Known or
suspected MPE
a
With goals of assessing lung expansion and relief of dyspnea. is step may not be necessary if the patient's
dyspnea is known to be attributable to the MPE.
b
Physicians are not great predictors of prognosis. As such, the recommendation of "Predicted very short
survival" should be used as a rough guideline and individualized on a case-by-case basis.
c
Note: there is a low likelihood (2–4%) of indwelling pleural catheter (IPC)–related infection. Escalation
of care (intravenous antibiotics, hospital admission, removal of catheter) should be made on a case-by-case
basis and is recommended if there are any signs/symptoms of worsening infection.
NO YES
Figure 1. Management of Patients with Known or Suspected
MPE
Management
Asymptomatic
Pleural intervention not needed
(unless for diagnostic purposes)
Symptomatic
Ultrasound-guided therapeutic
thoracentesis (i.e., large-volume tap
a
)
Improvement in dyspnea
Investigate for
other causes
of dyspnea
NO YES
Predicted very short
survival
b
Lung re-expansion
Discussion of relative risks/
benefits of IPC vs. pleurodesis
vs. combination approaches
NO YES
Palliate dyspnea with:
repeat thoracentesis
if needed, oxygen,
morphine
Consider placement of IPC
(IPC should also be considered
in patients with failed
pleurodesis or symptomatic
loculated effusion)
Talc poudrage or
talc slurry ± IPC
Evidence of IPC-
related infection
Initiation of oral
antibiotics based on
local sensitivities.
Attempt to keep
catheter in place
c
Lung re-expansion
NO
YES
Consider drainage as guided
by symptoms or local protocol
Consider daily drainage
and/or talc slurry
