MANAGEMENT OF PARAPNEUMONIC EFFUSIONS

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The annual incidence of bacterial pneumonia in the United States is estimated at 4 million and approximately 20% of those cases require hospitalization.32 The incidence of parapneumonic effusion in patients hospitalized with pneumonia is about 40%.25 The morbidity and mortality rates in patients with pneumonia and pleural effusions are greater than in patients with pneumonia alone. In one recent study,16 the relative risk of mortality in patients with community-acquired pneumonia was 7.0 times higher for patients with bilateral pleural effusions and 3.4 times higher for patients with unilateral-pleural effusion of moderate or greater size compared with other patients with community-acquired pneumonia. Delay in instituting proper therapy for effusions is responsible for much of the increased morbidity and mortality.

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DEFINITIONS

Any pleural effusion associated with bacterial pneumonia, lung abscess, or bronchiectasis is a parapneumonic effusion.26 An empyema, by definition, is pus in the pleural space. Pus is thick, purulent-appearing pleural fluid. A complicated-parapneumonic effusion is a parapneumonic effusion for which tube thoracostomy is necessary for resolution. A loculated parapneumonic effusion is a parapneumonic effusion that is not free-flowing. A multiloculated parapneumonic effusion is a

HISTORY

Writings on the treatment of empyema date back to around 500 bc, when Hippocrates recommended treating empyema with open drainage.1 At that early time, Hippocrates recognized that the prognosis of the patient depended on the characteristics of the fluid. He wrote the following: “Those cases of empyema are treated by incision or the cautery, if the water flows rapidly all at once certainly prove fatal. When empyema is treated, either by the incision or the cautery, if pure and white pus flows

NATURAL HISTORY OF PARAPNEUMONIC EFFUSIONS

The evolution of a parapneumonic pleural effusion can be divided into three stages—the exudative, the fibropurulent, and the organization stage.3 The three stages are not sharply defined, but rather form a continuous spectrum. The first stage is the exudative stage, characterized by the rapid outpouring of fluid into the pleural space. The pleural fluid probably originates in the interstitial spaces of the lung.52 In the exudative stage, the pleural fluid is not loculated and is characterized

CLASSIFICATION OF PARAPNEUMONIC EFFUSIONS

When a patient with pneumonia is first evaluated, one should attempt to determine whether or not a pleural effusion is present. A lateral radiograph should be obtained to screen for the presence of a pleural effusion. If both diaphragms cannot be seen throughout their entirety on the lateral chest radiograph, decubitus chest radiographs should be obtained. The amount of free-pleural fluid can be semiquantitated by measuring the distance between the inside of the chest wall and the outside of

Antibiotic Therapy

Patients with pneumonia and pleural effusion should be treated with antibiotic agents. The initial antibiotic selection is based on whether the pneumonia is community- or hospital-acquired and on the severity of illness. The initial antibiotic selection and the dose are not influenced by the presence or absence of a pleural effusion. Most antibiotic agents are present in pleural fluid at levels that are comparable with those in serum.23 Aminoglycosides, however, appear to penetrate poorly into

SUMMARY

When a patient with a parapneumonic pleural effusion is first evaluated, a therapeutic thoracentesis should be performed if more than a minimal amount of pleural fluid is present. Fluid obtained at the therapeutic thoracentesis should be gram-stained and cultured and analyzed for glucose, pH, LDH, white blood cells, and differential cell count. If the fluid cannot be drained because of loculations, a chest tube should be inserted and thrombolytic agents administered. If the pleural fluid recurs

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    Address reprint requests to Richard W. Light, MD, Director Pulmonary Disease, Saint Thomas Hospital, 4220 Harding Road, Nashville, TN 37027

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