The presence of a malignant pleural effusion (MPE) confers a poor prognosis, with a high burden of disabling symptoms due to altered respiratory mechanics and abnormal diaphragm function. Management is often palliative in nature, with the emphasis on preventing fluid re-accumulation. In the era of targeted therapies, pleural biopsies are often required for gene expression and receptor status profiling, for which local anaesthetic thoracoscopy provides the highest diagnostic yield. Interventions to achieve symptom control include thoracentesis, chest drain insertion, indwelling pleural catheters, medical thoracoscopy and surgery. The evidence base for these interventions has historically been lacking with a somewhat linear pathway, however, numerous well-designed, multicentre randomised controlled trials over the last decade using patient-centred outcomes have informed recent clinical practice guidelines. Several therapeutic options and combinations now exist to achieve optimal symptom control and pleurodesis, centred around patient choice and priorities, inpatient versus outpatient strategies and the presence of non-expandable lung. This review will explore the data that has shaped MPE management in the last decade, with the aim of providing a deeper understanding of the rationale behind current international guideline recommendations. It will also highlight areas where the evidence base is lacking, research currently in progress and potential future directions.