Parapneumonic Pleural Effusion and Empyema

Abstract

At least 40% of all patients with pneumonia will have an associated pleural effusion, although a minority will require an intervention for a complicated parapneumonic effusion or empyema. All patients require medical management with antibiotics. Empyema and large or loculated effusions need to be formally drained, as well as parapneumonic effusions with a pH <7.20, glucose <3.4 mmol/l (60 mg/dl) or positive microbial stain and/or culture. Drainage is most frequently achieved with tube thoracostomy. The use of fibrinolytics remains controversial, although evidence suggests a role for the early use in complicated, loculated parapneumonic effusions and empyema, particularly in poor surgical candidates and in centres with inadequate surgical facilities. Early thoracoscopy is an alternative to thrombolytics, although its role is even less well defined than fibrinolytics. Local expertise and availability are likely to dictate the initial choice between tube thoracostomy (with or without fibrinolytics) and thoracoscopy. Open surgical intervention is sometimes required to control pleural sepsis or to restore chest mechanics. This review gives an overview of parapneumonic effusion and empyema, focusing on recent developments and controversies.

Bilateral empyema treated by sequential pleuroscopy

“…Yet, treatement of patients with pleural infection by medical thoracoscopy may save money comparing to surgery, since the technique is less expensive [11,12] and better tolerated than VATS, which requires tracheal intubation [11]. However, its use in this patient population depends very much on local expertise [11,13].…”

Effects of Coexisting Pneumonia and End-stage Renal Disease on Pleural Fluid Analysis in Patients With Hydrostatic Pleural Effusion

“…[2][3][4][5][6] Pleural effusions from pneumonia or uremic pleuritis typically are exudative by both criteria. [7][8][9][10][11][12][13][14][15] In addition, transudative effusions as a result of CHF or CO are paucicellular with low neutrophil counts. Pleural effusions resulting from pneumonia or uremic pleuritis have a higher TNC and ANC and higher protein and LDH concentrations.…”

“…The PFA in a typical parapneumonic pleural effusion is an exudate by both protein and LDH criteria and is further characterized by elevated nucleated cell counts, particularly neutrophils in the acute phase, and a tendency to lower pH and glucose values than in the typical hydrostatic pleural effusion. [10][11][12][13][14][15] We found that all PFA parameters were affected by the presence of pneumonia in patients at risk for hydrostatic pleural effusion when looked at as a group. However, in eight of the 30 patients with PCHF, the pleural effusions remained transudates by protein and suspected diagnosis of coexisting pneumonia, which is clinically relevant because the differentiation of pulmonary parenchymal opacities on standard chest radiographs in patients in CHF is problematic.…”

Research in Thoracoscopy (Pleuroscopy)

“…A question among others is whether those patients should undergo early thoracoscopy or classic treatment. Early thoracoscopy is effective and less invasive than thoracotomy, and was shown to provide significant benefit compared with classic treatment in two small, non-blinded, randomised studies (37)(38)(39)(40). Also, early minimal intervention with pleuroscopy ( Figure 2) has shown excellent results in recent reports.…”