Key messages

• Indications for draining pleural effusions include an effusion suspected of being infected, a hemorrhagic effusion, and an effusion which is causing ventilatory compromise.

• Thoracentesis should not be attempted unless fluid can be clearly localized by chest radiography, ultrasound, or CT scan.

• It is important to determine whether an effusion is recurrent or of new onset, or if there is a history of trauma. Traumatic effusions should be assumed to be hemothoraces, and should be treated with tube thoracostomy.

• The treatment of effusion varies depending upon thoracentesis: thick and purulent empyema requires tube thoracostomy; thinner parapneumonic effusions with low protein content, high pH, and high glucose content can sometimes be treated with antibiotics alone; multiloculated pleural effusions require surgical drainage and decortication.

• Symptomatic recurrent pleural effusions may require pleurodesis via chest tube, video-assisted thoracoscopic surgery, or open thoracotomy.

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