Lung and breast cancer are responsible for the majority of malignant pleural effusions. The diagnosis of a malignant pleural effusion signifies a limited survival for most patients. During their final months, dyspnea is the most common symptom and requires palliation. A decision relating to palliation and the modality of therapy should be based on total assessment of the patient and not a single variable. Local treatment remains the most common and effective palliation. Assessing the response to therapeutic thoracentesis determines the degree of relief of dyspnea and the time-course of recurrence. Lack of a beneficial effect suggests the patient may have a trapped lung, atelectasis, lymphangitic carcinomatosis, or tumor embolism. Short-term chest tube drainage has variable results and is not recommended. Chemical pleurodesis through a standard chest tube or small-bore catheter is a commonly used and effective treatment. Talc slurry consistently produces the highest success rates, followed by the tetracyclines and bleomycin. Although acute respiratory failure has been reported following talc pleurodesis, these episodes represent a very small percentage of the total reported cases of talc poudrage and slurry pleurodesis. Whether acute respiratory failure is directly related to talc in the absence of other risk factors remains unclear. Other possible causes for acute respiratory failure following pleurodesis include re-expansion pulmonary edema, excessive premedication, severe comorbid disease, and sepsis from unsterile talc or poor chest tube technique. Factors that need to be considered before recommending chemical pleurodesis include response to therapeutic thoracentesis, general health of the patient, performance status, pleural space elastance, the primary malignancy, and pleural fluid pH. Chronic indwelling catheters have been shown to be effective alternatives to chemical pleurodesis. Pleuroperitoneal shunting can provide palliation to patients with a trapped lung, a malignant chylothorax, or others who have failed pleurodesis. Parietal pleurectomy should be reserved only for patients who have failed chemical pleurodesis or have a trapped lung with an expected survival > 6 months. To provide the highest quality of life for patients with malignant pleural effusions, the least invasive, morbid and costly therapy should be used. Success of the initial procedure is important, as repeat procedures are associated with additional hospitalization, patient discomfort, and increased expense; therefore, the selection of patients for palliation and the modality utilized is critical to avoiding further hardship to the patient.