Several approaches are available to manage MPEs: (1) thoracoscopy/pleuroscopy with pleurodesis; (2) tube thoracostomy with pleurodesis; and (3) indwelling, tunneled pleural catheters (TPCs) (Fig 1). Historically, either tube thoracostomy or thoracoscopy with pleurodesis was the standard approach, and a large randomized trial failed to demonstrate a significant difference in pleurodesis success rate between these two approaches.4 With TPC development, there has been increasing use of this approach to MPE, and several trials have investigated TPC compared with traditional approaches. In a retrospective review, Hunt et al5 reported that patients who had TPCs placed had shorter overall and postprocedure hospital stays and fewer ipsilateral reinterventions for fluid recurrence. Two small randomized prospective trials corroborated these findings, reporting that TPC compared with chest tube with talc pleurodesis resulted in shorter hospital stays, fewer repeat procedures, and improved 30-day survival with effusion control.6,7 The largest trial randomized patients with MPE to either TPC or small-bore chest tube with talc slurry pleurodesis. At 6 weeks, there was no difference in dyspnea scores, but at 6 months, TPC had statistically improved dyspnea compared with talc slurry. Similar to the prior reports, the TPC group had shorter hospital stay (0 days vs 4 days) and less need for further interventions (6% vs 22%), but did have a higher adverse event rate (40% vs 13%) when compared with the talc slurry group.8 Interestingly, in a cost-effectiveness decision analysis comparing thoracentesis, TPC, chest tube with pleurodesis, and thoracoscopic pleurodesis at 3-month and 12-month survival time points, TPC was more cost-effective with shorter life expectancy, while chest tube pleurodesis was better for longer life expectancy.9 The current data are not overwhelmingly convincing that one route is superior to another, so the “best” choice for any given patient with MPE must incorporate several factors–anticipated life expectancy, performance status, lung reexpansion, and patient preference after an informed discussion about the risks/benefits of each approach.