Management of pleural effusions in the neonate
- Joseph B Philips III, MD, FAAP
Joseph B Philips III, MD, FAAP
- Professor of Pediatrics
- University of Alabama at Birmingham
- Thomas Prescott Atkinson, MD, PhD
Thomas Prescott Atkinson, MD, PhD
- Professor, Division of Pediatric Allergy, Asthma & Immunology
- University of Alabama at Birmingham
Pleural effusion occurs as a result of an abnormal fluid collection within the pleural space. Once a pleural effusion has been diagnosed in the neonate, management decisions are based on the effusion's effect on the respiratory status of the patient, which is primarily based on the size of the effusion, and the cause and chronicity of the condition.
The management of neonatal pleural effusions will be reviewed here. The etiology, clinical manifestations, and evaluation of neonatal pleural effusions are discussed separately. (See "Etiology, clinical manifestations, diagnosis and evaluation of pleural effusions in the neonate".)
Symptomatic/large effusions — Most infants with large congenital pleural effusions are diagnosed by antenatal ultrasound. Affected fetuses often are also diagnosed with hydrops fetalis, as they have collection of fluids in other locations (eg, ascites, skin edema, or pericardial effusion) (see "Etiology, clinical manifestations, diagnosis and evaluation of pleural effusions in the neonate", section on 'Hydrops fetalis'). In severe cases, fetal thoracentesis may have been performed in an attempt to prevent pulmonary hypoplasia in fetuses during the second trimester, and prior to delivery to facilitate neonatal delivery, and if needed, resuscitation . In fetuses with hydrops fetalis, ex utero intrapartum treatment (EXIT) has also been used to allow drainage of pleural fluid in the partially delivered and intubated fetus prior to clamping of the umbilical cord, which maintains the fetoplacental circulation [2-4]. (See "Nonimmune hydrops fetalis", section on 'Prognosis' and "Prenatal diagnosis and management of bronchopulmonary sequestration", section on 'Prenatal management' and "Prenatal diagnosis and management of bronchopulmonary sequestration", section on 'Delivery'.)
For fetuses that are diagnosed with large pleural effusions, the delivery should be planned for a tertiary center with staff capable of resuscitating and managing neonates with respiratory compromise. In the delivery room, the neonatal team should anticipate the needs of the most severely affected patient and be prepared to provide respiratory support that includes intubation, positive pressure ventilation, and removal of fluid by needle aspiration. (See 'Needle aspiration' below and "Postnatal care of hydrops fetalis", section on 'Initial resuscitation' and "Neonatal resuscitation in the delivery room".)
Occasionally, an infant will be born with pleural effusions that were undiagnosed in utero. Many of these infants will be hydropic, which should lead to a strong suspicion of a pleural effusion.
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- ACUTE MANAGEMENT
- Symptomatic/large effusions
- - Needle aspiration
- Asymptomatic/small effusions
- MANAGEMENT OF CHRONIC PLEURAL EFFUSIONS
- - Tube thoracostomy
- Volume and electrolyte loss management
- - Pleurodesis
- - Surgical management
- Chylous effusions
- - Overview
- - Protein loss
- - Lymphocyte depletion
- - Dietary management
- - Pharmacologic management
- - Other interventions
- - Follow-up management
- OUR APPROACH
- SUMMARY AND RECOMMENDATIONS