Practical evaluation and management of symptomatic benign pleural effusions

Benign pleural effusions comprise a heterogeneous group of disorders, but recent advances have been uneven across different etiologies. This review summarizes the developments most likely to influence current clinical practice, focusing on heart failure-related pleural effusions, hepatic hydrothorax, and postcoronary artery bypass graft (CABG) pleural effusions.

Heart failure-related pleural effusions have experienced the greatest advances recently. A blood-free pleural fluid triple combination (protein, lactate dehydrogenase, and cholesterol) provides diagnostic accuracy comparable to Light's criteria, while an optimized pleural fluid N-terminal pro-B-type natriuretic peptide (NT-proBNP) threshold of ≥2500 ·mL-1 and the BANCA (Bilateral effusions, Age, NT-proBNP, Cholesterol, and Albumin gradient) score further improve diagnostic confidence. The first randomized trial showed that routine early therapeutic thoracentesis did not improve major 90-day clinical outcomes beyond optimized medical therapy. In hepatic hydrothorax, all patients with refractory disease should undergo early liver transplantation assessment, irrespective of the MELD score, with careful selection for transjugular intrahepatic portosystemic shunt and individualized use of indwelling pleural catheters, while conventional chest tubes should generally be avoided. For post-CABG pleural effusions, recent evidence supports the distinction between uncomplicated postoperative pleural effusions and postpericardiotomy syndrome, as colchicine is only indicated for the latter.

Recent evidence supports replacing the uniform approach to benign pleural effusions with disease-specific diagnostic and therapeutic strategies. Heart failure-related pleural effusions now benefit from integrated diagnostic algorithms, whereas the management of hepatic hydrothorax and post-CABG pleural effusions increasingly emphasizes the treatment of the underlying disease and selective use of pleural interventions.