Malignant pleural effusion (MPE) is a common problem in both respiratory and general medical practice, occurring in up to 15% of all patients with malignancy.1 Initial management is principally guided by the degree of symptoms experienced by the patient, especially breathlessness. For large volume symptomatic MPE, options include therapeutic aspiration, inpatient chest drainage with talc pleurodesis or indwelling pleural catheter insertion.

The precise strategy employed should be based on individual patient choice, taking into consideration the relative risks and benefits of each modality.2 In practice, this is largely influenced by the ability to intervene safely (ie, whether there is sufficient fluid amenable to drainage) and the presence or absence of non-expandable lung. The size of effusion is readily assessed using bedside thoracic ultrasound; however, non-expandable lung is not always evident from prior imaging. Consequently, a trial of therapeutic aspiration is frequently employed ‘first-line’ to help determine feasibility…