What is the treatment for pleural effusion?

Treatment of Pleural Effusion

The treatment of pleural effusion must be tailored to the underlying cause, with transudative effusions managed by treating the underlying condition and exudative effusions requiring specific interventions based on etiology. 1

Diagnostic Approach

• Ultrasound guidance should be used for all pleural interventions to improve success rates and reduce complications 1
• Thoracentesis should be performed for new and unexplained pleural effusions to determine if the fluid is a transudate or exudate 2
• Pleural fluid analysis should include cell count, protein, LDH, glucose, pH, microbiological studies, and cytology 1, 2
• Blood cultures should be performed when parapneumonic effusion is suspected 1

Treatment Based on Effusion Type

1. Transudative Effusions

• Primary treatment focuses on addressing the underlying medical condition (heart failure, cirrhosis, etc.) 1, 3
• Therapeutic thoracentesis may be necessary for symptomatic patients to provide temporary relief while treating the underlying condition 1
• Observation is appropriate for asymptomatic patients 1

2. Exudative Effusions

A. Parapneumonic Effusion/Empyema

• All patients with parapneumonic effusion should be hospitalized for monitoring and treatment 1
• Initial drainage should use a small-bore chest tube (14F or smaller) 1
• Intravenous antibiotics with coverage for common respiratory pathogens must be administered 1
• If pleural fluid pH is <7.2 or glucose <3.3 mmol/L, drainage is required as this indicates complicated parapneumonic effusion 1
• Intrapleural fibrinolytics may be considered for loculated effusions 4

B. Malignant Pleural Effusion

• Therapeutic thoracentesis should be performed to assess symptom relief and lung expandability 1, 5
• For recurrent malignant effusions with expandable lung, either talc pleurodesis or indwelling pleural catheter (IPC) placement is recommended 1, 5
• Talc pleurodesis can be performed either as a slurry through chest tube or as poudrage via thoracoscopy 5
• For talc slurry, 4-5g of talc in 50ml normal saline should be instilled through the chest tube 5
• Chemotherapy-responsive tumors (small-cell lung cancer, breast cancer, lymphoma) should receive appropriate systemic therapy, which may be combined with thoracentesis or pleurodesis 5
• If lung expansion is inadequate due to trapped lung, a pleuroperitoneal shunt may be considered 5

Special Considerations and Pitfalls

• Caution should be taken when removing more than 1.5L of fluid during a single thoracentesis to prevent re-expansion pulmonary edema 1
• Pleurodesis will fail if there is incomplete lung expansion or a trapped lung 1, 5
• Early involvement of a respiratory specialist is recommended for complicated cases 1
• Chest tubes should be removed when 24-hour drainage is 100-150ml 5
• If drainage remains excessive (≥250ml/24h) after 48-72 hours, repeat talc instillation should be considered 5
• For pleurodesis failure, options include repeat pleurodesis, pleuroperitoneal shunting, or long-term tube drainage 5
• Major surgical procedures like pleurectomy or decortication generally do not provide superior palliation compared to pleurodesis alone 5

Treatment of Specific Conditions

• Lung cancer: For non-small cell lung cancer at advanced stage, talc pleurodesis should be considered 5
• Small-cell lung cancer: Systemic chemotherapy is the treatment of choice, with pleurodesis indicated only when chemotherapy is contraindicated or ineffective 5
• Breast cancer: May respond to hormonal therapy or chemotherapy; if ineffective, local treatment with pleurodesis should be applied 5
• Lymphoma: Systemic chemotherapy is the primary treatment 5
• Mesothelioma: Multimodality therapy should be considered, as single-modality treatments have been disappointing 5