What is the management of pleural effusion?

From the Guidelines

Management of pleural effusion should prioritize a systematic approach, starting with ultrasound-guided thoracentesis for diagnostic and therapeutic purposes, as recommended by the American Thoracic Society (ATS) and Society of Thoracic Surgeons (STS) guidelines 1. The initial step involves removing 50-100 mL of fluid for diagnostic purposes, including cell count, biochemistry, cytology, microbiology, and pH if infection is suspected. For therapeutic thoracentesis, larger volumes (up to 1.5 L) can be removed to relieve symptoms, but it is essential to avoid removing more than 1.5 L at once to prevent re-expansion pulmonary edema. The underlying cause of the pleural effusion determines further management:

• For malignant effusions, consider pleurodesis with talc (4-5g) or doxycycline (500mg), as suggested by the BTS guidelines 1.
• For symptomatic malignant pleural effusions with expandable lung, either an indwelling pleural catheter (IPC) or chemical pleurodesis can be used as first-line definitive pleural intervention, as recommended by the ATS/STS guidelines 1.
• For patients with IPC-associated infections, treating through the infection without catheter removal is usually adequate, but catheter removal may be necessary if the infection fails to improve, as suggested by the ATS/STS guidelines 1. Key considerations in managing pleural effusions include:
• Using ultrasound imaging to guide pleural interventions, as recommended by the ATS/STS guidelines 1.
• Avoiding therapeutic pleural interventions in asymptomatic patients with known or suspected malignant pleural effusion, as suggested by the ATS/STS guidelines 1.
• Monitoring patients for complications, including pneumothorax, hemothorax, infection, and re-expansion pulmonary edema, during and after procedures.

From the Research

Diagnosis of Pleural Effusion

• Pleural effusion is an excessive accumulation of fluid in the pleural space, which can be related to disorders of the lung or pleura, or to a systemic disorder 2
• Patients commonly present with dyspnea, dry cough, and pleuritic chest pain 2
• Thoracocentesis should be performed for new and unexplained pleural effusions to determine the etiology 2
• Laboratory testing helps to distinguish pleural fluid transudate from an exudate, and chemical and microbiological studies, as well as cytological analysis, can provide further information about the etiology of the disease process 2

Management of Pleural Effusion

• Transudative effusions are usually managed by treating the underlying medical disorder 2
• Exudative effusions require management 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, 3
• Pleural biopsy is recommended for evaluation and exclusion of various etiologies, such as tuberculosis or malignant disease 2
• Empyemas need to be treated with appropriate antibiotics and intercostal drainage, and surgery may be needed in selected cases 2

Treatment Options for Malignant Pleural Effusions

• Therapeutic thoracenteses, thoracoscopic talc pleurodesis, bedside pleurodesis with talc or other sclerosing agents via small-bore chest catheters, indwelling pleural catheters, surgery, or a combination of these procedures can be used to manage malignant pleural effusions 4
• Selection of a treatment approach should take into account patient preferences and performance status, tumor type, predicted prognosis, presence of a non-expandable lung, and local experience or availability 4
• Indwelling pleural catheters provide a high degree of symptomatic relief on an outpatient basis and are being positioned as a first choice therapy in many centers 4

Emergency Department Management

• Rapid diagnosis and prompt management of massive pleural effusion or hemothorax can be lifesaving in symptomatic patients admitted to the emergency department 5
• Ultrasonography can facilitate diagnosis and guide invasive procedures, such as thoracentesis and insertion of small and large bore chest drains 5
• The emergency physician must have a systematic approach that allows rapid recognition, clinical cause identification, and definitive management of potential urgent pleural effusions 5