The modern diagnosis and management of pleural effusions

The bottom line

• Pleural effusions are common and may be caused by a variety of underlying illnesses

• An undiagnosed unilateral pleural effusion, without a history suggestive of acute infection, should be considered malignant until proved otherwise

• Bilateral effusions are usually due to cardiac, renal, or hepatic impairment—treatment of the cause will usually improve effusions without the need for intervention

• Chest radiography and computed tomography are vital early investigations in the diagnosis of pleural effusions

• Both the safety and the success of pleural procedures are improved by the use of thoracic ultrasonography to guide needle placement

• There is an increasing drive to diagnose and manage effusions in the outpatient setting, with pleural clinics and medical thoracoscopy streamlining the diagnostic pathway

• Indwelling pleural catheters can now allow many patients with recurrent effusions to be managed at home

Sources and selection criteria

We searched through PubMed, Embase, Medline, and the Cochrane database of systematic reviews from inception to April 2015 using the primary search terms “pleural effusion” and “indwelling pleural catheter”. We included abstracts published in English and related to adults. Priority was given to randomised controlled trials and meta-analyses, although citations from case series and retrospective studies have been included where appropriate. Further information was obtained from our personal libraries, trial registration databases (such as www.isrctn.com), and conference proceedings where necessary.