I. Introduction

Pleural disorders in the ICU often occur in patients with coagulopathy, mechanical ventilation, immunosuppression, pregnancy or pediatric age. These scenarios demand tailored procedural techniques, careful anticoagulation management, and specialized pharmacotherapy to optimize safety and outcomes.

Key Controversies:

• Safe INR/platelet thresholds for drainage procedures.
• Prothrombin Complex Concentrate (PCC) versus Fresh Frozen Plasma (FFP) for anticoagulation reversal.
• Small-bore versus large-bore chest tubes for different pleural conditions.
• The role of fibrinolytics versus surgical intervention in complex pleural infections.
• Palliative strategies, including indwelling pleural catheters versus pleurodesis.
• Mitigation strategies for Post-Intensive Care Syndrome (PICS) in patients with prolonged pleural issues.

II. Procedural and Pharmacologic Modifications in High-Bleeding-Risk Patients

Summary: Invasive pleural procedures can be performed safely in coagulopathic or thrombocytopenic patients when ultrasound guidance, individualized risk assessment, and appropriate reversal protocols are used.

A. Pre-procedural Assessment

• Platelet goal: Commonly ≥50,000/µL; select lower thresholds (30,000–50,000/µL) only with ultrasound guidance and urgent indication.
• No validated bleeding scores for pleural drainage; use clinical judgment.
• Always perform point-of-care thoracic ultrasound to avoid intercostal vessels and guide needle/catheter placement.

B. Anticoagulation Reversal

1. Warfarin

• Vitamin K (IV 5–10 mg; onset 6–12 h). Reserve oral doses for nonurgent cases.
• 4-Factor PCC (25–50 U/kg; rapid INR correction within minutes). Target INR <1.5 prior to high-risk procedures.
• Pearl: Give IV vitamin K concurrently to maintain sustained reversal.

2. PCC vs FFP

• PCC: Low volume, fast onset, minimal transfusion reaction risk.
• FFP: 10–15 mL/kg; slower, risk of volume overload, requires blood typing.

3. Protamine (Heparin/LMWH)

• 1 mg per 100 U heparin; for enoxaparin, 1 mg protamine per 1 mg enoxaparin.
• Monitor aPTT or anti-Xa.

4. DOAC Reversal

• Idarucizumab 5 g IV for dabigatran.
• Andexanet alfa infusion per last dose/timing for factor Xa inhibitors; high cost and thrombosis risk.

Clinical Decision Algorithm: Anticoagulation Reversal for Pleural Procedures

C. Platelet Transfusion Thresholds

• Empirical threshold ≥50,000/µL for most thoracentesis and chest tube placements.
• Some centers proceed at ≥30,000/µL with meticulous ultrasound technique.

D. Ultrasound Guidance & Catheter Selection

• Standard: ultrasound‐guided site marking and real‐time needle visualization.
• Small‐bore (8–14 F) pigtails match large‐bore efficacy for effusions and hemothorax; they cause less pain and tissue trauma.

III. Management in Mechanically Ventilated or Hemodynamically Unstable Patients

Summary: Positive‐pressure ventilation alters pleural physiology, increasing barotrauma risk; rapid recognition and adaptation of ventilator settings and drainage techniques are critical.

A. Ventilator–Pneumothorax Pathophysiology

In ventilated lungs, pneumothorax can progress swiftly to tension due to inability to equilibrate pressures.

B. Recognition & Needle Decompression

• Suspect tension with sudden hypoxemia, hypotension or raised airway pressures.
• Immediate needle decompression (2nd Intercostal Space Midclavicular Line or 5th Intercostal Space Anterior Axillary Line) is life-saving; do not delay for imaging.

C. Chest Tube Placement Adaptations

Use ultrasound to choose a safe window; small‐bore tubes suffice for effusions, tailor size for empyema/hemothorax viscosity.

D. Ventilator Setting Adjustments

Temporarily lower PEEP and tidal volume during and after fluid removal to mitigate re‐expansion pulmonary edema.

E. Hemodynamic Monitoring & Resuscitation

Arterial line and CVP enable close monitoring; anticipate hypotension from fluid shifts and support with fluids/vasopressors as needed.

IV. Considerations for Immunocompromised, Pediatric, and Pregnant Patients

Summary: Unique physiologies and risks in these populations necessitate modifications in antimicrobial selection, imaging modality, dosing, and procedural consent/sedation.

A. Immunocompromised Hosts

• Pathogen spectrum widened; Staphylococcus aureus most common in Indwelling Pleural Catheter (IPC)‐related infections (infection risk ~5.7%, median 60 days).
• Retain IPC during infection unless antibiotic therapy fails.
• Prefer ultrasound to avoid radiation and nephrotoxic contrast.

B. Pediatric Patients

• Use age/size‐appropriate catheters.
• Sedation and analgesia protocols tailored by developmental stage; obtain proper consent or assent.
• Prospective data show no difference in outcomes between repeated thoracentesis (average 2.4 aspirations) and chest tube drainage in empyema.

C. Pregnant Patients

• Physiologic pleural fluid shifts may occur.
• Avoid ionizing radiation—use ultrasound and shielding if other imaging is essential.
• Antibiotics: β-lactams and macrolides generally safe; avoid tetracyclines and NSAIDs in late pregnancy.
• Analgesics: Acetaminophen preferred; use opiates judiciously.

V. Transition-of-Care and PICS Mitigation

Summary: Structured criteria for drain removal, early rehab referral, and outpatient pathways reduce Post-ICU Syndrome (PICS) and readmissions.

A. Chest Tube Removal Criteria

• Drainage <150 mL/24 h.
• No air leak.
• Radiographic lung re‐expansion.
• Schedule post-discharge chest X-ray or ultrasound in 1–2 weeks.

B. PICS Identification & Rehabilitation

• High risk: Prolonged chest tube (>7 days), empyema, extended ICU stay.
• Early Physical Therapy (PT) / Occupational Therapy (OT) referral improves functional recovery and reduces long-term impairments.

C. Outpatient Care Pathways

• Multidisciplinary follow-up with pulmonology, primary care and rehab.
• Patient education on signs of recurrence and catheter care.

VI. Goals of Care Conversations & Palliative Strategies

Summary: Align pleural intervention with patient values in malignant effusions; weigh pleurodesis versus IPC placement, and emphasize symptom relief and Quality of Life (QoL).

A. Recurrent Malignant Effusions

• Pleurodesis (talc preferred): Consider when lung fully expands.
• Indwelling Pleural Catheter (IPC): Preferred for trapped lung or patients with limited life expectancy.
• The TIME1 Trial indicated NSAIDs are safe for pleurodesis; small (<12 F) drains had higher displacement and lower success rates for pleurodesis.

B. Communication Frameworks

Use structured approaches (e.g., SPIKES, NURSE) to discuss prognosis, risks/benefits, and patient goals effectively and empathetically.

C. Symptom Management & QoL

• Dyspnea relief: Low-dose opioids can be effective.
• Infections: Manage IPC-related infections with appropriate antibiotics.
• Involve palliative care early for refractory symptoms and complex decision-making.