Consider the case of a 65-year-old patient with metastatic lung cancer who presents to the pulmonary outpatient clinic with progressive dyspnea, both with exertion and intermittently at rest. On examination, breath sounds are markedly diminished on the right side. A point-of-care ultrasound confirms a large right pleural effusion. After a multidisciplinary discussion with the patient and her oncology team, thoracentesis was recommended to guide management and provide symptom relief. The options at the time of this case were to schedule the procedure in our bronchoscopy suite with a two-day wait or present to the emergency department (ED) for immediate intervention.
Alternatively, consider a 70-year-old new patient with metastatic lung cancer and malignant pleural effusion, status post-indwelling pleural catheter (IPC) placement, who presents with dyspnea. During the history, it is learned that the IPC has not been drained in four weeks and no home health services have been arranged.
These are just two examples of the many patients who present to my outpatient clinic with acute and symptomatic pleural effusions requiring intervention and, as such, highlight deficiencies in the current care model for patients with this debilitating condition. Despite having ultrasound capability and adequate space in clinic, thoracenteses were not performed on site due to lack of supplies and infrastructure. As a result, patients are funneled into the ED or procedural suite for intervention, creating unnecessary delays, fragmented care, and a diminished patient experience. Through these and similar experiences, I recognized a gap in the management of patients presenting with acute pleural effusions in the outpatient pulmonary setting.This observation prompted me to propose the development of an outpatient pleural disease clinic designed to provide thoracentesis and IPC care safely and efficiently at the point of care.
Identifying the gap in care
The management of pleural effusions is complex, requiring treatment of the underlying cause and interventions to remove fluid, prevent recurrence, and symptom relief. Thoracentesis, a minimally invasive procedure to drain fluid, remains a critical aspect of care, serving both diagnostic and therapeutic purposes.1 While all new pleural effusions necessitate thoracentesis for diagnostic evaluation, malignant or recurrent effusions may require additional interventions, such as IPC placement, pleurodesis, or other therapeutic options.2 Patient-centered care is particularly vital in managing recurrent effusions, ensuring that therapeutic decisions align with individual values, preferences, and goals. Comprehensive clinical assessment is essential to guide therapeutic decision-making, incorporating patient-specific factors to optimize outcomes and enhance quality of life (QOL).
Prior to the development of the pleural clinic at my institution, the management of pleural effusions was fragmented. Thoracentesis patients who were too unstable to wait for a bronchoscopy were advised to present to the ED, resulting in numerous patients receiving pleural effusion management and thoracentesis by ED or interventional radiology (IR) attending. This led to incomplete workups, inconsistent fluid studies, missing fluid studies, and sometimes delayed diagnoses. Additionally, opportunities for timely IPC placement were often missed, and follow-up care was poorly coordinated, with frequent referrals from outside providers and home health agencies for patients with IPCs not previously evaluated in clinic. This lack of standardized pathways contributed to repeated hospital admissions for thoracentesis and poor continuity of care. This was not only detrimental to the individual patient but also very costly to the health care institution.
Advocating for system-level change
In collaboration with my interventional pulmonary (IP) team, I proposed and implemented a dedicated pleural disease clinic, which I primarily staff. This model standardizes patient evaluation, provides timely access to thoracentesis and IPC placement, and ensures longitudinal follow-up through coordinated drainage schedules, home health referrals, and repeat imaging. Patients benefit from an improved experience through the continuity of care provided by a consistent clinician overseeing their management. Additionally, this model reduces the financial burden on both patients and the health care system. Referrals to our pleural clinic may be made by any specialty. Through increased access, shorter wait times, and ongoing follow-up and coordination, advanced practice providers (APPs) enhance the efficiency, quality, and continuity of care for patients with pleural disease within the IP program.3
A thoracentesis clinic led by nurse practitioners (NPs) offers direct, same-day outpatient care for pleural effusions, enabling NPs to perform both diagnostic and therapeutic procedures, speed up treatment, and quickly relieve patient symptoms. Literature recommends that patients with symptomatic malignant pleural effusions be referred to pleural services as early as possible to maximize QOL benefits from treatment. When an IPC is indicated, pleural services can also facilitate coordinated home drainage visits. Early intervention has been associated with a reduced risk of developing nonexpandable lung in later stages.4 NPs broaden procedural capacity by performing procedures such as thoracentesis and managing IPCs.
Pursuing the necessary training
APPs are highly trained clinicians who play an integral part of the health care team. Current literature supports that appropriately trained APPs can safely perform minimally invasive procedures, such as ultrasound-guided thoracentesis, with complication rates comparable to those of physicians.1 APPs have the capacity to bill independently for outpatient procedures and offer a more efficient and cost-effective route for patients as opposed to using IR.6 Several single-center studies and reviews show that real-time ultrasound-guided thoracentesis performed by trained nonradiology providers, such as APPs under supervision, results in low complication rates and favorable outcomes. APP-performed procedures may also decrease costs and increase revenue for health care systems by freeing up interventional radiologists and pulmonologists to perform a greater volume of image interpretation or more complex procedures.1 This evidence supports the development of APP-led outpatient thoracentesis clinics in settings where proper training, standardized protocols, and ultrasound resources are available.7
Adult-gerontology acute care nurse practitioners (AGACNPs) are advanced practice nurses with education and training in the treatment of complex health conditions in adults across acute, critical, and chronic care settings.5 Their scope of practice encompasses stabilizing patients who are acutely ill, managing chronic illnesses, and providing palliative and end-of-life care. AGACNPs are also qualified to perform nearly all diagnostic and therapeutic procedures traditionally carried out by physicians.3
As an AGACNP, my specialized training has equipped me to identify clinical gaps, develop practical solutions, and provide advanced procedural care. As the first NP in our office to perform outpatient thoracenteses and manage IPCs, establishing this service requires self-advocacy, initiative, and a strong commitment to expanding my role. Close collaboration and extensive mentorship from my attending physician and the broader care team were essential in ensuring both my competency and the safety of the patients we serve. Under direct supervision I performed more than 50 ultrasound-guided thoracenteses with efficiency and precision, leading to my application for procedural credentialing, which was fully supported by my attending physician.
Expanding access
Growing patient volume has supported the expansion to a second pleural clinic. Despite this success, barriers to APP autonomy persist across many institutions. Limitations such as the inability to independently obtain informed consent can affect workflow efficiency, particularly in high-volume procedural settings. These challenges highlight the need for ongoing institutional support to optimize APP practice and reinforce their vital role in addressing care gaps, expanding access, and advancing outcomes through multidisciplinary collaboration. Even with these challenges, this initiative illustrates the pivotal role of APPs in pulmonary medicine to enhance care delivery and improve patient outcomes within subspecialty, team-based care models. It also emphasizes the value of multidisciplinary collaboration in managing complex pulmonary diseases and optimizing patient care.
By identifying a gap in care, advocating for system-level change, and pursuing the necessary training to develop procedural competence, I contributed to establishing a service that addresses patient needs while enhancing the capabilities of the IP team. This experience reflects how APPs can play a critical role in filling care gaps, expanding access, and strengthening team-based care delivery models within subspecialty practices.
References
1. Tublin JM, Lindquester WS, Dhangana R, Tublin ME. Growth in thoracentesis and paracentesis performed by radiology and advanced practice providers: Medicare volume and reimbursement trends from 2012 to 2018. J Am Coll Radiol. 2022;19(5):597-603. doi:10.1016/j.jacr.2022.02.031
2. Krishna R, Antoine MH, Alahmadi MH, Rudrappa M. Pleural effusion. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; Updated August 31, 2024. https://www.ncbi.nlm.nih.gov/books/NBK448189/
3. Taylor K, Sansivero GE, Ray CE. The role of the nurse practitioner in interventional radiology. J Vasc Interv Radiol. 2012;23(3):347-350. doi:10.1016/j.jvir.2011.11.002
4. Munavvar M, Bodtger U, Carus A, Cordovilla R, Naik S, Salud A, et al. Current trends in treating malignant pleural effusion: evidence, guidelines, and best practice recommendations. JCO Oncol Pract. 2025;21(6):759-765. doi:10.1200/OP.24.00387
5. Peacock A, Blakely K, Maes C, Henson A, DiGiulio M, Henderson MJ. Adult-gerontology nurse practitioners: a discussion of scope and expertise. J Nurse Pract. 2022;18(10):1037-1045. doi:10.1016/j.nurpra.2022.07.017
6. Kozmic SE, Wayne DB, Feinglass J, Hohmann SF, Barsuk JH. Factors associated with inpatient thoracentesis procedure quality at university hospitals. Jt Comm J Qual Patient Saf. 2016;42(1):34-40. doi:10.1016/S1553-7250(16)42004-0
7. Rodriguez Lima DR, Yepes AF, Birchenall Jiménez CI, Mercado Díaz MA, Pinilla Rojas DI. Real-time ultrasound-guided thoracentesis in the intensive care unit: prevalence of mechanical complications. Ultrasound J. 2020;12(1):25. doi:10.1186/s13089-020-00172-9
