Periprocedural pain management in pleural disease: a narrative review of current and emerging strategies

Abstract

Background and Objective

Pleural diseases represent a significant healthcare burden globally, often requiring repeated diagnostic and therapeutic interventions. These procedures are associated with substantial patient discomfort due to the rich innervation of the parietal pleura. Given the variability in periprocedural analgesia, this narrative review aimed to evaluate the current literature on pain management techniques for common pleural procedures and highlight emerging strategies.

Methods

We conducted a narrative review based on a literature search executed using the PubMed and Ovid MEDLINE databases. The search spanned studies published between January 1990 and January 2025, and we identified publications using keywords related to pleural disease, specific pleural procedures, and pain control/analgesia. Studies were included if they investigated pain management methods in adult human subjects undergoing these procedures.

Key Content and Findings

Pain is primarily mediated by the parietal pleura and the intercostal nerves. Findings demonstrated significant variability in practice. For thoracentesis, methods related to controlling pleural pressure (especially with trapped lung) and buffered local anesthetics showed mixed evidence. For tube thoracostomy, smaller chest tube bore sizes were associated with less pain, and studies suggest that using intrapleural bupivacaine prolongs analgesia duration. For more invasive procedures like medical thoracoscopy and pleurodesis, regional nerve blocks, such as the erector spinae plane block, are emerging as viable, opioid-sparing alternatives to conventional systemic sedation. Overall, there is considerable variability in pain management strategies across all reviewed procedures.

Conclusions

While the current evidence base is heterogeneous, effective multimodal and regional analgesic techniques do exist to manage pain associated with common pleural procedures.

Introduction

Pleural disease represents a significant healthcare burden in the United States (U.S.). Pleural effusions are the most common manifestation, affecting an estimated 1.5 million individuals annually (1). Diseases of the pleura may arise from several independent or codependent processes including infection, inflammation, malignancy, and trauma (1,2).

Patients with malignant pleural effusion (MPE), which leads to approximately 125,000 hospitalizations per year in the U.S., typically require multiple procedures over their lifetime (3). While a single diagnostic and therapeutic thoracentesis may be sufficient for some, recurrence is common, necessitating repeated interventions.

The symptoms of pleural disease are non-specific and may include cough, pleurisy, dyspnea, respiratory distress and ultimately respiratory failure. Management is directed at obtaining a diagnosis and alleviating symptoms (4). Pain in pleural disease is often complex and multifactorial. While primary pleural pathology can be inherently painful, diagnostic and therapeutic interventions may cause further discomfort.

Although the visceral pleura lacks pain fibers, the parietal pleura is highly sensitive, innervated by somatic intercostal nerves. Additionally, pleural procedure-related pain can arise from irritation of cutaneous and periosteal nerve fibers or from local inflammatory processes induced by disease or intervention (5). The chest wall intercostal space contains three muscle layers. From outermost to innermost, they are the external intercostal muscle, the posterior intercostal membrane (part of the internal intercostal muscle), and the intercostalis intimus muscle. The intercostal nerves are located between the internal intercostal muscle and the intercostalis intimus muscle. Because the innermost intercostalis intimus is not a solid sheet, fluid may enter the pleural space, while the middle layer (posterior intercostal membrane) acts as a complete barrier (5).

When performing a pleural procedure, local anesthetic is typically introduced along the needle tract, traversing the parietal pleura and usually reaching the pleural space (between the parietal and visceral pleura) (6). Local anesthetic spreads to desensitize the nearby intercostal and paravertebral nerves, as well as adjacent sympathetic nerves, facilitating adequate pain control for most procedures (6).

Pain management is a critical component of any procedure. The lack of pain control can impact patient trust, success of the procedure, and may contribute to complications. Shallow breaths due to pain during inhalation, also referred to as splinting, has been well established to contribute to postprocedural pulmonary complications. Additionally, pleural diseases often require repeated procedures for diagnosis or palliation, and an uncomfortable initial experience may lead to delayed or incomplete care (7).

Given the ongoing opioid epidemic in the U.S., emphasis has been placed on opioid sparing and multimodal pain management strategies (8). Thus, it behooves physicians to be familiar with the scope of literature and varying strategies that exist for the most common pleural procedures such as thoracentesis, tube thoracostomy, indwelling pleural catheter (IPC) placement, and medical thoracoscopy (MT). We present this article in accordance with the Narrative Review reporting checklist (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-1-2476/rc).

Methods

The authors (J.S., M.F.) conducted a literature search using two databases, PubMed and Ovid MEDLINE, to identify relevant studies published between January 1990 and January 2025. Key words, outlined in Table 1, include: “pleural disease”, “pleural effusion”, “thoracentesis”, “chest tube”, “pleuroscopy”, “pleurodesis”, “medical thoracoscopy”, “pain control”, and “analgesia”, etc. This search was intended to capture a broad range of literature addressing pain management in the context of pleural disease and these procedures.

Table 1. Examples of concepts translated into keywords for the literature search.

Concept	Index terms
Pleural disease	Pleural effusion
	Pleuritis
	Empyema
	Pleural metastasis
	Parapneumonic effusion
	Malignant pleural effusion
Pleural procedures	Thoracentesis
	Chest tube
	Tube thoracostomy
	Pleuroscopy
	Pleurodesis
	Medical thoracoscopy
	Indwelling pleural catheter
	Tunneled pleural catheter
Pain management	Analgesia
	Pain control
	Pain score
	Opioids
	Non-steroidal anti-inflammatory drugs
	Anesthesia
	Patient controlled analgesia
	Transcutaneous electrical nerve stimulation

Study selection

The authors screened the titles and abstracts of identified studies to determine their relevance to the present review. Using the indexing terms shown in Table 1, The selection process prioritized studies that focused on pleural disease, pleural procedures and pain management. Full-text articles of potentially relevant studies were retrieved for more detailed review.

Studies included specifically addressed pain control methods employed during the management of pleural disease, or the performance of common pleural procedures in adult human subjects of age 18 years or older. Non-English articles were excluded. Studies were further excluded if they primarily involved animal subjects or pediatric populations. Publications such as study protocols, preliminary reports without final results, and conference abstracts lacking peer-review were also excluded. The search strategy is summarized in Table 2, and key studies included are outlined in Tables 3-5.

Table 2. The search strategy summary.

Items	Specification
Date of search	February 01, 2025
Databases and other sources searched	PubMed, Ovid MEDLINE
Search terms used	(“Pleural effusion” OR Pleuritis OR Empyema OR “Pleural metastasis” OR “Parapneumonic effusion” OR “Malignant pleural effusion”) AND (Thoracentesis OR “Chest tube” OR “Tube thoracostomy” OR Pleuroscopy OR Pleurodesis OR “Medical thoracoscopy” OR “Indwelling pleural catheter” OR “Tunneled pleural catheter”) AND (Analgesia OR “Pain control” OR “Pain score” OR Opioids OR “Non-steroidal anti-inflammatory drugs” OR Anesthesia OR “Patient controlled analgesia” OR “Transcutaneous electrical nerve stimulation”)
Timeframe	January 1990 to January 2025
Inclusion and exclusion criteria	Relevant studies including adults >18 years. Excluding non-English articles, studies involving animal subjects or pediatric populations. Excluding study protocols, preliminary reports, and conference abstracts without peer review
Selection process	Authors J.S. and M.F. independently conducted the search and selection. Using the indexing terms outlined, J.S. and M.F. screened titles and abstracts, and selected studies that specifically addressed pain control assessment and methods in the relevant pleural diseases outlined. The full text articles were then reviewed and included if they fulfilled the other criteria outlined above

Table 3. Key literature addressing pain assessment or management in patients undergoing thoracentesis.

First author, year	N	Intervention	Pertinent outcome(s)
Senitko et al., 2019 (9)	100	Vacuum drainage versus manual drainage during thoracentesis	Vacuum drainage was associated with earlier termination of the procedure and greater pain (26 mm for vacuum drainage vs. 12.5 mm for manual aspiration, P=0.02)
Lentz et al., 2019 (10)	124	Pleural manometry compared to only symptom assessment	Discomfort score was not altered by measuring pleural manometry (mean difference in chest discomfort score 2.4 mm, P=0.56). 10% of patients in control group developed asymptomatic pneumothorax ex vacuo, vs. none in the manometry group (P=0.01)
Lentz et al., 2020 (11)	140	Active aspiration compared to gravity drainage	Discomfort and dyspnea scores did not differ between groups (mean VAS difference was 5.3 mm, P=0.17)
Halili et al., 2021 (12)	36	Topical LPC at the site of thoracentesis needle insertion as compared to IL with 1% lidocaine	Level of patient satisfaction in the LPC and IL groups were not significantly different (P>0.05)
Shojaee et al., 2024 (13)	221	Drainage of large free-flowing pleural effusion by wall suction or gravity	Post-procedure chest discomfort did not differ between groups (P=0.08). There was no difference in rate of pneumothorax ex-vacuo or re-expansion pulmonary edema between groups

IL, local infiltration; LPC, lidocaine-prilocaine cream; VAS, visual analog scale.

Table 4. Selected studies addressing pain assessment or management in patients undergoing tube thoracostomy.

First author, year	N	Intervention	Pertinent outcome(s)
Engdahl et al., 1993 (14)	22	Intermittent 8-hourly bolus injections of 20 mL bupivacaine 0.5% with epinephrine were compared with placebo	No significant differences in pain scores were found after 4 or 8 h
Rahman et al., 2015 (15)	114	24 F chest tube and opioids (n=28); 24 F chest tube and NSAIDs (n=29); 12 F chest tube and opioids (n=29); or 12 F chest tube and NSAIDs (n=28)	Patients receiving smaller tubes reported significantly less pain overall (mean VAS difference 14.8 mm, P<0.001). When comparing analgesia types (opiates vs. NSAIDs), there was no significant difference in mean pain scores (P=0.42), but the NSAID group required more rescue opiate analgesia
Verma et al., 2019 (16)	28	Bupivacaine vs. bupivacaine + morphine vs. bupivacaine + dexmedetomidine administered via the chest drain	Analgesia duration was measured by time to first rescue analgesia. The bupivacaine + dexmedetomidine group had the longest pain-free duration (P<0.05 vs. control)
Soydan et al., 2021 (17)	180	Parallel three-arm (1:1:1), randomized controlled clinical trial consisted of 180 patients in two experimental groups (ice pack/gel pad) and one control group	Pain severity was measured using a NRS from 0–10 before and after chest tube removal. Both the ice pack and gel pack groups had significantly lower pain scores after removal compared to the control group. The mean post-removal NRS was 2.2 for the ice pack group, 2.5 for the gel pack group, and 6.6 for the control group (P<0.001)

NRS, numerical rating scale; NSAID, non-steroidal anti-inflammatory drug; VAS, visual analog scale.

Table 5. Selected studies addressing pain assessment or management in patients undergoing medical thoracoscopy or pleurodesis.

First author, year	N	Intervention	Pertinent outcome(s)
Davies et al., 2012 (18)	106	IPC and talc slurry vs. tube thoracostomy and talc slurry	No significant difference in VAS between groups at baseline (22 vs. 29) or 42 day follow up (8.2 vs. 4.4)
Alka et al., 2013 (19)	60	TENS and diclofenac vs. sham TENS and diclofenac to assess pain control and NSAID usage in patients undergoing pleurodesis for pneumothorax	VAS was similar immediately and 2 hours post procedure between groups. VAS score was significantly lower (P<0.001) at 4, 6 and 8 hours post procedure. The dose of diclofenac was significantly lower in the TENS group (P<0.02)
Abo-Zeid et al., 2017 (20)	63	3 level paravertebral nerve block vs. 2 level paravertebral nerve block vs. local infiltration	VAS was lower immediately (1.5 vs. 2.0 vs. 5.0, P=0.01) in the 3 level and 2 level paravertebral nerve block groups compared to local infiltration, and at the 1 hour post-procedure interval (2.0 vs. 2.0 vs. 4.0, P=0.012)
McPherson et al., 2022 (21)	9	Erector spinae plane nerve blocks administered, and pain scores and opioid usage were monitored.	78% of cases required oral analgesia on day 0, 55% required oral analgesia on day 1. All patients felt like their pain was well controlled via questionnaire. No complications reported
Sharp et al., 2022 (22)	26	Retrospective review of a protocol to reduce pain and opioid usage using erector spinae plane nerve block and moderate sedation for MT	Average intraoperative and post-procedural opioid usage in oral morphine equivalents was 18.4 mg, and 11.2 mg respectively. There was no difference in pre and post procedure pain scores (P=0.221). No complications reported
Adamo et al., 2023 (23)	16	Implementation of an opioid free MT protocol using combination serratus plane nerve blocks and erector spinae plane nerve blocks	4 patients required NSAIDs and/or acetaminophen in the 36 hours post-procedurally. No opioids were required
Bansal et al., 2020 (24)	76	Mini-thoracoscopy vs. semirigid thoracoscopy	Similar diagnostic yield. Semirigid thoracoscopy group experienced less pain (32.1 vs. 41.9 on VAS, P=0.02)
Bhatnagar et al., 2020 (25)	330	Talc poudrage vs. talc slurry pleurodesis failure rates	No significant difference in pleurodesis rate. No significant differences were noted related to pain (at baseline, 17.0 vs. 17.7 on VAS), or any other secondary outcome
Salguero et al., 2024 (26)	100	Intraprocedural chest tube removal	73% of patients required no analgesia in the recovery unit. Of the 27% who needed analgesia, no additional analgesia was needed after 24 hours

IPC, indwelling pleural catheter; MT, medical thoracoscopy; NSAID, non-steroidal anti-inflammatory drug; TENS, transcutaneous electrical nerve stimulation; VAS, visual analog scale.

Findings

Thoracentesis

Thoracentesis is a procedure typically performed at the bedside under local anesthesia.

Despite thoracentesis being a commonly performed procedure, few studies have specifically focused on interventions to mitigate periprocedural pain. Other studies focus on procedural techniques which may improve patient pain and tolerability.

Senitko et al. evaluated the safety and tolerability of vacuum drainage versus manual drainage during thoracentesis (9). While this was a pilot study, vacuum drainage was associated with earlier termination of the procedure and greater pain using a visual analog scale (VAS). This may have been related to the greater negative pressure generated by the vacuum bottles causing less time for equilibration and more rapid swings in pleural pressure. Additionally, the use of manual aspiration was thought to allow the operator to retract the catheter away from the diaphragm, possibly causing less pain due to phrenic nerve stimulation. However, in a recent randomized controlled study, Shojaee et al. found no difference in post procedure chest discomfort between gravity and wall suction (13). Lentz et al. compared active aspiration to gravity drainage, and they found that perceived discomfort did not differ between the two groups (11). Importantly, these studies did not comment on the percentage of trapped or entrapped lung encountered between groups. This is a critical factor, as it is well established that continued drainage when the lung cannot re-expand leads to increased transpulmonary pressures, commonly resulting in chest pain (27).

Other studies have investigated the use of topical lidocaine-prilocaine cream at the site of thoracentesis needle insertion as compared to local infiltration with lidocaine to reduce procedural pain, but no difference was found between the groups (12). Nuances in lidocaine delivery have been explored. The acidity of commercial lidocaine preparations is worth considering, which is thought to be the cause of the burning sensation upon injection. Buffering the lidocaine with sodium bicarbonate to raise the pH closer to physiologic levels has been shown to significantly decrease the pain of infiltration in numerous other procedures performed by interventional radiology, however this approach has not been explored specifically for pleural procedures (28).

An important consideration for patients with trapped or entrapped lung physiology is the development of chest discomfort caused by excessively negative pleural pressures during large-volume thoracentesis (27). Therefore, pleural manometry has been considered as a potential safeguard against pressure-related complications.

Pleural manometry involves measurement of intrapleural pressure during fluid drainage to guide procedural decision-making. Normally, the pleural space maintains a slightly negative pressure (−5 cmH₂O at end-expiration). As pleural fluid accumulates, it displaces the lung and chest wall, transitioning the intrapleural pressure from negative to positive. As pleural fluid is subsequently removed, pleural pressure becomes progressively more negative as the lung re-expands to fill the space previously occupied by fluid.

However, in patients with non-expandable lung, which affects approximately 30% of those with MPEs, the lung cannot fully re-expand due to visceral pleural restriction from inflammation, tumor encasement or fibrosis (10,29,30). Continued drainage in this setting generates excessively negative pleural pressures (typically defined as below −20 cmH₂O) which have been associated with complications including pneumothorax ex vacuo, re-expansion pulmonary edema, and chest discomfort (10,31).

A landmark multicenter randomized controlled trial by Lentz et al. demonstrated that manometry-guided thoracentesis did not reduce procedural chest discomfort compared to symptom assessment alone (mean difference in chest discomfort score 2.4 mm on 100 mm VAS, P=0.56) (10). This may be attributed to an inconsistent relationship between pleural pressure and pain, as only 22% of patients experiencing chest discomfort and 9% of asymptomatic patients developed pleural pressures below −20 cmH₂O (10,32). Notably, pleural pressure measurements are obtained during brief drainage interruptions, potentially missing acute pressure changes (10,31). While manometry did reduce asymptomatic pneumothorax ex vacuo (0% vs. 10%, P=0.01), no serious complications occurred in either group, and re-expansion pulmonary edema remained independent of pleural pressure and drainage volume (10).

Tube thoracostomy

Tube thoracoscopy, also referred to as chest tube placement, has been noted to be painful for patients; one study found that approximately 50% of patients who had a chest tube in place experienced pain rated as 9 or 10 on a scale from 1 to 10, with higher numbers signaling more pain (33). This may be attributed to continuous irritation of the pleura by the tube itself. This discomfort or pain is further compounded when there is disease or inflammation of the pleura or pleural fluid. Chest tube bore size significantly influences procedural pain, as insertional technique differs from percutaneous placement of smaller bore tubes (12 to 14 Fr), compared to blunt dissection with larger surgical chest tubes (24 Fr) (15). One study published in 1993 looked at the use of intra-pleural bupivacaine to reduce pain associated with chest tube placement post procedurally, however it was noted that there was no difference in pain scores in the bupivacaine group as compared to the placebo group after 4 and 8 hours (14). The British Thoracic Society guidelines published in 2010 recommended initiation of analgesia prior to percutaneous chest tube placement with a specific recommendation for opioids (2.5 mg of intravenous morphine or 10 mg of oral morphine) in conjunction with local anesthesia (1% lidocaine) (34).

A larger study performed in the context of chest tube placement and pleurodesis compared an opiate based strategy to non-steroidal anti-inflammatory drugs (NSAIDs) in reducing pain, and found no difference in the mean pain scores between the groups, but more rescue analgesia was needed in the NSAID group (15).

Limited literature exists regarding post chest drain insertion analgesia and often is based on individual physician preference. However, one small study by Verma et al., with 28 patients, compared the use of intrapleural bupivacaine versus intrapleural bupivacaine plus morphine, versus intrapleural bupivacaine plus dexmedetomidine compared to control (16). All three active treatment groups showed a longer time to first rescue analgesia compared to the control group. The longest duration was observed in the bupivacaine with dexmedetomidine group, providing a mean of 428 minutes of effective analgesia, compared to 280 minutes for bupivacaine with morphine, 195 minutes for bupivacaine alone, and 45 minutes for the saline control group (P<0.05) (16).

Non pharmacological options have also been explored. A randomized control trial involving 180 individuals found that the application of an ice or gel pack significantly reduced the severity of pain after chest tube removal compared to control (17).

IPC placement

Chest pain is a common complication frequently seen in approximately a third of patients who undergo IPC placement (also known as tunneled pleural catheter) (35,36).

Pain manifests across distinct temporal phases, each with characteristic mechanisms. Acute procedural pain primarily occurs during subcutaneous tunneling and parietal pleura puncture during insertion, with patient-reported discomfort at time of insertion occurring in 58% of patients in a multicenter survey study (37). Procedure-related pain represented one of the most common adverse events in randomized trials comparing IPCs to talc pleurodesis, though the incidence was similar between both interventions (38). Robust comparative studies specifically evaluating analgesic strategies for IPC insertion remain lacking, with pain management typically incorporated into procedural descriptions rather than studied as an independent outcome (36,39).

Drainage-related pain occurs during active fluid removal and reflects distinct pathophysiologic mechanisms related to pleural pressures. As reviewed above, pressure-related discomfort may develop as the lung expands against a restricted pleura, with discomfort during home IPC drainage reported by 36% of patients at 2-week follow-up (37). Non-expandable lung, which occurs in approximately 30% of patients with MPEs, predisposes to drainage-related pain. Non expandable lung may be due to entrapped lung, or trapped lung, which confer distinct clinical features and management strategies (30). IPCs are the preferred management strategy over pleurodesis for this subgroup of patients (10,29,30). In the AMPLE-2 trial comparing aggressive versus symptom-guided drainage strategies, pain at the IPC site requiring narcotics was the most common adverse event in the symptom-guided group (40). Of note, symptom-guided drainage strategies provided similar breathlessness control to aggressive drainage regimens while reducing overall drainage-related discomfort, supporting individualized approaches to IPC management (40).

Chronic pain related to IPCs may manifest as a persistent gnawing sensation, likely representing inflammatory changes or neuropathic pain from intercostal nerve irritation by the catheter itself (39). A small subset (0.6% of patients) develops refractory chest pain that is unresponsive to pharmacologic therapy and resolves only with catheter removal (36). Additionally, IPC-related pain must be differentiated from tumor-related chest wall pain, which may progress independently and requires distinct management strategies directed at cancer progression or inflammation (39).

MT

MT, also referred to as pleuroscopy, is a minimally invasive procedure performed by interventional pulmonologists for diagnosing and treating pleural diseases. It differs from video-assisted thoracic surgery (VATS), which is a surgical procedure performed by thoracic surgeons, with differences outlined in Table 6. MT is considered less invasive than VATS, with the use of fewer incisions/ports, avoidance of general anesthesia, and the avoidance of chest tube placement. Typically performed in the endoscopy suite under moderate sedation, MT presents a viable alternative to VATS in the diagnostic workup of pleural disease.

Table 6. Comparison of medical thoracoscopy and video-assisted thoracic surgery.

Feature	Medical thoracoscopy	Video-assisted thoracic surgery
Proceduralist	Interventional pulmonologist	Thoracic surgeon
Setting	Endoscopy suite, procedure room, or operating room	Operating room
Anesthesia	Moderate (conscious) sedation and local anesthesia	General anesthesia with single-lung ventilation
Airway	Patient breathes spontaneously	Intubation with a double-lumen endotracheal tube
Instrument	Semi-rigid or flexible scopes (5–7 mm)	Rigid-thoracoscope (7–10 mm) and specialized surgical instruments
Invasiveness	Typically 1 or 2 incisions (ports)	Typically 2 to 4 incisions (ports)
Lung collapse	No lung collapse induced	The operative lung is fully collapsed
Indications	Diagnostic (pleural biopsy, visualization) and limited therapeutic (pleurodesis, lysis of simple adhesions)	Diagnostic and major therapeutic/resecting procedures (e.g., lobectomy, decortication, complex adhesiolysis)

Considering these differences, MT is generally thought to be a less painful procedure compared to VATS. A simple four step approach in which the epidermis, aponeurosis, intercostal muscles and parietal pleura are anesthetized using local anesthetic was found to demonstrate effective analgesia, especially when combined with benzodiazepines and opiates (41). Previous studies have highlighted the importance of pain control to avoid splinting and post-operative pulmonary complications for chest surgeries and procedures (7). The literature regarding pain control for specifically MT is considerably limited, with most studies utilizing strategies involving local anesthetics, NSAIDs, and/or systemic opioids, as outlined in Table 5. More recently, various chest wall blocks have also been described.

Midazolam and fentanyl are the most commonly used sedatives (42). In a retrospective review of 521 procedures, only one case resulted in significant pain requiring opioids after the procedure (42). However, a review of 1,926 patients specifically focusing on complications of MT found that pain was the most common minor complication, occurring in 38% of cases (43). Pain was most frequently reported in patients undergoing pleurodesis (further discussed below), suggesting that MT by itself may not be the main driver of pain (43).

The type of scope used may also contribute to patient pain. As demonstrated by Bansal et al., the use of a semi-rigid thoracoscope may be more comfortable for patients as compared to a rigid mini-thoracoscope (24).

Regional anesthesia involving chest wall blocks have recently emerged as effective and well tolerated options for MT, and there are several approaches described (44). Multilevel paravertebral block (PVB) has been showed to provide better analgesia compared to local anesthetic, evidenced by lower pain scores (20). Additionally, the PVB group demonstrated higher forced expiratory volume in one second (FEV1) post procedurally, suggesting less splinting and lower risk for post-operative pulmonary complications (20). Erector spinae plane nerve blocks and serratus plane nerve blocks, which are considered less technically challenging compared to PVB, have also been shown to provide effective analgesia for MT, with the potential to reduce opioid requirements (21-23,44). In one study, erector spinal nerve block for MT found that in addition to effective analgesia, intraoperative opioid use was also less compared to only local anesthetic administration by the operator (22).

While these nerve block techniques offer promising, clinically relevant options for opioid-sparing pain management in MT, the current body of evidence consists primarily of small and retrospective studies. Further prospective validation in larger, randomized cohorts is necessary to establish their efficacy, safety, and outcomes prior to routine integration into clinical practice.

Non-opiate based pain regimens using primarily acetaminophen and NSAIDS have been shown to be effective for MT (45). Another small, retrospective study examined intraprocedural removal of chest tube during MT rather than in the post-anesthesia care unit (which is where the chest tube is typically removed). Intraprocedural chest tube removal was found to be safe, with an associated decrease in utilization of analgesia post procedurally (26).

The use of patient-controlled analgesia (PCA) for specifically MT has not been studied. For VATS however, multiple randomized controlled trials and meta-analyses demonstrate that intravenous PCA provides analgesia equivalent to thoracic epidural PCA in terms of pain scores, opioid consumption, and patient satisfaction, with no significant difference in adverse effects or pulmonary complications (46,47). Low-dose ketamine with fentanyl-based PCA was also shown to be non-inferior to thoracic epidural PCA for acute post-thoracotomy pain (no significant difference in pain scores) (48).

Chemical pleurodesis

Chemical pleurodesis is a procedure designed to obliterate the pleural space to prevent the re-accumulation of fluid or air. The primary indication is recurrent, symptomatic pleural effusion, or definitive pneumothorax management in patients who are not surgical candidates (25).

The procedure involves instilling a chemical sclerosant into the pleural space with the goal of inducing an inflammatory response, leading to fibrosis and adhesion between the visceral and parietal pleura. Common agents include talc (either via poudrage or slurry), doxycycline, bleomycin, or autologous blood patch (18,25).

Talc poudrage involves insufflating dry, sterile talc powder directly onto the pleural surfaces during thoracoscopy, allowing for direct visualization and even distribution of the agent. Talc slurry administration is performed by instilling a suspension of sterile talc mixed with saline through a chest tube or IPC at the bedside, without the need for thoracoscopy. Both methods use similar talc dosages (18,25).

When considering analgesia for pleurodesis, randomized control trials have found that there was no difference in pain scores in those undergoing pleurodesis with talc poudrage vs. talc slurry, nor was there a difference in pain between those who had talc instilled via chest tube vs. IPC (18,25). The use of scheduled NSAIDS was equally effective compared with opioids in reducing pain scores, without impacting pleurodesis rates (15,18).

Transcutaneous electrical nerve stimulation (TENS) presents a non-pharmacological adjunct for analgesia. It has been studied in various settings, however there is limited data on its use for MT or pleurodesis. One randomized control trial that included 60 individuals undergoing pleurodesis for pneumothorax found that TENS resulted in more effective lowering of pain scores compared to NSAIDS alone, and there was less total NSAID usage in the TENS group (19).

Emerging strategies

Non-pharmacological adjuncts, such as virtual reality (VR), are emerging as promising tools for periprocedural pain management, however there are only two studies that evaluated its use for pleural procedures. A randomized trial by Dalir et al. evaluated the use of VR during chest tube removal in 70 patients following coronary artery bypass grafting (49). Patients in the intervention group watched a 360-degree video using VR headsets starting 5 minutes before the procedure, and experienced significantly lower pain intensity immediately after chest tube removal (P<0.001) and 15 minutes post-removal (P<0.001) compared to standard care (49). A small feasibility study by Wijayaratne et al. explored the use of VR headsets across a broad range of pleural procedures, including thoracentesis, chest tube placement, IPC placement, and MT (50). The intervention group included 12 patients, compared to eight patients who followed standard protocols. Patient-reported pain and anxiety were lower in the intervention group, but the results did not reach statistical significance (50). This is expected given the small sample size and the broad heterogeneity of the pleural procedures evaluated, since this was a feasibility study. Nevertheless, VR offers a novel non-pharmacological approach that warrants a closer look with validation in larger prospective studies.

Limitations

The experience of pain is inherently subjective and difficult to quantify reliably across diverse patient populations. This difficulty is compounded by significant heterogeneity in the analyzed studies, including variations in procedural techniques, the experience levels of the proceduralists, and the specific sedation protocols used. Such factors introduce confounding variables that make it challenging to isolate the efficacy of any single analgesic intervention or to establish a standardized framework for pain management in pleural disease.

Furthermore, as this was a narrative review, we prioritized high quality randomized control trials when available, but did not perform an objective quality or risk of bias assessment. The scope of this review is limited by the scarcity of high-quality, large-scale data for several key procedures. While common interventions like thoracentesis are better represented, there is a notable lack of robust evidence and smaller sample size studies for more specialized procedures such as MT. Additionally, most included studies focused on short-term periprocedural outcomes, leaving a gap in understanding the long-term impact of these interventions on chronic pleural pain and overall patient quality of life.

Conclusions

The variability observed in literature related to pain management during pleural interventions highlights the need for an individualized periprocedural analgesia regimen that optimizes patient comfort. The core principle of anesthetizing the highly innervated parietal pleural remains relevant for common bedside procedures, while adjuncts including procedural variation and use of pleural manometry seem less impactful on patient reported pain.

There is sparse literature on analgesia for more advanced procedures such as MT, however the type of sedation and instruments utilized may affect patient reported pain, favoring propofol and semirigid thoracoscopy in select cases. Emerging techniques including regional nerve blocks and non-pharmacological methods such as TENS and VR show favorable initial results. However, these were small studies, and these techniques warrant validation in larger prospective studies before conclusive assessments can be done. For pleurodesis involving talc, there were no differences in perceived pain regardless of preparation or method of administration.

Ultimately, more studies are needed to help standardize periprocedural pain control and provide a standard framework to better assess and enhance patient comfort, which may facilitate improved overall management of pleural diseases. Future guidelines are needed to provide evidence-based recommendations which can be utilized by proceduralist across different resource settings, and improve patient centered outcomes.

Supplementary

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Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.