How is a pleural effusion treated?

Treatment of Pleural Effusion

Treatment of pleural effusion depends fundamentally on whether it is transudative or exudative, with transudates managed by treating the underlying medical condition (heart failure, cirrhosis) and exudates requiring intervention based on etiology, symptoms, and specific pleural fluid characteristics. 1

Initial Diagnostic and Treatment Framework

Asymptomatic Effusions

• Do not perform therapeutic interventions on asymptomatic pleural effusions regardless of radiological size—observation alone is appropriate, as the decision to intervene must be based on symptoms, not imaging. 1

Transudative Effusions

• Direct therapy toward the underlying medical condition (heart failure, cirrhosis, nephrotic syndrome) rather than draining the effusion itself. 1, 2
• Therapeutic thoracentesis may provide temporary symptomatic relief while treating the underlying disease, but limit fluid removal to 1.5L during a single procedure to prevent re-expansion pulmonary edema. 3, 1
• Consider pleurodesis with a sclerosant only if patients with recurrent transudative effusion have severe dyspnea despite optimal medical management. 4

Management of Exudative Effusions

Parapneumonic Effusion and Empyema

All patients with parapneumonic effusion require hospitalization with intravenous antibiotics covering common respiratory pathogens. 1

Indications for Chest Tube Drainage

Insert a small-bore chest tube (14F or smaller) if any of the following are present: 5, 1

• pH <7.0 (or <7.2 in some guidelines)
• Glucose <2.2 mmol/L (or <40 mg/dL)
• Positive Gram stain
• Frank pus (empyema)
• LDH >3 times upper limit of normal for serum
• Presence of pleural loculations

Management of Loculated Effusions

• If the pleural fluid cannot be completely evacuated due to loculations, administer intrapleural thrombolytic therapy (streptokinase or urokinase). 5, 4, 6
• If thrombolytics are ineffective after appropriate trial, proceed to video-assisted thoracoscopic surgery (VATS) with breakdown of adhesions and debridement, or thoracotomy with decortication if VATS is unsuccessful. 5, 6

Timing of Chest Tube Removal

• Remove chest tubes when 24-hour drainage is less than 100-150 mL to reduce infection risk and promote healing. 5, 3
• Earlier drain removal at higher outputs (up to 450 mL/day) following thoracic surgery has been shown to be safe and efficacious. 5

Malignant Pleural Effusion

The treatment pathway for malignant effusions depends on three critical factors: tumor chemosensitivity, patient performance status, and lung expandability. 1

Step 1: Assess Tumor Chemosensitivity

For chemotherapy-responsive tumors (small-cell lung cancer, breast cancer, lymphoma), systemic chemotherapy is the primary treatment—do not delay systemic therapy in favor of local treatment. 5, 3, 1

• Small-cell lung cancer: Systemic chemotherapy is the treatment of choice; pleurodesis is indicated only when chemotherapy is contraindicated or ineffective. 5, 3
• Breast cancer: May respond to hormonal therapy or chemotherapy; if ineffective, apply local treatment with pleurodesis. 5, 3
• Lymphoma: Systemic chemotherapy is primary treatment, with pleurodesis considered only for symptomatic relief in recurrent effusions. 5, 3

Step 2: Initial Therapeutic Thoracentesis

Perform large-volume thoracentesis (maximum 1.5L) to assess symptomatic response and lung expandability—this is essential before considering definitive pleural interventions. 3, 1

• Remove fluid at approximately 500 mL/hour if using continuous drainage. 3
• Check post-thoracentesis chest radiograph for mediastinal shift and complete lung expansion. 3

Step 3: Choose Definitive Intervention Based on Lung Expandability

For expandable lung (mediastinal shift present, complete lung expansion on post-thoracentesis imaging):

• Either talc pleurodesis or indwelling pleural catheter (IPC) can be used as first-line definitive intervention, with similar efficacy. 3, 1
• Talc pleurodesis technique: Use 4-5g of talc in 50 mL normal saline, administer intrapleural lignocaine (3 mg/kg; maximum 250mg) for analgesia, clamp the chest tube for 1 hour after instillation. 3
• Talc can be administered either as slurry through chest tube or as poudrage via thoracoscopy with similar efficacy. 3
• Avoid corticosteroids at the time of pleurodesis, as they reduce the pleural inflammatory reaction and prevent successful pleurodesis. 3

For non-expandable lung (trapped lung, no mediastinal shift post-thoracentesis, incomplete lung expansion):

• IPC is preferred over chemical pleurodesis—pleurodesis will fail if there is incomplete lung expansion. 3, 1
• If expansion is inadequate due to cortex of malignant tissue or fibrosis, consider pleuroperitoneal shunt insertion. 5

Step 4: Palliative Approach for Limited Life Expectancy

For patients with very short life expectancy (<3 months) or poor performance status (ECOG ≥2):

• Repeated therapeutic pleural aspiration provides transient symptom relief without hospitalization and is appropriate for palliation. 3, 1
• Note that recurrence rate at 1 month after aspiration alone is close to 100%. 3
• Do not perform intercostal tube drainage without pleurodesis—it has a nearly 100% recurrence rate and offers no advantage over simple aspiration. 3, 1

Management of Failed Pleurodesis

If initial pleurodesis fails, several alternatives may be considered: 5

• Repeat pleurodesis (either through chest tube or by thoracoscopy with talc poudrage)
• Repeat thoracentesis for terminal patients with short expected survival
• Pleuroperitoneal shunting for patients with reasonably good clinical condition
• IPC placement

Special Populations

Post-Surgical Pleural Effusions

• Most postoperative pleural effusions do not require intervention—radiological features alone should not dictate the need for intervention, as there is no evidence these effusions impact morbidity or mortality. 5
• Ultrasound-guided thoracentesis has largely replaced more invasive surgical tube thoracostomy and is both effective and well tolerated. 5
• A protocolized pathway for intervention resulted in small improvements in walking distance, had no impact on quality of life or self-reported symptoms, and reduced hospital length of stay. 5

End-Stage Renal Failure (ESRF)

• If the etiology is fluid overload, aggressive medical management or renal replacement therapy (RRT) adequately treats pleural effusions. 5
• However, adverse event rates of aggressive RRT can limit this approach; pleural interventions have been shown to be relatively safe. 5
• Offer serial thoracocentesis as the first treatment option, with IPCs or attempted talc pleurodesis reserved for refractory cases, given the high adverse event rate and increased drainage volume with IPCs. 5
• There is significant risk of pleural infection or malignancy in this population—conduct cross-sectional imaging early if clinical suspicion exists. 5

Critical Pitfalls to Avoid

• Never remove more than 1.5L during single thoracentesis to prevent re-expansion pulmonary edema. 3, 1
• Never attempt pleurodesis without confirming lung expandability—it will fail in non-expandable lung. 3, 1
• Do not delay systemic therapy in chemotherapy-responsive tumors (small-cell lung cancer, breast cancer, lymphoma) in favor of local treatment. 3, 1
• Major surgical procedures (parietal pleurectomy, decortication, pleuropneumonectomy) performed alone provide neither superior palliation nor cure compared to pleurodesis alone and carry 12% perioperative mortality. 5, 1
• Always use ultrasound guidance for all pleural interventions—it significantly reduces pneumothorax risk (1.0% vs 8.9% without guidance) and improves success rates. 3, 1
• IPC-associated infections can usually be treated with antibiotics without removing the catheter; consider catheter removal only if infection fails to improve. 3