What are the management options for pleural effusion?

From the Guidelines

Management of pleural effusion should prioritize a patient-centered approach, focusing on symptom relief and quality of life, with the initial step involving thoracentesis for diagnostic and therapeutic purposes, as recommended by the most recent guidelines 1. The management of pleural effusion depends on its underlying cause, severity, and patient symptoms.

• The initial approach involves thoracentesis, which serves both diagnostic and therapeutic purposes by removing fluid for analysis and relieving symptoms.
• For recurrent or large effusions, chest tube drainage may be necessary, often followed by pleurodesis using agents like talc or doxycycline to prevent reaccumulation.
• Specific treatments target the underlying cause:
  • diuretics for heart failure-related effusions
  • antibiotics for parapneumonic effusions or empyema (often requiring drainage)
  • chemotherapy or targeted therapy for malignant effusions.
• Indwelling pleural catheters offer long-term management for recurrent malignant effusions, allowing outpatient drainage.
• In cases of trapped lung or loculated effusions, video-assisted thoracoscopic surgery (VATS) may be required for decortication.
• Thoracoscopy can also facilitate direct visualization, biopsy, and pleurodesis in a single procedure.
• Symptomatic treatment includes pain management and supplemental oxygen as needed.
• Regular follow-up imaging is essential to monitor resolution or recurrence, with treatment adjustments based on clinical response.
• The management approach should be individualized, considering the patient's overall condition, prognosis, and preferences, as emphasized in recent guidelines 1. The use of ultrasound imaging to guide pleural interventions is recommended, and therapeutic pleural interventions should not be performed in asymptomatic patients with known or suspected malignant pleural effusion, as stated in the official ATS/STS/STR clinical practice guideline 1.

From the Research

Management Options for Pleural Effusion

The management of pleural effusion depends on the underlying etiology of the effusion. The following are some of the management options:

• Transudative effusions are usually managed by treating the underlying medical disorder 2
• Exudative effusions are managed based on the underlying etiology of the effusion 2
• Malignant effusions are usually drained to palliate symptoms and may require pleurodesis to prevent recurrence 2
• 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
• Pleural biopsy is recommended for evaluation and exclusion of various etiologies, such as tuberculosis or malignant disease 2
• Percutaneous closed pleural biopsy is easiest to perform, the least expensive, with minimal complications, and should be used routinely 2
• Thoracocentesis should be performed for new and unexplained pleural effusions 2
• Laboratory testing helps to distinguish pleural fluid transudate from an exudate 2
• The diagnostic evaluation of pleural effusion includes chemical and microbiological studies, as well as cytological analysis, which can provide further information about the etiology of the disease process 2
• Immunohistochemistry provides increased diagnostic accuracy 2
• A systematic approach is needed to enable a rapid diagnosis and an appropriate treatment 3
• Pleural fluid analysis is the first step to perform which allows a presumptive diagnosis in most cases 3
• Further analysis of the pleural fluid or thoracic imaging or pleural biopsy may be necessary 3
• In symptomatic patients, a rapid diagnosis and prompt management of massive pleural effusion or hemothorax can be lifesaving 4
• The emergency physician must have a systematic approach that allows rapid recognition, clinical cause identification and definitive management of potential urgent pleural effusions 4
• The combination of CT plus pleural fluid cytology significantly improved sensitivity and accuracy in distinguishing between benign and malignant pleural effusion 5
• Precise differential diagnostic categorization is essential, as the treatment and prognosis of pleural effusion largely depend on its cause 6
• The specific treatment of pleural effusion ranges from pleurodesis, to thoracoscopy and video-assisted thoracoscopy (with early consultation of a thoracic surgeon), to the placement of a permanently indwelling pleural catheter 6