Key messages

• With relatively large effusions, thoracentesis can be performed using physical examination and chest radiography for landmarks. In smaller effusions, or those in which fluid is not easily drained, ultrasound is useful to guide insertion and placement of the pleural catheter.

• Post-thoracentesis chest radiography should be routine.

• The maximum volume of fluid which should be removed is 1.5 liters. Tube thoracostomy is most effective when performed early in the course of empyema. The use of fibrinolytic therapy may improve success rates of tube drainage of empyema.

• CT scans are useful for defining the anatomy and the extent of loculation in empyema, and may predict success rates of chest tube drainage.

• Pleurodesis can be performed via the chest tube, by video-assisted thoracoscopic surgery, or by open thoracotomy. Pleuroperitoneal shunts or indwelling catheters with implanted reservoirs may provide symptomatic relief in selected patients with malignant pleural effusions.

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