Parapneumonic effusion - Revision history

Aidan: /* Management */

2020-08-18T15:45:01Z

Management

← Older revision		Revision as of 15:45, 18 August 2020
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	==Background==		==Background==

	===Definition===

	*Pleural effusion secondary to bacterial pneumonia		*Pleural effusion secondary to bacterial pneumonia
	*Complicated (i.e. infected and needs drainage) if:
⚫	**Frankly purulent drainage
⚫	**Positive Gram stain or culture
⚫	**Pleural fluid pH <7.2
⚫	**Possibly also:
⚫	***>50% of the hemithorax
⚫	***Loculated
⚫	***LDH > 1000
⚫	***WBC > 25
⚫	***Glucose < 3.4

	===Stages===		===Stages===
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	== Clinical Manifestations ==		==Clinical Manifestations==

	* Fever, cough, pleuritic chest pain		*Fever, cough, pleuritic chest pain

	=== Empyema Necessitans ===		===Empyema Necessitans===

	* Chronic empyema that drains through chest wall		*Chronic empyema that drains through chest wall
	* Caused by [[tuberculosis]] or [[actinomycosis]]		*Caused by [[tuberculosis]] or [[actinomycosis]]

	==Differential Diagnosis==		==Differential Diagnosis==
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	==Management==		==Management==

			*Generally treated with the same antibiotics as for [[community-acquired pneumonia]]
	*Can add [[metronidazole]] for anaerobic coverage (unless confirmed pneumococcal infection)		*Can add [[metronidazole]] for anaerobic coverage (unless confirmed pneumococcal infection)

	*Drainage, if complicated (see Definition, above)
			=== Drainage ===
⚫	**Ideally chest tube

⚫	**If not chest tube, then pigtail catheter, but this often needs upsizing to chest tube
			*Indicated for '''complicated''' pleural effusions:
		⚫	**Frankly purulent drainage
		⚫	**Positive Gram stain or culture
		⚫	**Pleural fluid pH <7.2
		⚫	**Possibly also:
		⚫	***>50% of the hemithorax
		⚫	***Loculated
		⚫	***LDH > 1000
		⚫	***WBC > 25
		⚫	***Glucose < 3.4
		⚫	*Ideally use a chest tube
		⚫	*If not chest tube, then pigtail catheter, but this often needs upsizing to chest tube
	*Can add intrathoracic tPA and DNAse, but unclear benefit		*Can add intrathoracic tPA and DNAse, but unclear benefit

Aidan at 15:42, 18 August 2020

2020-08-18T15:42:35Z

← Older revision		Revision as of 15:42, 18 August 2020
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			== Clinical Manifestations ==

			* Fever, cough, pleuritic chest pain

			=== Empyema Necessitans ===

			* Chronic empyema that drains through chest wall
			* Caused by [[tuberculosis]] or [[actinomycosis]]

	==Differential Diagnosis==		==Differential Diagnosis==

Aidan: /* Stages */

2020-08-18T15:39:30Z

Stages

← Older revision		Revision as of 15:39, 18 August 2020
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	===Stages===		===Stages===

	*''Stage 1:'' not infected but exudative, generally echo-free on pleural ultrasound, free flowing, and with minimal to no enhancement on CT scan		*''Exudative (Stage 1):'' not infected but exudative, generally echo-free on pleural ultrasound, free flowing, and with minimal to no enhancement on CT scan
	*''Stage 2:'' generally fibropurulent, likely infected, usually loculated with echogenic fluid, debris, and septations, and associated with pleural enhancement		*''Fibropurulent (Stage 2):'' generally fibropurulent, likely infected, usually loculated with echogenic fluid, debris, and septations, and associated with pleural enhancement
	*''Stage 3:'' organized ~~empyemas~~ with significantly thickened, scarred pleural membranes		*''Organizing (Stage 3):'' organized empyema with significantly thickened, scarred pleural membranes

	===Risk Classification===		===Risk Classification===

Aidan at 17:31, 30 July 2020

2020-07-30T17:31:52Z

← Older revision		Revision as of 17:31, 30 July 2020
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	== Background ==		==Background==

	===Definition===		===Definition===
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	==Differential Diagnosis==		==Differential Diagnosis==

	*Pleural ~~effusions~~ from other causes		*[[Pleural effusion]] from other causes

	==Investigations==		==Investigations==

			*Chest x-ray with PA, lateral, and lateral decubitus
	*Imaging
	**~~Chest x-ray with PA, lateral, and lateral decubitus to check~~ to free-flowing or loculated effusion		**Check to free-flowing or loculated effusion
	**If base of meniscus on the lateral is > 5cm or on the lateral decubitus is > 1cm, need to perform diagnostic thoracentesis		**If base of meniscus on the lateral is > 5cm or on the lateral decubitus is > 1cm, need to perform diagnostic thoracentesis
			*Diagnostic thoracentesis, sent for pH, protein, cell count and differential, and Gram stain and culture

	==Management==		==Management==

	*Can add metronidazole for anaerobic coverage (unless confirmed ~~pneumococal~~ infection)		*Can add [[metronidazole]] for anaerobic coverage (unless confirmed pneumococcal infection)
	*Drainage, if complicated (see Definition, above)		*Drainage, if complicated (see Definition, above)
			**Ideally chest tube
⚫	*Can add intrathoracic tPA and DNAse, but ~~makes~~ ~~no significant difference~~
			**If not chest tube, then pigtail catheter, but this often needs upsizing to chest tube
		⚫	*Can add intrathoracic tPA and DNAse, but unclear benefit

	==Further Reading==		==Further Reading==

Aidan at 17:30, 30 July 2020

2020-07-30T17:30:08Z

Show changes

Aidan: Text replacement - "Clinical Presentation" to "Clinical Manifestations"

2020-07-14T23:19:31Z

Text replacement - "Clinical Presentation" to "Clinical Manifestations"

← Older revision		Revision as of 23:19, 14 July 2020
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	== Clinical ~~Presentation~~ ==		== Clinical Manifestations ==

	* History		* History

Maintenance script: Imported from text file

2020-07-04T01:17:48Z

Imported from text file

New page

== Definition ==

* Pleural effusion secondary to bacterial pneumonia
* Complicated (i.e. infected and needs drainage) if:
** Frankly purulent drainage
** Positive Gram stain or culture
** Pleural fluid pH <7.2
** Possibly also:
*** >50% of the hemithorax
*** Loculated
*** LDH > 1000
*** WBC > 25
*** Glucose < 3.4

== Pathophysiology ==

== Differential Diagnosis ==

* Pleural effusions from other causes

== Epidemiology ==

== Risk Factors ==

== Stages ==

* ''Stage 1:'' not infected but exudative, generally echo-free on pleural ultrasound, free flowing, and with minimal to no enhancement on CT scan
* ''Stage 2:'' generally fibropurulent, likely infected, usually loculated with echogenic fluid, debris, and septations, and associated with pleural enhancement
* ''Stage 3:'' organized empyemas with significantly thickened, scarred pleural membranes

== Risk Classification ==

{|
! Risk
! Anatomy
! Microbiology
! Chemistry
|-
| Very low
| free-flowing effusion <1cm on lateral decubitus
| AND Gram stain and culture unknown
| AND pH unknown
|-
| Low
| free-flowing effusion 1cm ot 1/2 hemithorax
| AND Gram stain and culture negative
| AND pH ≥7.2
|-
| Moderate
| free-flowing effusion ≥1/2 hemithorax, or loculated effusion, or thickened parietal pleura
| OR Gram stain or culture positive
| OR pH <7.2
|-
| High
|
| pus
|
|}

== Clinical Presentation ==

* History
* Signs & Symptoms

== Investigations ==

* Labs
* Imaging
** Chest x-ray with PA, lateral, and lateral decubitus to check to free-flowing or loculated effusion
** If base of meniscus on the lateral is > 5cm or on the lateral decubitus is > 1cm, need to perform diagnostic thoracentesis

== Management ==

* Can add metronidazole for anaerobic coverage (unless confirmed pneumococal infection)
* Drainage, if complicated (see Definition, above)
* Can add intrathoracic tPA and DNAse, but makes no significant difference

== Further Reading ==

* Light RW. [https://doi.org/10.1513/pats.200510-113JH Parapneumonic effusions and empyema]. ''Proc Am Thorac Soc'' 2005;3:75-80.
* Colice GL ''et al''. [https://doi.org/10.1378/chest.118.4.1158 Medical and surgical treatment of parapneumonic effusions: an evidence-based guideline]. ''Chest'' 2000;118(4):1158-71.
* Davies HE ''et al''. [https://doi.org/10.1136/thx.2010.137000 Management of pleural infection in adults: British Thoracic Society Pleural Disease Guideline 2010]. ''Thorax'' 2010;65 Suppl 2:ii41-53.

[[Category:Respirology]]
[[Category:Infectious diseases]]