Diagnosis and Management of Parapneumonic Effusions

Christopher Hampson; Julio A. Lemos; Jeffrey S. Klein

doi:10.1055/s-2008-1081284

Seminars in Respiratory and Critical Care Medicine, Table of Contents

Semin Respir Crit Care Med 2008; 29(4): 414-426
DOI: 10.1055/s-2008-1081284

Diagnosis and Management of Parapneumonic Effusions

Christopher Hampson¹ ^, ² , Julio A. Lemos¹ ^, ² , Jeffrey S. Klein¹ ^, ²

¹Department of Radiology, Fletcher Allen Health Care, Burlington, Vermont
²University of Vermont College of Medicine, Burlington, Vermont

Abstract

ABSTRACT

Parapneumonic effusions affect many patients and are associated with considerable morbidity and mortality. It is necessary to differentiate complicated effusions requiring intervention from uncomplicated effusions. Differentiation is achieved using clinical, pleural fluid, and imaging parameters. Intervention takes the form of blind catheter placement and drainage, image-guided catheter placement and drainage, and surgical decortication [video-assisted thoracoscopic surgery (VATS) or open thoracotomy]. Image-guided drainage and management of complicated effusions in adults and pediatric patients are safe and highly effective in select patients. The use of intrapleural fibrinolytic agents to facilitate resolution of complicated effusions is widespread and considered effective by many despite a lack of conclusive data supporting this method. We propose an algorithmic approach to patients with parapneumonic effusions and advocate image-guided drainage and management in patients likely to benefit from this treatment.

KEYWORDS

Parapneumonic - effusion - empyema - intervention - fibrinolytic

Full Text

References

REFERENCES

1 Jimenez Castro D, Diaz Nuevo G, Sueiro A, Muriel A, Perez-Rodriguez E, Light R W. Pleural fluid parameters identifying complicated parapneumonic effusions. Respiration. 2005; 72 357-364
2 Colice G L, Curtis A, Deslauriers J et al.. Medical and surgical treatment of parapneumonic effusions: an evidence-based guideline. Chest. 2000; 118 1158-1171
3 Light R W. Parapneumonic effusions and empyema. Proc Am Thorac Soc. 2006; 3 75-80
4 Bouros D, Antoniou K M, Light R W. Intrapleural streptokinase for pleural infection. BMJ. 2006; 332 133-134
5 Rahman N M, Gleeson F V. New directions in the treatment of infected pleural effusion. Clin Radiol. 2006; 61 719-722
6 Light R W. Clinical practice. Pleural effusion. N Engl J Med. 2002; 346 1971-1977
7 Lee Y C, Davies R J, Light R W. Diagnosing pleural effusion: moving beyond transudate-exudate separation. Chest. 2007; 131 942-943
8 Moulton J S. Image-guided management of complicated pleural fluid collections. Radiol Clin North Am. 2000; 38 345-374
9 Hamm H, Light R W. Parapneumonic effusion and empyema. Eur Respir J. 1997; 10 1150-1156
10 Manuel Porcel J, Vives M, Esquerda A, Ruiz A. Usefulness of the British Thoracic Society and the American College of Chest Physicians guidelines in predicting pleural drainage of non-purulent parapneumonic effusions. Respir Med. 2006; 100 933-937
11 Barnes N P, Hull J, Thomson A H. Medical management of parapneumonic pleural disease. Pediatr Pulmonol. 2005; 39 127-134
12 Rahman N M, Chapman S J, Davies R J. The approach to the patient with a parapneumonic effusion. Clin Chest Med. 2006; 27 253-266
13 Kearney S E, Davies C W, Davies R J, Gleeson F V. Computed tomography and ultrasound in parapneumonic effusions and empyema. Clin Radiol. 2000; 55 542-547
14 Qureshi N R, Gleeson F V. Imaging of pleural disease. Clin Chest Med. 2006; 27 193-213
15 Jimenez Castro D, Diaz G, Perez-Rodriguez E, Light R W. Prognostic features of residual pleural thickening in parapneumonic pleural effusions. Eur Respir J. 2003; 21 952-955
16 Kearney S E, Davies C W, Tattersall D J, Gleeson F V. The characteristics and significance of thoracic lymphadenopathy in parapneumonic effusion and empyema. Br J Radiol. 2000; 73 583-587
17 Smolikov A, Smolyakov R, Riesenberg K et al.. Prevalence and clinical significance of pleural microbubbles in computed tomography of thoracic empyema. Clin Radiol. 2006; 61 513-519
18 Baysal T, Bulut T, Gokirmak M, Kalkan S, Dusak A, Dogan M. Diffusion-weighted MR imaging of pleural fluid: differentiation of transudative vs exudative pleural effusions. Eur Radiol. 2004; 14 890-896
19 Tu C Y, Hsu W H, Hsia T C et al.. Pleural effusions in febrile medical ICU patients: chest ultrasound study. Chest. 2004; 126 1274-1280
20 Pinotti K F, Ribeiro S M, Cataneo A J. Thorax ultrasound in the management of pediatric pneumonias complicated with empyema. Pediatr Surg Int. 2006; 22 775-778
21 Shankar S, Gulati M, Kang M, Gupta S, Suri S. Image-guided percutaneous drainage of thoracic empyema: can sonography predict the outcome?. Eur Radiol. 2000; 10 495-499
22 Chen K Y, Liaw Y S, Wang H C, Luh K T, Yang P C. Sonographic septation: a useful prognostic indicator of acute thoracic empyema. J Ultrasound Med. 2000; 19 837-843
23 Balik M, Plasil P, Waldauf P et al.. Ultrasound estimation of volume of pleural fluid in mechanically ventilated patients. Intensive Care Med. 2006; 32 318-321
24 Ozcelik C, Ulku R, Onat S, Ozcelik Z, Inci I, Satici O. Management of postpneumonic empyemas in children. Eur J Cardiothorac Surg. 2004; 25 1072-1078
25 Fartoukh M, Azoulay E, Galliot R et al.. Clinically documented pleural effusions in medical ICU patients: how useful is routine thoracentesis?. Chest. 2002; 121 178-184
26 Simmers T A, Jie C, Sie B. Minimally invasive treatment of thoracic empyema. Thorac Cardiovasc Surg. 1999; 47 77-81
27 Feller-Kopman D, Walkey A, Berkowitz D, Ernst A. The relationship of pleural pressure to symptom development during therapeutic thoracentesis. Chest. 2006; 129 1556-1560
28 Heffner J E. Multicenter trials of treatment for empyema–after all these years. N Engl J Med. 2005; 352 926-928
29 Maskell N A, Gleeson F V, Darby M, Davies R J. Diagnostically significant variations in pleural fluid pH in loculated parapneumonic effusions. Chest. 2004; 126 2022-2024
30 Cameron R, Davies H R. Intra-pleural fibrinolytic therapy versus conservative management in the treatment of parapneumonic effusions and empyema. Cochrane Database Syst Rev. 2004; 2 CD002312
31 Mitri R K, Brown S D, Zurakowski D et al.. Outcomes of primary image-guided drainage of parapneumonic effusions in children. Pediatrics. 2002; 110 e37
32 Chiu C Y, Wong K S, Huang Y C, Lai S H, Lin T Y. Echo-guided management of complicated parapneumonic effusion in children. Pediatr Pulmonol. 2006; 41 1226-1232
33 Maskell N A, Davies C W, Nunn A J et al.. U.K. Controlled trial of intrapleural streptokinase for pleural infection. N Engl J Med. 2005; 352 865-874
34 Bouros D, Tzouvelekis A, Antoniou K M, Heffner J E. Intrapleural fibrinolytic therapy for pleural infection. Pulm Pharmacol Ther. 2007; 20 616-626
35 Diacon A H, Theron J, Schuurmans M M, Van de Wal B W, Bolliger C T. Intrapleural streptokinase for empyema and complicated parapneumonic effusions. Am J Respir Crit Care Med. 2004; 170 49-53
36 Dikensoy O, Zhu Z, Na M J, Liao H, Donnelly E, Light R W. Intrapleural heparin or heparin combined with human recombinant DNase is not effective in the treatment of empyema in a rabbit model. Respirology. 2006; 11 755-760
37 Kim B Y, Oh B S, Jang W C, Min Y I, Park Y K, Park J C. Video-assisted thoracoscopic decortication for management of postpneumonic pleural empyema. Am J Surg. 2004; 188 321-324
38 Gates R L, Caniano D A, Hayes J R, Arca M J. Does VATS provide optimal treatment of empyema in children? A systematic review. J Pediatr Surg. 2004; 39 381-386
39 Huang H C, Chang H Y, Chen C W, Lee C H, Hsiue T R. Predicting factors for outcome of tube thoracostomy in complicated parapneumonic effusion for empyema. Chest. 1999; 115 751-756
40 Lardinois D, Gock M, Pezzetta E et al.. Delayed referral and gram-negative organisms increase the conversion thoracotomy rate in patients undergoing video-assisted thoracoscopic surgery for empyema. Ann Thorac Surg. 2005; 79 1851-1856
41 Luh S P, Chou M C, Wang L S, Chen J Y, Tsai T P. Video-assisted thoracoscopic surgery in the treatment of complicated parapneumonic effusions or empyemas: outcome of 234 patients. Chest. 2005; 127 1427-1432
42 Suchar A M, Zureikat A H, Glynn L, Statter M B, Lee J, Liu D C. Ready for the frontline: is early thoracoscopic decortication the new standard of care for advanced pneumonia with empyema?. Am Surg. 2006; 72 688-692 discussion 692-683
43 Wurnig P N, Wittmer V, Pridun N S, Hollaus P H. Video-assisted thoracic surgery for pleural empyema. Ann Thorac Surg. 2006; 81 309-313
44 Hope W W, Bolton W D, Stephenson J E. The utility and timing of surgical intervention for parapneumonic empyema in the era of video-assisted thoracoscopy. Am Surg. 2005; 71 512-514
45 Bouros D, Antoniou K M, Chalkiadakis G, Drositis J, Petrakis I, Siafakas N. The role of video-assisted thoracoscopic surgery in the treatment of parapneumonic empyema after the failure of fibrinolytics. Surg Endosc. 2002; 16 151-154
46 Wait M A, Sharma S, Hohn J, Dal Nogare A. A randomized trial of empyema therapy. Chest. 1997; 111 1548-1551
47 Coote N, Kay E. Surgical versus non-surgical management of pleural empyema. Cochrane Database Syst Rev. 2005; Oct 19(4) CD001956
48 Margau R, Amaral J G, Chait P G, Cohen J. Percutaneous thoracic drainage in neonates: catheter drainage versus treatment with aspiration alone. Radiology. 2006; 241 223-227
49 Shoseyov D, Bibi H, Shatzberg G et al.. Short-term course and outcome of treatments of pleural empyema in pediatric patients: repeated ultrasound-guided needle thoracocentesis vs chest tube drainage. Chest. 2002; 121 836-840
50 Pierrepoint M J, Evans A, Morris S J, Harrison S K, Doull I J. Pigtail catheter drain in the treatment of empyema thoracis. Arch Dis Child. 2002; 87 331-332

Jeffrey S KleinM.D.

Department of Radiology, Fletcher Allen Health Care

111 Colchester Ave., Burlington, VT 05401

Email: Jeffrey.Klein@uvm.edu