Management of malignant pleural effusion in adults

The presence of pleural effusion in malignancy indicates a poor prognosis. Symptomatic malignant pleural effusions usually require drainage. Reaccumulation of fluid after drainage is very common. Treatment with pleurodesis depends on individual patient circumstances and preferences.

Pleurodesis is usually carried out under direct specialist supervision. It can be performed as dry talc poudrage at thoracoscopy, or by instillation of a sclerosant (eg talc slurry) through an intercostal catheter.

Instillation of talc and other sclerosing agents into the pleural space can cause considerable pain, although this is less common in patients with malignant effusion. Pain associated with pleurodesis can be managed with lidocaine before instillation of the sclerosant, and parenteral opioid therapy (both for premedication and for treatment of pain following the procedure).

Placement of a permanent indwelling tunnelled pleural catheter is an alternative to pleurodesis in cases where the lung fails to re-expand (trapped lung) or in the case of patient preference. This is performed in a specialist centre.