When are further invasive procedures considered in the evaluation of undiagnosed exudative pleural effusions?

Updated: Dec 28, 2018
  • Author: Kamran Boka, MD, MS; Chief Editor: Guy W Soo Hoo, MD, MPH  more...
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For other patients with undiagnosed exudative effusions, approximately 20% have a specific etiology determined, including malignancy. For such patients, weigh the benefits and risks of pursuing a diagnostic strategy that will involve using progressively more invasive procedures, given the low likelihood of finding a curable etiology. Note the following:

  • Bronchoscopy - Consider only if a patient has parenchymal abnormalities or hemoptysis

  • Surgical approaches to the diagnosis of pleural effusions - Includes video-assisted thoracoscopy (pleuroscopy) and open thoracotomy, allows direct visualization and biopsy of the pleura for diagnosis of exudative effusions, which reveals an etiology in 92% of effusions that remain undiagnosed after a medical evaluation, with an operative mortality of less than 0.5% [40]

  • Medical thoracoscopy - Where available, may be diagnostic and therapeutic; complete drainage of the effusion and talc sclerosis can be performed at the time of the procedure

Note that in most medical centers, surgical exploration using thoracoscopy or thoracotomy entails the risks of general anesthesia and is probably warranted only in patients who are symptomatic and anxious for a (potentially incurable) diagnosis.

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