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

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.