The most frequent reason for draining recurrent pleural effusions is to relieve symptoms or improve ventilatory status. If the recurrent effusion of known cause is not symptomatic, observation is warranted. The majority of patients with large pleural effusions are symptomatic and experience cough, chest pain, or dyspnea on exertion. It is important to know the cause of the effusion. If it is sympathetic, thoracentesis should be performed to confirm the diagnosis. Then treating the underlying medical problem will usually improve the effusion. If treatment does not improve the effusion and the patient remains symptomatic, chest tube insertion should be performed. If the symptomatic effusion remains problematic, video-assisted thoracic pleurodesis or pleuroperitoneal shunt should be considered, depending on the patient's overall medical condition (Fig 2).
The most common cause of exudative pleural effusions in patients aged over 60 years is malignancy ( KellerJ993). A malignant pleural effusion is usually an exudate (fluid protein, above 3 g/dl; pleural fluid to serum protein ratio, above 0.5; lactate dehydrogenase content, above 200 IU/l; pleural fluid to serum lactate dehydrogenase ratio, above 0.6) and hemorrhagic in appearance (LightJ 983). In patients with malignant effusions that have previously been drained, pleurodesis should be attempted either via chest tube or by video-assisted thoracoscopic surgery. Repeat thoracentesis is a reasonable option in the patient with a previously undrained malignant effusion that recurs slowly. If this proves to be unsuccessful, tube thoracostomy with or without pleurodesis should be attempted. With the emerging use of video-assisted thoracoscopic surgery the management of malignant pleural effusions is changing. In those patients with recalcitrant effusions who can tolerate general anesthesia and single-lung ventilation, lysis of adhesion, decortication, and pleurodesis using video-assisted thoracoscopic surgery is the treatment of choice. In those patients in whom the lung remains trapped, a viable option is pleuroperitoneal shunt. In the patient who cannot tolerate general anesthesia, tube thoracostomy should be performed; if the lung can be fully expanded, pleurodesis will resolve the effusion in 66 to 92 per cent of patients, depending on the sclerosing agent used (Bayly 1978).
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