RT Book, Section A1 Stutz, Matthew R. A1 Kress, John P. A2 Schmidt, Gregory A. A2 Kress, John P. A2 Douglas, Ivor S. SR Print(0) ID 1201804037 T1 Pleural Diseases T2 Hall, Schmidt and Wood’s Principles of Critical Care, 5th Edition YR 2023 FD 2023 PB McGraw Hill PP New York, NY SN 9781264264353 LK accesssurgery.mhmedical.com/content.aspx?aid=1201804037 RD 2024/10/03 AB KEY POINTSPneumothorax in critically ill patients is often missed with conventional chest radiography. Ultrasound is a more reliable means of detecting pneumothorax.Pleural effusions can be detected by chest radiograph, chest CT and ultrasound. Ultrasound can be used for real time guidance of thoracentesis and chest tube placement.Indications for placement of a chest drain include: the presence of frank pus, positive gram stain or culture of pleural fluid and/or pH <7.2.An empyema is the presence of pus within the pleural space and should be treated with systemic antibiotics, insertion of a chest drain and intrapleural tissue plasminogen activator (TPA) plus DNase.Recurring pleural effusions (e.g. malignant) can be managed by placement of a tunneled drainage system which frequently results in spontaneous pleurodesis or patients can undergo directed pleurodesis (chemical or surgical).Chemical and surgical pleurodesis is extremely painful and should always be preceded by aggressive anesthesia and analgesia.Chest tubes placed for pneumothorax should be evaluated daily for air leak. Pleural drainage systems can usually be placed on water seal rather than suction. This may hasten the resolution of the visceral pleural defect and subsequently stop the air leak, facilitating chest tube removal.Chest tube removal can be considered when there is no air leak in the pleural drainage system (pneumothorax) and/or there is less than 100 to 300 mL of fluid drainage per day (effusion).