Management of Acute Pulmonary Congestion in Malignant Pleural Effusion

Pathophysiology and Prevention

The American Thoracic Society suggests that re-expansion pulmonary edema (RPE) develops through reperfusion injury of the chronically hypoxic underlying lung, increased capillary permeability, and local production of neutrophil chemotactic factors such as interleukin-8, which occurs when more than 1-1.5L of pleural fluid is evacuated at once or when the pleural pressure gradient exceeds 17 cm H₂O 1
The British Thoracic Society recommends limiting evacuation to no more than 1-1.5L at a single time, or slow drainage to approximately 500 mL/hour to prevent RPE 1, 2

The European Respiratory Society advises discontinue aspiration as soon as the patient develops chest discomfort, persistent cough, or vasovagal symptoms during thoracentesis, as these symptoms are warning signs that precede frank pulmonary edema 1
The American College of Chest Physicians recommends providing supplemental oxygen for hypoxemia 2
The American Thoracic Society suggests considering morphine for dyspnea palliation 3

The American College of Chest Physicians recommends that for recurrent symptomatic malignant pleural effusion with expandable lung, either talc pleurodesis or indwelling pleural catheter (IPC) should be used as first-line definitive intervention, with talc pleurodesis achieving approximately 90% success rate with thoracoscopic poudrage 3, 2, 4, 5
The European Respiratory Society advises that IPCs are preferred over chemical pleurodesis for non-expandable lung, failed pleurodesis, or loculated effusions 3, 2

The National Comprehensive Cancer Network recommends that for patients with very short predicted survival, repeated therapeutic thoracentesis for palliation is appropriate rather than pursuing definitive pleurodesis, however, each thoracentesis must still adhere to the 1-1.5L volume limit to prevent RPE 3, 2, 1