Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

congestive heart failure

1st line – diuretic

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ACUTE
|
congestive heart failure
1st line – 

diuretic

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 weight, 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.

Primary options

furosemide: 40-160 mg/dose orally/intravenously initially, increase by 20-40 mg/dose every 6-12 hours according to response, maximum 600 mg/day

OR

bumetanide: 0.5 to 2 mg orally/intravenously once or twice daily initially, increase dose according to response, maximum 10 mg/day

Secondary options

furosemide: 40-160 mg/dose orally/intravenously initially, increase by 20-40 mg/dose every 6-12 hours according to response, maximum 600 mg/day

-- AND --

hydrochlorothiazide: 25 mg orally once daily

or

metolazone: 2.5 to 5 mg orally once daily

Consider – physical therapy

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ACUTE
|
congestive heart failure
Consider – 

physical therapy

Treatment recommended for SOME patients in selected patient group

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]

Consider – therapeutic thoracentesis

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ACUTE
|
congestive heart failure
|
symptomatic large effusion
Consider – 

therapeutic thoracentesis

Treatment recommended for SOME patients in selected patient group

If the effusion is large and is causing significant symptoms such as dyspnea or pain, an ultrasound-guided therapeutic thoracentesis with further removal of fluid will allow lung re-expansion.

A needle-catheter system should be used because, as the lung expands, the needle can lacerate the lung, leading to a pneumothorax.

The thoracentesis needle should be inserted at the upper border of the rib to avoid the neurovascular bundle that runs along the bottom of the ribs.[109] The safest insertion site is the lateral chest wall (between the anterior and posterior axillary lines).

The risks of the procedure include bleeding, infection, and organ puncture.

Draining large volumes of pleural fluid too rapidly, especially in the first hour after insertion of the needle, can cause rapid deterioration due to a reduction in blood pressure and acute breathlessness associated with potentially life-threatening re-expansion pulmonary edema. Measures to reduce the risk of this include controlling the rate at which the fluid is drained, checking vital signs (every 15 minutes for the first hour), and chest drain volume checks after the procedure.[75][76] It is advisable to drain no more than 1.5 L of fluid in the first hour.[76]

Chest x-ray is not required after aspiration of an effusion, unless there is clinical suspicion of iatrogenic pneumothorax such as free air aspiration.

Consider – oxygen

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ACUTE
|
congestive heart failure
|
symptomatic large effusion
Consider – 

oxygen

Treatment recommended for SOME patients in selected patient group

Patients with large symptomatic effusions may benefit from oxygen therapy.[74]

infective

1st line – empiric intravenous antibiotics

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ACUTE
|
infective
1st line – 

empiric intravenous antibiotics

All patients should receive empirical 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 effusion.[79] Anaerobic pathogens are also important and present in a more insidious fashion. MRSA should be covered if a hospital-acquired infection is suspected.[79]

Penicillin-based antibiotics, including those combined with beta-lactamase inhibitors, and metronidazole, penetrate the pleural space well, but aminoglycosides should be avoided. Vancomycin plus piperacillin/tazobactam can be used in hospital-acquired pneumonia with appropriate monitoring of serum vancomycin levels.

Primary options

ampicillin/sulbactam: 1-2 g intravenously every 6 hours

More

and

metronidazole: 500 mg intravenously every 8 hours

OR

clindamycin: 1200-4800 mg/day intravenously given in divided doses every 6-12 hours

OR

vancomycin: 500 mg intravenously every 6 hours; or 1000 mg intravenously every 12 hours

and

piperacillin/tazobactam: 4.5 g intravenously every 8 hours

More

Consider – therapeutic thoracentesis

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ACUTE
|
infective
Consider – 

therapeutic thoracentesis

Treatment recommended for SOME patients in selected patient group

Timely, ultrasound-guided removal of fluid is indicated if there is clinical deterioration or increasing fluid accumulation on chest x-ray despite antibiotic therapy. Therapeutic thoracentesis is likely to be definitive in most patients with parapneumonic effusions.

Needle-catheter system should be used because, as the lung expands, the needle can lacerate the lung, leading to a pneumothorax.

The thoracentesis needle should be inserted at the upper border of the rib to avoid the neurovascular bundle that runs along the bottom of the ribs.[109] The safest insertion site is the lateral chest wall (between the anterior and posterior axillary lines).

The risks of the procedure include bleeding, infection, and organ puncture.

Draining large volumes of pleural fluid too rapidly, especially in the first hour after insertion of the needle, can cause rapid deterioration due to a reduction in blood pressure and acute breathlessness associated with potentially life-threatening re-expansion pulmonary edema. Measures to reduce the risk of this include controlling the rate at which the fluid is drained, checking vital signs (every 15 minutes for the first hour), and chest drain volume checks after the procedure.[75][76] It is advisable to drain no more than 1.5 L of fluid in the first hour.[76]

Chest x-ray is not required after aspiration of an effusion, unless there is clinical suspicion of pneumothorax such as free air aspiration.

Consider – physical therapy

Back
ACUTE
|
infective
Consider – 

physical therapy

Treatment recommended for SOME patients in selected patient group

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]

Consider – oxygen

Back
ACUTE
|
infective
|
symptomatic large effusion
Consider – 

oxygen

Treatment recommended for SOME patients in selected patient group

Patients with large symptomatic effusions may benefit from oxygen therapy.[74]

Plus – tube thoracostomy

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ACUTE
|
infective
|
empyema
Plus – 

tube thoracostomy

Treatment recommended for ALL patients in selected patient group

Initial drainage of pleural infection should be undertaken using well-placed small bore chest tubes (14 French or smaller).[7]

If the fluid obtained from thoracentesis is frank pus, the bacterial smear or culture is positive, glucose is <60 mg/dL, pH is <7.20, LDH >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]​​​ Small-bore chest tubes with regular (4 times a day) flushing are sufficient for adequate drainage in empyema.

In loculated effusions multiple chest tubes are often placed.

Chest tubes should not be routinely placed in patients with a chylothorax or effusion resulting from cirrhotic ascites.

Chest x-ray after chest tube drainage is recommended.[73]​​

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.

malignant: poor performance status or limited lifespan (Karnofsky score ≤30% or ECOG score of ≥2)

1st line – therapeutic thoracentesis

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ACUTE
|
malignant: poor performance status or limited lifespan (Karnofsky score ≤30% or ECOG score of ≥2)
1st line – 

therapeutic thoracentesis

Malignant effusions are difficult to manage, as they usually re-accumulate after drainage. Therapeutic thoracentesis is effective at providing symptom relief. 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] 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]

Needle-catheter system should be used because, as the lung expands, the needle can lacerate the lung, leading to a pneumothorax.

The thoracentesis needle should be inserted at the upper border of the rib to avoid the neurovascular bundle that runs along the bottom of the ribs.[109] The safest insertion site is the lateral chest wall (between the anterior and posterior axillary lines).

The risks of the procedure include bleeding, infection, and organ puncture.

Draining large volumes of pleural fluid too rapidly, especially in the first hour after insertion of the needle, can cause rapid deterioration due to a reduction in blood pressure and acute breathlessness associated with potentially life-threatening re-expansion pulmonary edema. Measures to reduce the risk of this include controlling the rate at which the fluid is drained, checking vital signs (every 15 minutes for the first hour), and chest drain volume checks after the procedure.[75][76] It is advisable to drain no more than 1.5 L of fluid in the first hour.[76]

Chest x-ray is not required after aspiration of an effusion, unless there is clinical suspicion of iatrogenic pneumothorax such as free air aspiration.

Consider – physical therapy

Back
ACUTE
|
malignant: poor performance status or limited lifespan (Karnofsky score ≤30% or ECOG score of ≥2)
Consider – 

physical therapy

Treatment recommended for SOME patients in selected patient group

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]

Consider – oxygen

Back
ACUTE
|
malignant: poor performance status or limited lifespan (Karnofsky score ≤30% or ECOG score of ≥2)
|
symptomatic large effusion
Consider – 

oxygen

Treatment recommended for SOME patients in selected patient group

Patients with large symptomatic effusions may benefit from oxygen therapy.[74]

malignant: good performance status (Karnofsky score >30% or ECOG score of 0 or 1)

1st line – pleurodesis or intercostal drainage (pleural catheter drainage)

Back
ACUTE
|
malignant: good performance status (Karnofsky score >30% or ECOG score of 0 or 1)
1st line – 

pleurodesis or intercostal drainage (pleural catheter drainage)

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]

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] IPC drainage is associated with less time in hospital, but more adverse effects.[89][90][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] [ Cochrane Clinical Answers logo ]

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. 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]

Consider – physical therapy

Back
ACUTE
|
malignant: good performance status (Karnofsky score >30% or ECOG score of 0 or 1)
Consider – 

physical therapy

Treatment recommended for SOME patients in selected patient group

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]

Consider – oxygen

Back
ACUTE
|
malignant: good performance status (Karnofsky score >30% or ECOG score of 0 or 1)
|
symptomatic large effusion
Consider – 

oxygen

Treatment recommended for SOME patients in selected patient group

Patients with large symptomatic effusions may benefit from oxygen therapy.[74]

ONGOING

persistent empyema despite chest tube

1st line – direct visualization and lysis of adhesions

Back
ONGOING
|
persistent empyema despite chest tube
1st line – 

direct visualization and lysis of adhesions

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

Surgical thoracoscopy allows close inspection of the pleural surfaces and the opportunity to break down fibrin membranes that produce loculations. By using video-assisted thoracoscopy surgery, the fibrous coating over the visceral pleural can be removed (decortication), which will allow the underlying lung to expand. The risks include infection, bleeding, and anesthetic risks.

Other surgical options include drainage with or without decortication.

Tissue plasminogen activator (tPA; alteplase) combined with a deoxyribonuclease (a viscosity-disrupting agent, e.g., dornase alfa) reduces pus/fluid viscosity and can improve fluid drainage in patients with pleural infection.[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 who 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]

Primary options

thoracoscopy or VATS

Secondary options

surgical decortication

OR

open drainage

Tertiary options

alteplase: consult specialist for guidance on intrapleural dose

and

dornase alfa inhaled: consult specialist for guidance on intrapleural dose

recurrent symptomatic malignant effusions

1st line – repeated therapeutic thoracentesis or consider indwelling pleural catheter (IPC)

Back
ONGOING
|
recurrent symptomatic malignant effusions
1st line – 

repeated therapeutic thoracentesis or consider indwelling pleural catheter (IPC)

Repeated therapeutic thoracenteses can be considered for the treatment of recurrent symptomatic malignant pleural effusion if the life expectancy of the patient is very short (i.e., days to weeks).[85]

Draining large volumes of pleural fluid too rapidly, especially in the first hour after insertion of the needle, can cause rapid deterioration due to a reduction in blood pressure and acute breathlessness associated with potentially life-threatening re-expansion pulmonary edema. Measures to reduce the risk of this include controlling the rate at which the fluid is drained, checking vital signs (every 15 min for the first hour), and chest drain volume checks after the procedure.[75][76] It is advisable to drain no more than 1.5 L of fluid in the first hour.[76]

Chest x-ray is not required after aspiration of an effusion, unless there is clinical suspicion of pneumothorax such as free air aspiration. Treatment for the underlying condition should also be optimized as far as possible.

1st line – pleurodesis

Back
ONGOING
|
recurrent symptomatic malignant effusions
1st line – 

pleurodesis

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; or a talc poudrage at the time of medical or surgical thoracoscopy.

Pleurodesis with talc, bleomycin, or tetracycline creates an inflammatory response with coagulation activation and fibrin deposition. This results in fusion of visceral and parietal pleura and obliteration of the pleural space where the fluid is collecting.[110]

Large particle talc by poudrage under thoracoscopic guidance is the most effective agent for pleurodesis and is recommended by the ACCP.[85][88][92]

Effective analgesia, including the use of intrapleural lidocaine, is mandatory.[93] 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, indwelling catheter drainage may be indicated. Treatment for the underlying condition should also be optimized as far as possible. All hospitals should have a local pleurodesis guideline.

1st line – intercostal drainage (pleural catheter drainage)

Back
ONGOING
|
recurrent symptomatic malignant effusions
1st line – 

intercostal drainage (pleural catheter drainage)

In patients with recurrent malignant pleural effusion that is refractory to oncological management, use of a pleural catheter may be useful in relieving respiratory symptoms, decreasing the rate of hospitalization and achieving pleurodesis.[95] Treatment for the underlying condition should also be optimized as far as possible.

Indwelling pleural catheter (IPC) is the intervention of choice when there is failure of the parietal and visceral pleura to oppose one another. IPCs are also useful in the absence of lung entrapment, allowing ambulatory management without the need for hospital admission.

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]

recurrent benign effusion

1st line – medical or surgical thoracoscopy

Back
ONGOING
|
recurrent benign effusion
1st line – 

medical or surgical thoracoscopy

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]

Thoracoscopy is traditionally carried out by surgeons but medical rigid or semi-rigid thoracoscopy is a safe, simple, and accurate alternative.[53]

One meta-analysis of the usefulness of semi-rigid thoracoscopy in undiagnosed exudative pleural effusions (following thoracentesis with or without blind pleural biopsy) found a pooled sensitivity of 91%, with a specificity of 100%.[54]

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Choose a patient group to see our recommendations

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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