The management of benign non-infective pleural effusions

Abstract

The evidence base concerning the management of benign pleural effusions has lagged behind that of malignant pleural effusions in which recent randomised trials are now informing current clinical practice and international guidelines.The causes of benign pleural effusions are broad, heterogenous and patients may benefit from individualised management targeted at both treating the underlying disease process and direct management of the fluid. Pleural effusions are very common in a number of non-malignant pathologies, such as decompensated heart failure, and following coronary artery bypass grafting. Pleural fluid analysis forms an important basis of the diagnostic evaluation, and more specific assays and imaging modalities are helpful in specific subpopulations.Options for management beyond treatment of the underlying disorder, whenever possible, include therapeutically aspirating the fluid, talc pleurodesis and insertion of an indwelling pleural catheter. Randomised trials will inform clinicians in the future as to the risks and benefits of these options providing a guide as to how best to manage patient symptoms in this challenging clinical setting.

Conflict of interest statement

Conflict of interest: Disclosures can be found alongside the online version of this article at err.ersjournals.com

Copyright ©ERS 2016.

Figures

FIGURE 1

Schematic diagram illustrating a range of multisystem pathologies leading to non-malignant effusions, categorised by their tendency to cause exudates or transudates.

FIGURE 2

Lymphoscintigram and SPECT-CT (single photon emission computer tomography combined with integrated low-dose computed tomography) imaging in a patient with a chylothorax. A 74-year-old man with non-Hodgkin lymphoma had recurrence of a right-sided pleural effusion following previous talc pleurodesis. An intercostal catheter was inserted and drained >3.5 L of milky fluid with a triglyceride level of 17 mmol·L−1, confirming a chylothorax. Chyle flow decreased but continued despite total parental nutrition. Computed tomography of the abdomen also indicated a confluent lymphomatous mass around the aorta and inferior vena cava with ascites and lymphadenopathy. A lymphoscintigraphy was performed to determine the point of chyle leakage. Tc99-labelled human serum albumin-DTPA was injected into the first pedal interdigital web space bilaterally and serial whole body SPECT-CT was performed at intervals between 90 min and 6.5 h following tracer administration. This case illustrates the importance of Tc99 lymphangioscintigraphy as it identified an abdominal chyle leak site for the right chylothorax (instead of leakage at the thoracic portion of the thoracic duct), and changed the management of the patient. The patient was referred for radiotherapy to the abdominal mass. a) Lymphoscintigram showing a site of chyle leak in the abdomen at 2 h following injection. b) Low dose SPECT-CT showed pooling of the tracer below the diaphragm confirming chyle leak from the abdominal source into the abdomen. c) Follow-up lymphoscintigram showed tracer uptake over the right pleural cavity, confirming that chyle leak from the abdomen migrated transdiaphragmatically causing the right chylothorax at 6.5 h after injection. (Images courtesy of A. Yogendran, University of Western Australia, Perth, Australia).

FIGURE 3

Chest radiographs of a patient with a transudative pleural effusion due to biopsy confirmed systemic amyloidosis causing nephrotic syndrome. a) At presentation with right-sided pleural effusion. b) Recurrent pleural effusion following attempted talc pleurodesis which was performed due to frequent requirement for pleural aspiration. c) 6 months after placement of an indwelling pleural catheter. At this point a reduction in the volume of fluid drained indicated a “spontaneous” pleurodesis and allowed drain removal.