What is the treatment for pleural effusion?

Treatment of Pleural Effusion

The treatment of pleural effusion should be directed at the underlying cause, with therapeutic thoracentesis for symptomatic relief and definitive interventions such as pleurodesis or indwelling pleural catheters for recurrent effusions. 1, 2

Diagnostic Approach

• Thoracentesis should be performed for new and unexplained pleural effusions
• Laboratory testing to distinguish between transudate and exudate using Light's criteria
• Ultrasound guidance is recommended for all pleural interventions to reduce complications 2

Treatment Algorithm Based on Type and Etiology

Transudative Effusions

• Treat the underlying medical condition:
  • Congestive heart failure: Diuretics and cardiac medications
  • Cirrhosis: Sodium restriction, diuretics, paracentesis
  • Nephrotic syndrome: Treat underlying renal disease

Exudative Effusions

Malignant Pleural Effusions

1. Asymptomatic patients:

   • Observation without intervention 2

2. Symptomatic patients with expandable lung:

   • Options for first-line definitive intervention:

     • Indwelling pleural catheter (IPC) OR
     • Chemical pleurodesis 2

   • For pleurodesis:

     • Talc is the preferred sclerosing agent
     • Either talc poudrage or talc slurry can be used 2, 1
     • Patient should be maintained on 220 cm H₂O suction after talc instillation
     • Remove chest tube when 24-hour drainage is 100-150 ml 2
     • If drainage remains excessive after 48-72 hours, repeat talc instillation 2

3. Symptomatic patients with non-expandable lung, failed pleurodesis, or loculated effusion:

   • Indwelling pleural catheter is preferred 2, 1
   • Pleuroperitoneal shunt may be considered 2, 1

4. Patients with chemotherapy-responsive tumors:

   • Systemic therapy (chemotherapy, hormone therapy) should be initiated if no contraindications exist
   • May be combined with therapeutic thoracentesis or pleurodesis 2
   • Particularly effective for breast cancer, small-cell lung cancer, lymphoma, prostate, ovarian, thyroid, and germ-cell tumors 2

Parapneumonic Effusions/Empyema

• Appropriate antibiotics based on culture results
• Chest tube drainage
• Consider intrapleural thrombolytic therapy for loculated effusions
• Surgical intervention (VATS or thoracotomy with decortication) if drainage fails 1

Special Considerations for Indwelling Pleural Catheters

• Drainage frequency:

  • Symptom-based drainage is effective for controlling breathlessness
  • Daily drainage recommended if catheter removal is a priority (higher pleurodesis rates) 1

• Management of IPC-associated infections:

  • Usually can be treated without catheter removal
  • Consider catheter removal if infection fails to improve 2

Surgical Options

• Video-Assisted Thoracoscopic Surgery (VATS):

  • Indicated for undiagnosed effusions requiring tissue diagnosis
  • Combined diagnostic and therapeutic management
  • Talc poudrage for malignant pleural effusions 1

• Thoracotomy:

  • Reserved for cases where VATS fails
  • Extensive surgical repair of diaphragmatic defects
  • Parietal pleurectomy for recurrent effusions
  • Decortication for trapped lung
  • Note: Has higher perioperative mortality (12%) 2, 1

Complications to Monitor

• Re-expansion pulmonary edema if >1.5L of fluid removed at once
• Pneumothorax during thoracentesis (reduced with ultrasound guidance)
• Infection with indwelling catheters (8-10% of cases)
• Acute respiratory distress syndrome with talc (less common with large-particle talc) 1

The treatment approach should prioritize symptom relief while addressing the underlying cause, with the goal of minimizing repeated procedures and healthcare interactions, particularly for malignant effusions where average survival is 4-7 months 2.