to relieve severe inflammation that is not responsive to NSAIDs. Steroids and other anti-inflammatory Drugs help with reducing the irritation and the swelling caused by rubbing the pleural layer together during breathing.⁵ Prednisone is an example of a steroid drug that should be prescribed only by healthcare professionals because a proper dose and awareness of drug side effects are important.⁶

Antibiotics

When pleurisy is caused by a bacterial infection like pneumonia, doctors recommend in this case the administration of antibiotics such as Amoxicillin and Azithromycin, along with instructions for the importance of completing the full course. 

Some patients may experience a specific kind of bacteria called tuberculosis (TB). This infection leads to Tuberculous Pleurisy that should be treated with Antitubercular Drugs such as Isoniazid and rifampin, alongside steroids.⁷

Anticoagulants

In the case of Pulmonary embolism-induced pleurisy, blood thinners or anticoagulants, such as Warfarin and heparin, play an important role in preventing the clots from getting bigger and forming new clots. On the other hand, the blood clot dissolver, which is called thrombolytics, can be considered dangerous in life-threatening situations. The most common precaution while administering anticoagulant drugs and thrombolytics is a regular blood test for adjusting the dose.⁸

Thoracentesis

Definition and indications

Pleurisy can be accompanied by a condition called pleural effusion which can be caused by the pleurisy or other medical conditions. Thoracentesis, as a therapeutic procedure, helps to remove the excessive fluid in the pleural space and relieve the symptoms of pleural effusion. Accumulation of fluid in the pleural space prevents the lung from fully inflating, which leads to difficulty of breathing.⁹ Additionally, thoracentesis is a diagnostic procedure that can help to find out different health conditions such as:

• Congestive heart failure (CHF)
• Liver failure
• Tuberculosis (TB)
• Pneumonia
• Viral, fungal, or bacterial infections
• Pancreatitis
• Pulmonary embolism
• Cancer
• Systemic lupus erythematosus (SLE) and other autoimmune diseases
• Empyema
• Reactions to medicines

Procedure

The process of thoracentesis varies according to the severity of the condition, however, there are common steps in most cases such as:

• Anaesthesia: local anaesthesia before the procedure to ensure not feel any pain
• Needle insertion and fluid aspiration: the target area of the procedure is in the back between the ribs, the healthcare provider puts the needle and withdraws fluid slowly. After removing the needle, a bandage will be put on the injected area
• A chest X-ray may be required after the procedure to ensure the safety of the lungs
• Ultrasound guidance during the procedure may be required in some cases to enhance safety

Risk and complications

The most common complications of thoracentesis are hemothorax, pneumothorax and pulmonary edema, in addition to bleeding and infection. The healthcare professionals explain the procedure and answer the questions of the patients to ensure that they don’t have any concerns before the intervention. They also provide proper care after the procedure such as monitoring the vitals and dressing over the site of the puncture.¹⁰

Surgery

Pleurodesis

To prevent a recurrence of pleural effusion or pneumothorax, or to treat a persistent pneumothorax, pleurodesis is performed by eliminating the pleural space. The procedure is indicated in cases of malignant pleural effusion that is resistant to other treatments.¹¹

There are two types of pleurodesis:

• Chemical pleurodesis: Using a chest tube, sclerosing agents such as Tetracyclines and Iodopovidone are injected into the pleural cavity
• Mechanical/surgical pleurodesis: Typically performed through a thoracoscopy or an open thoracotomy

Decortication

A lung decortication involves removing the diseased, often chronically infected, pleura from the adjacent lung for situations like chronic thoracic empyema or chronic hemothorax.¹² An open surgery or VATS (video-assisted thoracoscopic surgery) can be done. An optimum result after decortication surgery mainly depends on the underlying lung condition. The fibrothorax's duration doesn't determine its outcome.¹³

Complications of lung decortication include:

• Haemorrhage
• Persistent air leak and bronchopleural fistula
• Persistent lung collapse
• Injury to vital structures
• Retained infective focus and sepsis

Pleurectomy

A pleurectomy involves removing part of the pleura. This procedure prevents fluid from collecting in the affected area in the treatment of mesothelioma, a form of pleural mesothelial cancer. The pleurectomy/decortication (P/D) surgery consists of two parts. It involves opening up the chest cavity and removing the pleural lining around the lung. Afterwards, any visible tumour masses are removed from the chest and lung surface.¹⁴

Risks and complications of surgery

Surgical procedures come with risks, such as complications that can be quite serious and sometimes even lead to death. Certain surgeries, like those involving the lungs, heart, and upper abdomen are more prone to causing lung issues. These complications may include atelectasis, hypoxemia, bronchospasm, pneumothorax, pneumonia, pulmonary embolism, and respiratory failure. When someone experiences failure and cannot breathe properly on their own they might need mechanical ventilation support, from a breathing machine until their condition improves.¹⁵

Recovery and rehabilitation

Studies have shown that pulmonary rehabilitation can enhance the patient's breathing and alleviate shortness of breath leading to recovery. A person's outcome following treatment for pleurisy will largely determine how serious the illness is and how it is treated. After taking medication, patients need to be monitored for symptom relief and any possible side effects. It is vital to have rehabilitation plans that focus on respiratory workouts to boost lung function and avoid issues like atelectasis.¹⁶

Conclusion

Pleurisy treatment consists of options, such as medications, thoracentesis and surgical procedures. Medications aim to reduce inflammation and pain, treat infections, and manage conditions. Thoracentesis is used for both diagnosis and treatment by removing pleural fluid. Surgical interventions like pleurodesis, decortication, and pleurectomy are reserved for recurrent cases when other treatments are ineffective.

Treating pleurisy involves a range of strategies tailored to address symptoms and root causes. Effective management often involves a mix of medication procedures like thoracentesis and in some situations, surgical solutions. Providing patient outcomes requires personalised treatment plans that consider each patient's unique clinical situation. Advances in research and technology are continually improving the effectiveness and safety of pleurisy treatments, offering promise for better patient care.

Future directions

Future treatments for pleurisy will focus on new medications and less invasive methods. There is ongoing research to discover new anti-inflammatory drugs and advanced antibiotics. Enhanced thoracentesis methods and minimally invasive surgical techniques are also being investigated. In addition to improving patient outcomes, these advances aim to speed up recovery times and reduce complications.

It is crucial to conduct research on new medications and less invasive procedures in order to advance pleurisy treatment. Inflammation and infection can be managed more effectively and safely through innovations in pharmacotherapy. Furthermore, less invasive surgical techniques are reducing recovery times and improving patient outcomes.