›Symptom and physiology support
›Oxygen therapy
›Nasal cannula titration to SpO2 target
›Target SpO2 92% to 96% for most patients
›Ventilatory support
›If COPD with hypercapnia, target SpO2 88% to 92%
›If cardiogenic pulmonary edema, noninvasive ventilation
›Analgesia
›Acetaminophen oral
›Opioid sparing strategy when possible
›Procedural analgesia
›Lidocaine 1% local infiltration
›Minimal sedation approach when respiratory reserve limited
Etiology-directed therapy
›Heart failure related effusion
›Loop diuretics
›Furosemide IV 20 to 80 mg based on prior exposure
›If diuretic naive, 20 to 40 mg IV
›Reassess urine output at 2 hours
›If on home loop diuretic, IV dose at least equivalent to total daily oral dose
›If inadequate diuresis, double IV dose
›Electrolyte monitoring
›Potassium target 4.0 to 5.0 mmol/l
›Replace if low
›Magnesium target 1.0 to 1.2 mmol/l
›Replace if low
›Guideline strength
›Acute decompensated heart failure IV diuretics supported as Class I recommendation in major HF guidelines
›Parapneumonic effusion and empyema
›Antibiotics
›If community-acquired pneumonia source, ceftriaxone IV 2 g daily
›Add azithromycin IV 500 mg daily when atypical coverage desired
›Macrolide QT risk awareness
›If aspiration risk, add metronidazole IV 500 mg every 8 hours
›Anaerobic coverage
›If MRSA risk, add vancomycin IV 15 to 20 mg/kg per dose
›Trough or AUC monitoring per local protocol
›Nephrotoxicity mitigation
›If hospital-acquired source, piperacillin-tazobactam IV 4.5 g every 6 to 8 hours
›Add vancomycin when MRSA risk
›De-escalation with cultures
›Drainage indications
›If pleural fluid pH < 7.20, chest tube drainage recommended (Class I, consensus)
›If pH unavailable, glucose < 3.3 mmol/l as surrogate
›High risk of complicated effusion
›If frank pus, immediate drainage
›Empyema definition
›If loculated effusion with persistent fever, drainage and specialist input
›Consider intrapleural therapy
›Intrapleural fibrinolytic therapy
›If ongoing sepsis with loculations despite tube, consider tPA plus DNase per pleural service
›Bleeding risk assessment
›Avoid if active bleeding
›Malignant pleural effusion
›Therapeutic thoracentesis for symptom relief
›Recurrent effusion planning
›Indwelling pleural catheter referral
›Outpatient drainage program
›Pleurodesis referral when lung re-expands
›Specialist procedure
›Hemothorax
›Tube thoracostomy
›Large-bore chest tube per trauma protocol
›Ongoing output monitoring
›If massive initial output or ongoing bleeding, urgent thoracic surgery
›Hemodynamic resuscitation coordination
Thoracentesis and pleural drainage
›Thoracentesis strategy
›Indications
›New unilateral effusion without clear cause
›Diagnostic sampling priority
›Moderate to large effusion with dyspnea
›Therapeutic drainage
›Suspicion for infection, malignancy, hemothorax
›Full pleural fluid panel
›Contraindications and precautions
›Uncorrected severe coagulopathy as relative contraindication
›Individualized risk assessment
›Very small or inaccessible effusion without safe window
›Ultrasound guidance to confirm
›Positive pressure ventilation
›Higher pneumothorax risk
›Technique safety
›Ultrasound guidance as standard when available (ACEP Level B)
›Site selection avoiding intercostal vessels
›Patient positioning
›Upright seated if tolerated
›Lateral decubitus alternative
›Volume and re-expansion considerations
›If chest discomfort or cough, stop drainage
›Pleural pressure change signal
›If high risk for re-expansion pulmonary edema, staged drainage
›Large chronic effusion
›Young patients and rapid drainage
›Chest tube drainage
›Indications
›Empyema and complicated parapneumonic effusion
›Low pH or pus
›Hemothorax
›Trauma protocol alignment
›Tube selection
›Small-bore catheter for simple infected effusions when appropriate
›Ultrasound guided placement
›Large-bore for hemothorax
›Clot management
›Post-placement management
›Drainage system setup
›Water seal versus suction per protocol
›Output monitoring
›Hourly early output in unstable patients
›Post-procedure complications
›Pneumothorax
›If symptomatic or large, chest tube
›If small and stable, observation and oxygen
›Bleeding
›If hemodynamic compromise, resuscitation and urgent imaging
›Interventional radiology or surgery escalation
›Re-expansion pulmonary edema
›If hypoxemia after drainage, supportive ventilation
›Avoid further rapid drainage
›Vasovagal reaction
›Trendelenburg positioning
›IV fluids if needed