How I Do It: Pleural Interventions in the Management of Hepatic Hydrothorax.

Hepatic hydrothorax can be present in 5-15% of patients with underlying cirrhosis and portal hypertension, often reflecting advanced liver disease. Its impact can be variable as patients may have small pleural effusions and minimal pulmonary symptoms or massive pleural effusions and respiratory failure. Management of hepatic hydrothorax can be difficult as these patients often have a number of co-morbidities and potential for complications. Currently, there is minimal high-quality data for guidance specifically related to hepatic hydrothorax, potentially resulting in pulmonary and/or critical care physician struggling for best management options. We therefore provide a case-based presentation with management options based on currently available data and opinion. We discuss the role of pleural interventions, including thoracentesis, tube thoracostomy, indwelling tunneled pleural catheter, pleurodesis, and surgical interventions. In general, we recommend that management be conducted within a multi-disciplinary team including pulmonology, hepatology, and transplant surgery. Patients with refractory hepatic hydrothorax that are not transplant candidates should be managed with palliative intent, we suggest indwelling tunneled pleural catheter placement unless otherwise contraindicated. For patients with unclear or incomplete hepatology treatment plans or those unable to undergo more definitive procedures we recommend serial thoracentesis. In patients that are transplant candidates we often consider serial thoracentesis as a standard treatment, while also evaluating the role indwelling tunneled pleural catheter placement may play within the course of disease and transplant evaluation