Approach

The treatment of a pleural effusion is dictated by the precipitating cause. Patients with large symptomatic effusions may benefit from oxygen therapy.[74] Chest x-ray is not required after aspiration of an effusion, unless there is clinical suspicion of pneumothorax such as free air aspiration. Chest x-ray after chest tube drainage is recommended.[73]

Where a therapeutic thoracentesis is required, it is recommended that large volumes of pleural fluid are drained at a controlled rate, and subsequent timely checks of vital signs and chest drain volume are carried out after the procedure.[75][76] This is to prevent the risk of rapid deterioration due to a reduction in blood pressure and acute breathlessness associated with potentially life-threatening re-expansion pulmonary edema, which has been observed when large volumes of pleural fluid are drained too rapidly, especially in the first hour after insertion of the needle.[75]

Congestive heart failure

Pleural effusions from heart failure are managed with diuretic therapy. Initial treatment is with loop diuretics. Oral or intravenous furosemide or bumetanide is titrated in response to clinical signs, daily weights, and renal function to avoid excessive volume depletion. In patients with refractory volume overload, nonloop diuretics such as hydrochlorothiazide or metolazone may be used in combination with loop diuretics to improve diuresis.

A therapeutic thoracentesis (thoracocentesis) should be considered if the pleural effusion is large and is causing significant symptoms. It is generally safe to remove 1.5 L of fluid from a hemithorax without the risk of re-expansion pulmonary edema.

Infective

A considerable proportion of patients with pneumonia develop parapneumonic effusions,[77] but the fluid typically resolves if appropriate antibiotic therapy is instigated early.[78]

All patients with suspected or confirmed pleural infection should receive empiric intravenous antibiotics based on local microbiology guidelines to cover the likely causative organisms, both aerobic and anaerobic. The results of pleural fluid culture will further guide antibiotic use.[7]

Gram-positive bacteria are the most common pathogens in community-acquired parapneumonic effusions; Streptococcus pneumoniae, Streptococcus milleri, and Streptococcus intermedius comprise approximately 50% of all cases, while Staphylococcus aureus comprises approximately 11% of all cases. Gram-negatives account for 9%, and anaerobes for 20%.[79] Anaerobic pathogens are also important and present in a more insidious fashion. In hospital-acquired pleural infection, S aureus (total 35%, mostly MRSA 25%) are relevant as well as gram-negative organisms (17%), including E coli, Enterobacter and Pseudomonas species, and anaerobes 8%.[79] These organisms should be covered with broad-spectrum antibiotics by the intravenous route if the clinical scenario dictates. Penicillin-based antibiotics, including those combined with beta-lactamase inhibitors, metronidazole, and cephalosporins, penetrate the pleural space well, but aminoglycosides should be avoided. MRSA should be covered if a hospital-acquired infection is suspected.[79]

Initial drainage of pleural infection should be undertaken using a small bore chest tube (14 French or smaller).[7] If the patient's clinical state worsens and the effusion progresses to a complicated effusion or empyema, timely removal of the fluid is indicated. Septations can develop in a matter of 12-24 hours. Therapeutic thoracentesis is likely to be definitive in most patients. However, if the fluid obtained is frank pus, the bacterial smear or culture is positive, glucose is <60 mg/dL, pH is <7.20, lactate dehydrogenase >1000 U/L, or the fluid is septated, a more aggressive approach should be undertaken with a tube thoracostomy.

Large-bore tubes are traditionally used (28-36 French) and can be inserted at the bedside by a trained physician. However, the British Thoracic Society recommends using small bore needles where possible to minimize the risk of complications.[80]

When chest tubes fail, thoracoscopy with lysis of adhesions, decortication, and open drainage are surgical options.

With regards to intrapleural fibrinolytics, there is no additional benefit in instilling intrapleural fibrinolytic therapy alone in the treatment of parapneumonic effusions or empyema.[81][82] [ Cochrane Clinical Answers logo ] [Evidence B] One double-blind randomized placebo-controlled trial found that tissue plasminogen activator (tPA, a fibrinolytic agent) combined with deoxyribonuclease (DNAse, a viscosity-disrupting agent) improved fluid drainage in patients with pleural infection, reduced the frequency of surgical referral, and reduced the duration of hospital stay.[83] Combined therapy had no effect on mortality or adverse events compared with placebo.[83] Combination therapy with a fibrinolytic agent and a viscosity-disrupting agent should only be considered on a case by case basis in patients who fail to respond to antibiotic therapy and conventional drainage, and are not suitable or willing to proceed to surgery.[83] The BTS recommends that combination tPA and DNAse should be considered for the treatment of pleural infection, where initial chest tube drainage has ceased and leaves a residual pleural collection.[7] Single agent tPA or DNAse should not be considered for treatment of pleural infection.[7]

Due to the lack of supporting evidence, early surgical drainage under video-assisted thoracoscopy surgery (VATS), thoracotomy and medical thoracoscopy should not be considered as initial treatment for pleural infection.[7]

Malignant

Malignant effusions are difficult to manage, as they usually re-accumulate after drainage. Patient preferences need to be taken into account.[84] Therapeutic thoracentesis is effective at providing symptom relief. However, simple thoracentesis is not recommended as the treatment of choice for patients with a good performance status (Karnofsky score >30% or Eastern Cooperative Oncology Group [ECOG] score of 0 or 1).[85] This is because repeated thoracentesis carries a risk of pneumothorax and empyema, and reduces the chances of success of subsequent drainage procedures or thoracoscopy due to pleural adhesions.[85]

Repeated therapeutic thoracenteses can be considered for the treatment of symptomatic recurrent malignant pleural effusion if the life expectancy of the patient is very short (i.e., days to weeks).[85] In patients with a longer life expectancy and/or good performance status, the primary management options are: insertion of a temporary chest tube, with introduction of talc slurry when the patient has drained to dryness; insertion of a tunneled indwelling pleural catheter (IPC); or a talc poudrage at the time of medical or surgical thoracoscopy. The ACCP recommends thoracoscopy with talc poudrage for pleurodesis in patients with lung cancer with a malignant effusion if there are no contraindications to thoracoscopy.[85] However, a more recent RCT comparing thoracoscopy and talc poudrage with intercostal drainage (pleural catheter drainage) and talc slurry infusion in patients with a malignant effusion found no difference in pleurodesis failure rates at 3 months between talc poudrage and talc slurry.[86]

Patients who wish to be treated as outpatients (and who have a home situation where it is feasible to drain the fluid) can be treated with an IPC. There is no difference in relief of dyspnea, and no significant difference in quality of life, between IPC drainage and talc slurry pleurodesis.[87][88] [ Cochrane Clinical Answers logo ] IPC drainage is associated with less time in hospital, but more adverse effects.[89][90][91] A 2022 meta-analysis found that the overall complication incidence was 20.3% in 4983 patients with an IPC, with the most common complications being infection and catheter-related abnormalities.[91]

Patients who do not wish to have an IPC should be treated with sclerosing agents to create an inflammatory reaction that will essentially stick the parietal and visceral pleura together. Talc, bleomycin, and tetracycline are commonly used agents. Sterile large particle talc by poudrage under thoracoscopic guidance is the most effective agent for pleurodesis.[85][88][92] Pleurodesis may be a painful procedure, and effective analgesia (including the use of intrapleural lidocaine) is mandatory.[93] One randomized trial found no significant difference in pain scores between patients receiving nonsteroidal anti-inflammatory drug (NSAID) or opiate analgesia for pleurodesis in malignant pleural effusion; NSAID use resulted in noninferior rates of pleurodesis efficacy at 3 months.[94] Safe administration of agents inducing conscious sedation, such as benzodiazepines, should also be considered, ensuring appropriate monitoring with pulse oximetry.

Chemical pleurodesis is unlikely to be successful if there is "lung entrapment," which is when a section of lung cannot re-expand to the chest wall, commonly as a result of visceral pleural restriction due to active disease. In the case of malignancy, this may be due to inflammation of the pleura. In such a scenario, IPC drainage may be indicated.

In patients with recurrent malignant pleural effusion that is refractory to oncologic management, use of an IPC may be useful in relieving respiratory symptoms, decreasing the rate of hospitalization and need for repeated pleural intervention, and achieving pleurodesis.[95] IPC is the intervention of choice when there is failure of the parietal and visceral pleura to oppose one another. While pleurodesis is not the primary therapeutic endpoint for IPC treatment, a systematic review reported an overall spontaneous pleurodesis rate of 45%;[96] however, when limiting inclusion criteria to patients who may have been candidates for pleurodesis (re-expansion ≥80% and survival ≥90 days), pleurodesis rates climb to 70%.[97]

Treatment for the underlying condition should also be optimized as far as possible, however, there is no evidence to support oncological therapies as an alternative to malignant effusion drainage.[55]

All hospitals should have a local pleurodesis guideline.

Intrapleural administration of fibrinolytics can be considered for symptomatic management of dyspnea related to multiloculated/septated malignant effusions not amenable to simple drainage, although no randomized trials have been done to support this.[98][99][100]

Recurrent benign

Recurrent benign pleural effusions are unusual but may occur in various conditions such as inflammatory, infectious, or other systemic diseases (e.g., congestive heart failure, hepatic hydrothorax, post-lung transplantation, post-coronary artery bypass graft surgery, and chronic exudative pleurisy).

Thoracoscopy for diagnostic purposes should be considered if the patient is not improving, the cause of the effusion is unknown, tuberculosis is suspected, or cytology is negative when pleural malignancy is suspected.[12]

Physical therapy

In a small randomized controlled trial, physical therapy (including mobilization techniques, limb exercises, deep breathing exercises, and incentive spirometry) showed a statistically significant improvement in forced vital capacity and chest x-ray appearance, and reduced hospital stay compared with standard treatment.[101]

Insertion of intercostal drain, Seldinger technique: animated demonstration
Insertion of intercostal drain, Seldinger technique: animated demonstration

How to insert an intercostal (chest) drain using the Seldinger technique. Video demonstrates: how to identify a safe site for insertion; use of an introducer needle, guidewire, dilators, and intercostal drain; how to confirm drain position; and postprocedure care.

Insertion of intercostal drain, open technique: animated demonstration
Insertion of intercostal drain, open technique: animated demonstration

How to insert an intercostal (chest) drain using the open technique. Video demonstrates: tube selection, how to identify the site for drain insertion, how to make the correct incision, how to insert the intercostal drain, how to secure the drain, and postprocedure care.

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