Management

Management of pleural effusion should be aimed at identifying the aetiology and treatment of the underlying disease.

If a transudative effusion is identified, treatment of the underlying cause will usually resolve the effusion.

Exudative effusions often require removal of fluid to relieve symptoms. This can be achieved through:

• therapeutic aspirations
  • repeated aspiration may be required in malignant pleural effusions
• intercostals chest drain
  • often required for complex parapneumonic effusion and empyema,
  • indwelling pleural catheters is used for the drainage of all recurrent pleural effusions (with malignant effusions)
    • it is inserted under local anaesthetic as a day case procedure and a detachable vacuum bottle system is used to drain off fluid periodically (usually two or three times each week)

Pleurodesis is used for management of recurrent malignant effusions

• aim is to obliterate the pleural space through inflammation and fibrosis between the visceral and parietal membranes by application of an irritant substance (talc is the agent of choice) (2,3)

Pleurectomy may be considered in exceptional cases e.g. - specially in mesothelima and in patients in good general condition with pleurodesis failure (3)

Intrapleural fibrinolytic therapy - a systematic review stated " with complicated infective pleural effusion or empyema, intrapleural fibrinolytic therapy was associated with a reduction in the requirement for surgical intervention and overall treatment failure but with no evidence of change in mortality" (4)

Reference:

• (1) Rahman NM, Chapman SJ, Davies RJ. Pleural effusion: a structured approach to care. Br Med Bull. 2005;72:31-47
• (2) Bhatnagar R, Maskell N. The modern diagnosis and management of pleural effusions. BMJ. 2015;351:h4520.
• (3) Villena Garrido V et al. Recommendations of diagnosis and treatment of pleural effusion. Update. Arch Bronconeumol. 2014;50(6):235-49
• (4) Altmann ES et al. Intra-pleural fibrinolytic therapy versus placebo, or a different fibrinolytic agent, in the treatment of adult parapneumonic effusions and empyema. Cochrane Systematic Review October 2019