Parapneumonic effusion: Difference between revisions
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+ | ==Background== |
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+ | *Pleural effusion secondary to bacterial pneumonia |
− | * Complicated (i.e. infected and needs drainage) if: |
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− | == Pathophysiology == |
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− | == Epidemiology == |
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− | == Risk Factors == |
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+ | |Very low |
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+ | |free-flowing effusion <1cm on lateral decubitus |
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+ | |AND Gram stain and culture unknown |
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+ | |AND pH unknown |
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+ | |Low |
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+ | |free-flowing effusion 1cm ot 1/2 hemithorax |
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+ | |AND Gram stain and culture negative |
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+ | |AND pH ≥7.2 |
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+ | |Moderate |
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+ | |free-flowing effusion ≥1/2 hemithorax, or loculated effusion, or thickened parietal pleura |
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+ | |OR Gram stain or culture positive |
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+ | |OR pH <7.2 |
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+ | |High |
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+ | |pus |
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− | == |
+ | ==Clinical Manifestations== |
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+ | *Fever, cough, pleuritic chest pain |
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+ | ===Empyema Necessitans=== |
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+ | *Chronic empyema that drains through chest wall |
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+ | *Caused by [[tuberculosis]] or [[actinomycosis]] |
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− | * History |
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+ | **Check to free-flowing or loculated effusion |
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− | * Signs & Symptoms |
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+ | *Diagnostic thoracentesis, sent for pH, protein, cell count and differential, and Gram stain and culture |
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+ | ==Management== |
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+ | *Generally treated with the same antibiotics as for [[community-acquired pneumonia]] |
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− | * Labs |
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− | * Imaging |
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− | == |
+ | === Drainage === |
+ | *Indicated for '''complicated''' pleural effusions: |
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− | * Drainage, if complicated (see Definition, above) |
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+ | *Ideally use a chest tube |
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+ | *If not chest tube, then pigtail catheter, but this often needs upsizing to chest tube |
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− | == |
+ | ==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:Respirology]] |
Latest revision as of 11:45, 18 August 2020
Background
- Pleural effusion secondary to bacterial pneumonia
Stages
- Exudative (Stage 1): not infected but exudative, generally echo-free on pleural ultrasound, free flowing, and with minimal to no enhancement on CT scan
- Fibropurulent (Stage 2): generally fibropurulent, likely infected, usually loculated with echogenic fluid, debris, and septations, and associated with pleural enhancement
- Organizing (Stage 3): organized empyema 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 Manifestations
- Fever, cough, pleuritic chest pain
Empyema Necessitans
- Chronic empyema that drains through chest wall
- Caused by tuberculosis or actinomycosis
Differential Diagnosis
- Pleural effusion from other causes
Investigations
- Chest x-ray with PA, lateral, and lateral decubitus
- 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
- Diagnostic thoracentesis, sent for pH, protein, cell count and differential, and Gram stain and culture
Management
- Generally treated with the same antibiotics as for community-acquired pneumonia
- Can add metronidazole for anaerobic coverage (unless confirmed pneumococcal infection)
Drainage
- 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
Further Reading
- Light RW. Parapneumonic effusions and empyema. Proc Am Thorac Soc 2005;3:75-80.
- Colice GL et al. Medical and surgical treatment of parapneumonic effusions: an evidence-based guideline. Chest 2000;118(4):1158-71.
- Davies HE et al. Management of pleural infection in adults: British Thoracic Society Pleural Disease Guideline 2010. Thorax 2010;65 Suppl 2:ii41-53.