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Patient guide

Pleural disease: effusions and pneumothorax

The pleura is the thin double lining around the lungs. Fluid (a pleural effusion) or air (a pneumothorax) can collect between its two layers. This guide explains how these problems are investigated and treated.

When to get urgent help

Sudden chest pain or new breathlessness needs urgent medical assessment. Call 999 for severe breathing difficulty, collapse, sudden confusion or rapidly worsening symptoms. If symptoms return after a previous pneumothorax, or you develop fever, increasing breathlessness or worsening pain after a pleural procedure, seek urgent advice rather than waiting for a routine appointment.

Our pleural team

Dr Andrew Barlow and Dr Alessio Navarra have undertaken advanced training in interventional pulmonology and advanced pleural procedures, including European Respiratory Society (ERS) pleural training and qualification, and regularly carry out complex diagnostic and therapeutic pleural procedures. Dr Rahul Mogal completed an advanced fellowship in interventional bronchoscopy at Thoraxklinik, Heidelberg, Germany.

Thoracic ultrasound is used at the bedside to assess the pleura, guide procedures and make them safer. Where surgery is needed, our consultants work with thoracic surgeon Mr Nizar Asadi.

Pleural effusion

What is it?

A pleural effusion is a build-up of fluid in the space between the lung and chest wall. It is a finding with several possible causes, including heart failure, infection, inflammation and cancer. Fluid around a lung does not, by itself, mean that cancer is present.

An effusion may cause breathlessness, cough or chest discomfort. A small collection can be found incidentally on a scan. Symptoms and the underlying cause guide how urgently investigation or drainage is needed.

Finding the cause

Assessment usually includes chest imaging and thoracic ultrasound, alongside relevant blood tests. CT may provide more detail. When a sample is needed, ultrasound identifies a safe place to remove fluid using a needle or small tube after local anaesthetic (a pleural aspiration). Laboratory tests look for infection, abnormal cells and other clues.

A fluid sample does not always give a final diagnosis. If the cause remains uncertain, an image-guided pleural biopsy or a local anaesthetic thoracoscopy may be discussed. Thoracoscopy allows the specialist to inspect the lining of the chest through a small incision and take tissue samples; fluid can be drained and, where appropriate, pleurodesis performed at the same time.

Treatment

Treatment addresses the cause and, where helpful, removes fluid to ease breathlessness. A pleural infection may require antibiotics and a chest drain. Other effusions may improve when the underlying condition, such as heart failure, is treated.

If a symptomatic cancer-related effusion keeps returning, options include pleurodesis or an indwelling pleural catheter. Pleurodesis aims to prevent fluid collecting by making the two pleural surfaces stick together, usually using sterile talc. An indwelling pleural catheter is a soft tube left in place so that fluid can be drained at home, with appropriate community support. The choice depends on whether the lung re-expands, your general health and your preferences.

Pneumothorax (collapsed lung)

What is it?

A pneumothorax happens when air enters the space between the lung and chest wall, allowing the lung to partially or completely collapse. It can occur without a known lung condition (primary spontaneous pneumothorax), alongside an existing lung disease such as COPD (secondary pneumothorax), after an injury or following a medical procedure. Symptoms commonly include sharp pain on one side of the chest and breathlessness.

Diagnosis

Assessment includes examination, oxygen levels and usually a chest X-ray. Thoracic ultrasound can help, and CT may be needed when the diagnosis or underlying cause is unclear. Treatment depends on symptoms, stability and underlying lung health, rather than the X-ray size alone. A tension pneumothorax is an emergency requiring immediate treatment.

Treatment options

Selected people with a primary spontaneous pneumothorax and few symptoms can be monitored with planned follow-up. Others need air removed using a needle or a chest drain. An ambulatory device may allow treatment outside hospital where a suitable pathway and support are available.

A persistent air leak or repeated episodes may lead to discussion of surgery or pleurodesis to reduce the chance of recurrence. Your team will explain the benefits, risks and alternatives for your circumstances.

Recovery, flying and prevention

Attend the arranged follow-up and imaging even if you feel better. Stopping smoking, including cannabis, reduces the risk of another episode. Ask for advice about returning to work, exercise and lifting.

Do not fly with an unresolved pneumothorax. Once full resolution has been confirmed on a chest X-ray, it is often safe to fly within one to two weeks, but advice varies: please confirm with your consultant before you travel. Scuba diving carries particular risk after pneumothorax and should not be resumed without specialist advice.

Before and after a pleural procedure

  • Tell the team about blood-thinning medicines before any procedure. Do not stop them without advice.
  • Most procedures are performed under local anaesthetic, sometimes with light sedation. The team explains the intended benefit, risks – such as pain, bleeding, infection and, rarely, a collapsed lung – and alternatives before you consent.
  • Follow your hospital’s instructions about dressings, medicines and follow-up.

Sources and further information

This guide gives general information for adults and does not replace individual medical advice.