21st February 2025

Management of pleural effusion

Management depends on the underlying cause and generally targets the underlying disease, e.g. loop diuretics for an effusion related to heart failure. 

Thoracocentesis

Transudates do not generally require drainage, but it can be beneficial for any large-volume symptomatic effusion.

Re-expansion pulmonary oedema is a possible complication of drainage of large effusions, these should be drained at a controlled rate (no more than 1.5 L over the first hour). Other potential complications of thoracocentesis are pneumothorax and trapped lung (incomplete re-expansion of the lung following drainage). A routine chest X-ray is recommended following drainage (this is not normally required after aspiration). 

If drainage is required, BTS guidelines suggest that this should be done in working hours, as this minimises the risk of complications. This does not apply to patients in extremis, such as with tension pneumothorax or severe respiratory failure thought to be due to the pleural effusion.

Malignant effusions

Malignant effusions are often recurrent and may require repeat drainage, pleurodesis and indwelling pleural catheters.

Parapneumonic effusions

Parapneumonic effusions exist on a spectrum from a simple parapneumonic effusion to empyema, and differentiating between these is important to define management. 

Table 13 Stratification of parapneumonic effusions

Post-myocardial infarction pleural effusion

NSAIDs are the mainstay of treatment for pleural and pericardial effusions following MI. Steroids can be useful if NSAIDs are contraindicated or symptoms are refractory. Colchicine can be used to prevent recurrence.