Contemporary Pleural Drainage in Adult Practice: Image-Guided Techniques, Procedural Safety, Training Standards, and Malignant Pleural Effusion Management

Pleural drainage is a fundamental procedure in the management of pneumothorax, pleural effusion, hemothorax, and complex pleural disease. Advances in imaging guidance, small-bore catheter technology, and structured training have improved the safety and effectiveness of pleural interventions. Despite its widespread use, pleural drainage continues to be associated with substantial complication rates, largely driven by operator inexperience, suboptimal insertion technique, and inadequate imaging support. Contemporary guidelines from the American Thoracic Society, European Respiratory Society, and British Thoracic Society emphasize evidence-based indications, routine ultrasound guidance, avoidance of trocar insertion, and the use of appropriately sized small-bore drains in most non-traumatic conditions. This review integrates current evidence and recommendations regarding indications, procedural techniques, imaging modalities, complication prevention, training standards, and malignant pleural effusion management into a practical framework for contemporary pleural drainage while highlighting areas of changing practice, persistent uncertainty, and key challenges in implementation.