What is the treatment for a large pleural effusion?

From the Guidelines

Treatment of a large pleural effusion should involve thoracentesis to drain the fluid, followed by addressing the underlying cause, with the use of an indwelling pleural catheter (IPC) or chemical pleurodesis as first-line definitive pleural intervention for symptomatic patients with expandable lung and no prior definitive therapy, as recommended by the American Thoracic Society (ATS) and the Society of Thoracic Surgeons (STS) 1. The goal of treatment is to alleviate symptoms, prevent recurrence, and improve quality of life. For symptomatic patients, therapeutic thoracentesis provides immediate relief by removing 1-1.5 liters of fluid, as suggested by the ATS/STS guideline 1. If the effusion recurs or is caused by conditions like malignancy or infection, a chest tube may be inserted for continuous drainage. The European Respiratory Society (ERS) and European Association for Cardio-Thoracic Surgery (EACTS) also recommend definitive pleural intervention for patients with symptomatic malignant pleural effusions, including pleurodesis using a chemical agent or talc pleurodesis via thoracoscopy or chest tube 1. Specific treatments depend on the underlying cause, such as antibiotics for infectious effusions or chemotherapy for malignancy-related effusions. Patients should be monitored with follow-up chest imaging to ensure resolution, and treatment is essential as large effusions can cause respiratory compromise through lung compression and mediastinal shift, potentially leading to hypoxemia and hemodynamic instability if left untreated. Key considerations in the management of large pleural effusions include:

• Ultrasound imaging to guide pleural interventions, as recommended by the ATS/STS guideline 1
• The use of IPCs or chemical pleurodesis as first-line definitive pleural intervention for symptomatic patients with expandable lung and no prior definitive therapy
• The importance of addressing the underlying cause of the effusion, such as malignancy or infection
• The need for ongoing monitoring and follow-up to ensure resolution and prevent recurrence.

From the Research

Treatment Options for Large Pleural Effusion

• The main goals of management are evacuation of the pleural fluid and prevention of its re-accumulation 2.
• Treatment should be tailored to the individual patient, considering comorbidities, size of the effusion, rate of fluid accumulation, underlying cardiac or respiratory conditions, rate of recurrence, presence of loculations or trapped lung, tumor characteristics, cancer type, and patient preferences 3.
• For large, refractory pleural effusions, drainage is necessary to provide symptomatic relief, and management depends on the underlying etiology of the effusion 4.

Drainage and Pleurodesis

• Thoracentesis should be performed for new and unexplained pleural effusions, and laboratory testing helps to distinguish pleural fluid transudate from an exudate 4.
• Chemical pleurodesis is the most common modality of therapy for patients with recurrent pleural effusion, with talc being the most successful pleurodesis agent 2.
• A Pleur-X catheter can reduce hospital stay and adds value to the treatment of patients with trapped lung, who are not appropriate candidates for pleurodesis 2.
• Talc is not recommended for pleurodesis in some cases, as it induces acute respiratory distress syndrome in about 5% of patients, with an overall mortality of 1% 5.

Surgical and Other Invasive Approaches

• Surgical options include thoracentesis, chest tube drainage, thoracoscopy followed by chemical and mechanical pleurodesis, Pleur-X catheter drainage, and pleurectomy 2.
• Percutaneous closed pleural biopsy is recommended for evaluation and exclusion of various etiologies, such as tuberculosis or malignant disease 4.
• Empyemas need to be treated with appropriate antibiotics and intercostal drainage, and 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 4.
• Outpatient management of malignant pleural effusion using a tunneled pleural catheter is a viable alternative to conventional therapy and is better tolerated 6.