When is it appropriate to refer a patient with a pleural effusion for further investigation or management, such as thoracentesis or imaging?

It is appropriate to refer a patient with a pleural effusion for further investigation or management, such as thoracentesis or imaging, when:

• There is clinical evidence or imaging (e.g., chest X-ray or ultrasound) confirming the presence of a pleural effusion that requires drainage or further assessment.
• The patient presents with breathlessness or other symptoms suggestive of pleural effusion, and emergency admission is not required; referral should be made for drainage and investigation of the underlying cause.
• There is suspicion of an underlying malignancy (such as lung cancer or mesothelioma), especially in patients aged 40 and over with risk factors like smoking or asbestos exposure, warranting urgent chest X-ray and specialist referral.
• There are chest signs compatible with pleural disease or pleural effusion in patients aged 40 and over, indicating the need for urgent imaging and specialist assessment.
• In cases of suspected pleural tuberculosis, appropriate imaging and specialist investigations should be arranged.

Referral pathways should be urgent (within 2 weeks) if cancer is suspected based on symptoms or imaging findings, or routine if the cause is uncertain but not an emergency.

Thoracentesis is generally performed after referral to a specialist for diagnostic and/or therapeutic purposes once pleural effusion is confirmed.

Ultrasound is recommended to exclude pleural effusion and guide thoracentesis safely.

Overall, clinical judgement, symptom severity, and risk factors guide the timing and urgency of referral for further imaging and management.

References: ³, ⁴, ¹, ⁵