Management of Malignant Pleural Effusions

Initial Assessment and Management

The British Thoracic Society recommends that observation is suitable for asymptomatic patients or those with no recurrence of symptoms after initial thoracentesis 1, 3
For symptomatic patients with recurrent malignant pleural effusions, consultation with a thoracic malignancy multidisciplinary team is recommended by the British Thoracic Society 1, 4
Therapeutic pleural aspiration provides transient relief of breathlessness and is appropriate for patients with very short life expectancy or poor performance status, as suggested by the British Thoracic Society 1, 3
The British Thoracic Society guidelines suggest that drainage volume should be guided by patient symptoms and generally limited to 1-1.5 L at a single time to reduce the risk of re-expansion pulmonary edema 1, 5

The European Respiratory Society states that talc is the most effective pleurodesis agent with success rates approaching 90% 1, 6
Small bore tubes (10-14 F) should be considered initially for drainage of malignant effusions due to reduced patient discomfort and comparable success rates to large bore tubes, as recommended by the British Thoracic Society 6, 5
The British Thoracic Society suggests that once effusion drainage and lung re-expansion have been radiographically confirmed, pleurodesis should not be delayed 1, 6
Premedication with intrapleural lignocaine (3 mg/kg; maximum 250 mg) should be administered just prior to sclerosant administration, as recommended by the British Thoracic Society 6
The European Respiratory Society recommends that indwelling pleural catheters (IPCs) are an effective alternative for controlling recurrent and symptomatic malignant effusions, particularly in patients with trapped lung or failed pleurodesis 2, 7
IPCs reduce hospitalization time compared to chemical pleurodesis (0-1 days versus 4-6.5 days), as reported by the European Respiratory Society 2, 7
Daily IPC drainage increases pleurodesis rates when compared with alternate drainage or symptom-based drainage regimes, according to the British Thoracic Society 4

The British Thoracic Society suggests that in patients where only partial pleural apposition can be achieved, chemical pleurodesis should still be attempted and may provide symptomatic relief 1, 6
For loculated malignant pleural effusions, intrapleural fibrinolytic treatment may decrease pleurodesis failure rate and improve breathlessness compared to no treatment, as recommended by the British Thoracic Society 4
Pleuroperitoneal shunts are an alternative and effective option in patients with a trapped lung or failed pleurodesis, according to the British Thoracic Society 7

Re-expansion pulmonary edema is a rare but potentially life-threatening complication following rapid evacuation of large amounts of pleural fluid, as reported by the British Thoracic Society 6, 5
Complication rates are higher with IPCs (14-30%) compared to talc pleurodesis, with local cellulitis being most common, according to the European Respiratory Society 2, 7
Suction is usually unnecessary for pleural drainage but if applied, a high volume, low pressure system is recommended with gradual increment in pressure to about -20 cm H₂O, as suggested by the British Thoracic Society 6, 5