Management of Complicated Parapneumonic Effusions

Abstract

Pneumonia remains one of the most common infections in both the community and the hospital (1), and it is associated with a 36 to 57% incidence of pleural effusions (2-4), resulting in an estimated one million people a year in the United States developing parapneumonic effusions. Parapneumonic effusions (pleural fluids associated with pneumonia) may be uncomplicated, free-flowing effusions that resolve spontaneously with antibiotic therapy, or complicated effusions that require pleural space drainage for resolution of pleural sepsis (2, 5-8). The natural course of a complicated parapneumonic effusion is to develop a single loculus or multiple loculations and to progress to an empyema cavity. Empyema, from the Greek meaning accumulation of pus in a body cavity, represents the end stage of a complicated parapneumonic effusion. The best analytical approach to diagnosis and the optimal modality of treatment of complicated parapneumonic effusions are controversial because of the lack of prospective, randomized trials. Furthermore, the value of early pleural fluid markers to predict the transformation of uncomplicated to complicated parapneumonic effusions is still disputed (2, 5, 6, 8-10). The availability of new options for management of complicated parapneumonic effusions further confounds clinical decision making. The heterogeneous responses from a recent American College of Chest Physicians interactive session on pleural space infections was confirmatory (11).