Surgical Care:

• Surgical intervention most often is required for parapneumonic effusions that cannot be drained adequately by needle or small-bore catheters, and surgery might be required for diagnosis and sclerosis of exudative effusions.

• Video-assisted thoracoscopy (VATS) under local or general anesthesia allows direct visualization and biopsy of the pleura for diagnosis of exudative effusions.

• Pleural sclerosis by insufflating talc directly onto the pleural surface using VATS might be more effective than methods using talc slurries.

• Decortication usually is needed to remove a thick, inelastic pleural peel that restricts ventilation and produces progressive or refractory dyspnea. In cases of chronic, organizing parapneumonic pleural effusions, technically demanding operations might be required to drain loculated pleural fluid and obliterate the pleural space.

• Surgically implanted pleuroperitoneal shunts are another treatment option for recurrent symptomatic effusions, most often in the setting of malignancy. Actively pump the subcutaneous chamber at frequent intervals to shunt fluid from the pleural space to the peritoneal cavity. The shunts are prone to malfunction over time and can require surgical revision.

• In unusual cases, surgery might be required to close diaphragmatic defects, thereby preventing recurrent accumulation of pleural effusions in patients with ascites, and to ligate the thoracic duct to prevent reaccumulation of chylous effusions.