Management of refractory nonmalignant pleural effusions
- David J Feller-Kopman, MD
David J Feller-Kopman, MD
- Associate Professor of Medicine
- Johns Hopkins Hospital
Primary treatment of a nonmalignant pleural effusion (NMPE) should target the underlying cause of the effusion. Sometimes, nonmalignant effusions persist or recur despite appropriate treatment of the primary process. In this situation, symptomatic pleural effusions are usually treated with intermittent thoracentesis or pleurodesis; other options include placement of an indwelling pleural catheter for intermittent drainage, pleurectomy, or a pleural-peritoneal shunt.
In this topic review, strategies for management of refractory nonmalignant pleural effusions are discussed. A diagnostic approach to pleural effusions is provided separately. (See "Diagnostic evaluation of a pleural effusion in adults: Initial testing" and "Diagnostic evaluation of pleural effusion in adults: Additional tests for undetermined etiology".)
Options for primary treatment of malignant pleural effusions and specific types of nonmalignant pleural effusion are discussed within those topic reviews. (See "Management of malignant pleural effusions" and "Etiology, clinical presentation, and diagnosis of chylothorax" and "Parapneumonic effusion and empyema in adults" and "Pleural effusions following cardiac surgery" and "Pleural effusions in HIV-infected patients" and "Tuberculous pleural effusions in HIV-infected patients" and "Tuberculous pleural effusion" and "Diagnosis and management of pleural causes of unexpandable lung" and "Hepatic hydrothorax".)
Primary treatment is directed at the underlying cause of the pleural effusion in all patients with nonmalignant pleural effusions (table 1 and table 2). Patients who have symptoms due to a pleural effusion that is refractory to primary treatment are candidates for additional therapies. Dyspnea is the most common symptom that necessitates additional therapy.
Prior to proceeding with more invasive therapy, the underlying cause of the nonmalignant pleural effusion (NMPE) should be reconfirmed and trapped lung excluded. Trapped lung refers to development of a fibrous pleural peel that encases the visceral pleura and prevents the lung from expanding fully. This may occur after an underlying inflammatory condition of the pleura has been successfully treated. (See "Diagnosis and management of pleural causes of unexpandable lung", section on 'Diagnosis'.)
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