Navigating complexity: current evidence and recommendations for management of selected, non-malignant pleural effusions

INTRODUCTION: Pleural effusions are common and carry substantial morbidity, mortality, and healthcare costs. Management can be particularly challenging when effusions arising from systemic diseases such as congestive heart failure (CHF) or cirrhosis are refractory to medical management or when the effusion occurs due to disruption of the thoracic lymphatic system, as in chylothorax. AREAS COVERED: This review examines current approaches to the diagnosis and management of congestive heart failure-related effusions, hepatic hydrothorax, and chylothorax. In addition, we seek to identify areas for future investigation across all three conditions, particularly the evidence guiding invasive management such as thoracentesis, indwelling pleural catheters, and pleurodesis. To accomplish this, we conducted a literature search in PubMed between 1 August 2026 - 13 August 2026, using a combination of free-text keywords related to the listed effusions. EXPERT OPINION: If medical/conservative management of complicated pleural effusion fails, there are multiple treatment options for each of the discussed effusions, but no clear-cut superior option as the current literature is limited. Future studies will require multi-center and multi-disciplinary collaboration but will likely reveal that treatment should be based on an individual level, accounting for local expertise and incorporating patients' preferences.