From the Guidelines
In patients with symptomatic malignant pleural effusion, large-volume thoracentesis or an indwelling pleural catheter (IPC) should be considered as first-line treatment to manage dyspnea, as suggested by the American Thoracic Society guidelines 1. When managing pleural effusions, it's crucial to determine the underlying cause, as treatment varies significantly. For malignant pleural effusions, the American Thoracic Society recommends using ultrasound imaging to guide pleural interventions 1.
Key Considerations
- In asymptomatic patients with known or suspected malignant pleural effusion, therapeutic pleural interventions should not be performed 1.
- For symptomatic patients, large-volume thoracentesis can be used to assess lung expansion, especially if pleurodesis is contemplated 1.
- The choice between an indwelling pleural catheter (IPC) and chemical pleurodesis as first-line definitive pleural intervention depends on the patient's symptoms, lung expandability, and prior therapy 1.
Treatment Options
- Indwelling pleural catheter (IPC) or chemical pleurodesis are recommended as first-line treatments for symptomatic malignant pleural effusions with expandable lung and no prior definitive therapy 1.
- Talc poudrage or talc slurry can be used for chemical pleurodesis in patients with expandable lung 1.
- IPCs are preferred over chemical pleurodesis for patients with nonexpandable lung, failed pleurodesis, or loculated effusion 1.
Management of Complications
- In patients with IPC-associated infections, treatment through the infection without catheter removal is usually adequate, but catheter removal may be necessary if the infection fails to improve 1.
From the Research
Definition and Causes of Pleural Effusion
- Pleural effusion is defined as an excessive accumulation of fluid in the pleural space 2, 3
- It can be caused by various underlying diseases, including congestive heart failure, cancer, pneumonia, and pulmonary embolism 3, 4
- The most common causes of pleural effusion are congestive heart failure, cancer, pneumonia, and pulmonary embolism 4
Diagnosis of Pleural Effusion
- Pleural fluid puncture (pleural tap) enables the differentiation of a transudate from an exudate, which remains the foundation of the further diagnostic work-up 4
- Laboratory testing, including chemical and microbiological studies, as well as cytological analysis, can provide further information about the etiology of the disease process 2
- Immunohistochemistry provides increased diagnostic accuracy 2
- Ultrasonography can facilitate diagnosis and guide invasive procedures 5
Management of Pleural Effusion
- The treatment of pleural effusion depends on its cause and can range from pleurodesis to thoracoscopy and video-assisted thoracoscopy 4
- Transudative effusions are usually managed by treating the underlying medical disorder 2, 6
- Exudative effusions require attempts to define the etiology, and treatment depends on the underlying cause 2, 6
- Malignant effusions are usually drained to palliate symptoms and may require pleurodesis to prevent recurrence 2, 6
- Empyemas need to be treated with appropriate antibiotics and intercostal drainage 2
- Surgery may be needed in selected cases where drainage procedure fails to produce improvement or to restore lung function and for closure of bronchopleural fistula 2
Treatment Options
- Thoracentesis is a procedure that can provide symptomatic relief for patients with large, refractory pleural effusions 2, 5
- Pleurodesis is a procedure that can be used to prevent recurrence of malignant pleural effusions 2, 6, 4
- Insertion of small and large bore chest drains can be used to manage pleural effusions in emergency settings 5
- Percutaneous closed pleural biopsy is recommended for evaluation and exclusion of various etiologies, such as tuberculosis or malignant disease 2