Management Of Parapneumonic Effusions Research Articles

Management of parapneumonic effusion and thoracic empyema with intrapleural instillation of 2-mercaptoethane sulfonate sodium and conservative approach - A comparative study

Management of parapneumonic effusion and thoracic empyema with intrapleural instillation of 2-mercaptoethane sulfonate sodium and conservative approach - A comparative study

Intrapleural Streptokinase in Parapneumonic / Complicated Pleural Effusion/Empyema: Experience in Dhaka Shishu (Children) Hospital

Background: Parapneumonic effusion/complicated pleural effusion/empyema thoracis in children causes significant morbidity. Standard treatment of pleural effusion includes tube drainage and antibiotics. But the tube drainage often fails. Intrapleural Streptokinase has been used in empyema thoracis as well as complicated pleural effusion with good success rate. Though its efficacy is documented in Western literatures and textbooks, there are no clinical trials in children has been reported from Bangladesh.
 Objectives: We evaluated the efficacy of intra-pleural Streptokinase in the management of Parapneumonic effusion / complicated pleural effusion/ empyema thoracis even in advanced stages.
 Patients and Methods: A total of 3 patients with parapneumonic effusion requiring intercostal tube drainage, aged 4 year 6 month to twelve years were included in the study who were admitted in Pediatric respiratory medicine unit in Dhaka Shishu (Children) Hospital. Intercostal chest tube drain was given in all patients and inj: Streptokinase (10,000 units/kg/dose) was instilled into the pleural cavity and kept the Streptokinase for 4 hour in pleural cavity. Response was assessed by clinical outcome, after unclamping and serial chest ultrasounds and subsequent chest radiography.
 Results: Streptokinase enhanced drainage of pleural fluid and complete resolution of effusion in all the 3 patients.
 Conclusions: Intrapleural Streptokinase is the preferred treatment for treating pediatric empyema/parapneumonic effusion/complicated pleural effusion even in advanced stages and can avoid surgery.
 Bangladesh J Child Health 2020; VOL 44 (2) :104-108

To lyse or not to lyse? Use of intrapleural tissue plasminogen activator and DNase in the management of parapneumonic effusions and empyema

Despite a range of management options, pleural effusions and empyema continue to present therapeutic challenges in the clinical setting. With treatment options ranging from simple use of antibiotics to more complex surgical procedures, several important considerations need be made as to what type of treatment is best for each patient on a case by case basis. One treatment modality of increasing interest is the use of intrapleural fibrinolytics to facilitate drainage of effusions. This presents a viable option especially in patients in whom surgery is not preferred. But, as with many therapeutic approaches, the use of intrapleural fibrinolytics is laden with significant controversies and has been a subject of considerable debate over the last couple of years. With accruing evidence for and against this modality of treatment, the ensuing discussion has been whether or not it should be a routine treatment choice and which group of patients should this consideration be made for. This paper gives a background on the epidemiology and etiology of parapneumonic effusions and empyema and briefly outlines the available options of management. Furthermore, we extensively discuss available evidence on the use of intrapleural fibrinolytics as a management option for parapneumonic effusions and empyema, with particular emphasis on use of tissue plasminogen activator (tPA) and DNase.

MRSA COMPLICATING A PARAPNEUMONIC EFFUSION DESPITE TIMELY ANTIBIOTICS

TYPE: Case Report Publication TOPIC: Chest Infections INTRODUCTION: Parapneumonic effusions (PE) can be complicated by empyema or loculations and predicts worse morbidity and mortality. PE management is guided by fluid characteristics instead of organism. We present a case of methicillin resistant Staphylococcus aureus (MRSA) pneumonia causing uncomplicated PEs, which eventually developed into loculations despite timely long-term antibiotics. CASE PRESENTATION: A 69-year-old male presented for nausea, vomiting, and altered mentation. On admission, his blood pressure was 93/60 mmHg, heart rate 106/min, temperature 98 F, oxygen saturation 96%. White blood cells were 10.15 10E9/L, procalcitonin was 15.9 ng/mL, and both blood cultures were positive for MRSA. Chest computed tomography (CT) showed multifocal pneumonia. Blood culture cleared on hospital day (HD) 6 after intravenous (IV) vancomycin and piperacillin/tazobactam. Repeat chest CT on HD 10 showed bilateral PEs. Pleural fluid had pH 7.45, glucose 145 mg/dL, lactate dehydrogenase (LDH) 475 U/L, and negative Gram-stain and culture; serum LDH 358 U/L. He was discharged with 6 weeks of IV vancomycin without chest tube placement. Six weeks later, he presented for nausea and vomiting. CT chest showed right pleural rim enhancement of a loculated effusion. He underwent thoracoscopic adhesiolysis, decortication, 2 lung wedge resections, and mechanical pleurodesis with subsequent resolution of symptoms. Tissue biopsy culture was negative. DISCUSSION: Complicated PE from MRSA is a well-documented complication due to the virulent pro-coagulant behavior of MRSA. Current guidelines do not specifically address the management of MSRA pneumonia related PE. CONCLUSIONS: Early intervention or close monitoring of MRSA PE will need to be considered to reduce morbidity and mortality. DISCLOSURE: No significant relationships. KEYWORDS: Parapneumonic effusion, MRSA pneumonia

Video assisted thoracoscopic surgery in the management of acute fibrinopurulent empyema in paediatric patients

Background: Empyema is the presence of pus in the pleural space that usually follows an episode of pneumonia in pediatric age group. The aim of this study was to assess the efficacy of management of acute fibrinopurulent stage of empyema by early video assisted thoracoscopic surgery (VATS) in paediatric patients.Methods: The study was carried out at a tertiary care hospital in India. It was a prospective interventional observational study. The study included 40 children between age group 0-12 years attending the surgery in-patient department referred for further management of parapneumonic effusions who had clinical and radiological evidence of empyema and thoracocentesis confirmed purulent exudate in pleural cavity, were subjected to early VATS after thorough pre-operative workup.Results: The mean age was 7.22 years. Average operative time was 135.5 minutes. The mean duration of hospital stay was 7.5 days. Few complications were bleeding, superficial wound infection, bronchopleural fistula, pneumothorax, recurrence of empyema and incomplete expansion of lung.Conclusions: VATS facilitates the management of fibrinopurulent and organised pyogenic pleural empyema with less post-operative discomfort and complications and reduced hospital stay. However larger sample size study is required to come to a definitive conclusion.

Management of Complicated Pneumonia in Children: Evidence Beyond Guidelines

What is already known? Complicated pneumonia is an area of debate, and a rapid diagnosis is essential for patient survival. Due to the importance of stage-adapted therapeutic decisions, different classification systems have been established. Depending on the stage of the disease, both antimicrobial and interventional approaches are indicated. Conservative management remains the mainstay for the management of parapneumonic effusion, and continuous pleural fluid drainage is not necessary in some children. However, an established consensus worldwide for the management of complicated pneumonia and thoracic empyema with different therapeutic algorithms lacks clear evidence to evaluate complex cases with minimally invasive intervention versus open decortication. Such controversy concerning the best surgical approach persists, especially for sick patients in intensive care who are not doing well despite chest tube or fibrinolytic agents. This article aimed to review current treatment standards for children with different phases of thoracic empyema and complicated pneumonia, this review article will discuss the usefulness of different diagnostic methods and most recent updates on management. 1. Outline the definition, pathophysiology and common causes 2. Review the diagnosis and current treatment standards for complicated pneumonia 3. Review different surgical approaches and their outcomes 4. Provide an update on the recent utilization of video-assisted thoracoscopy (VATS) 5. Review evidence regarding the best fibrinolytic agent 6. Review evidence concerning when to indicate decortication 7. Provide a simplified pathway for the management of complicated pneumonia (figure 9).

Management of parapneumonic effusion and empyema

Parapneumonic effusions are pleural effusions that occur in the pleural space adjacent to a bacterial pneumonia. When bacteria invade the pleural space, a complicated parapneumonic effusion or empyema may result. Empyema is collection of pus in pleural cavity. If left untreated, complicated parapneumonic effusion/empyema leads to chronic encasement and pleural thickening. Simple parapneumonic effusions can be managed conservatively with appropriate antibiotics, but complicated parapneumonic effusions often require some kind of drainage along with antibiotics. Delay in treatment is associated with high morbidity and mortality. Clinically it is diagnosed with persistent fever, stony dull tender percussion, and absent breath sounds. Majority of cases are due to anaerobic infection. Gram-positive as well as Gram-negative organisms are also implicated. Many cases may have mixed organisms. Tuberculosis should be suspected if no organism is grown in empyema. Chest skiagram, thoracic ultrasound, and CT scan help in localization of effusion and detection of loculations. Confirmation is done by thoracocentesis and pleural fluid analysis, which shows exudate with polymorphonuclear leukocytosis. Management includes well-selected antibiotics and drainage by tube thoracostomy. Intrapleural fibrinolytics have been used in multiloculated complicated parapneumonic effusions with success. Advent of thoracoscopy and VATS has left very few cases requiring surgical decortication. Properly treated parapneumonic effusions have good prognosis.

Management of parapneumonic effusion in pregnant women.

Pneumonia and parapneumonic effusion (PPE) are not more common in pregnant women compared to normal population. Pneumonia is considered the second most common infection in pregnant women. PPE is a serious complication of pneumonia and occurs especially in case of treatment delay or inappropriate antibiotic selection. The data on the management of PPE in pregnant women is limited to few case reports.

Evolution of practice in the management of parapneumonic effusion and empyema in children.

To assess the evolution in management of children with parapneumonic effusion and empyema in a tertiary referral centre. We conducted a retrospective case note review of paediatric patients with parapneumonic effusion, pleural effusion and pleural empyema between December 2006 and December 2015. Digital database searches were performed to identify demographic data, referring hospital, radiological and microbiological investigations. Length of stay and morbidity were analysed. One hundred fifteen patients had 159 interventions over the study period. Fifty-four children were successfully treated with intercostal drainage (ICD) and urokinase fibrinolysis alone. There were 19 primary video assisted thoracoscopic surgeries (VATS) and 12 VATS after initial intercostal drains. Thirty-three children required a thoracotomy, a reduction of 26% from the previous era (p=0.009). The median length of stay was 9days (range 2-54). Parapneumonic effusion can be successfully treated with intercostal drainage and intrapleural fibrinolytics, but a proportion requires further surgical intervention. In our hospital, increased utilisation of fibrinolysis and VATS occurred with a corresponding decrease in the need for thoracotomy. Patients needing thoracotomy all had severe disease on ultrasound, but ultrasound did not reliably predict failure of fibrinolytic therapy. III.

Hyaluronic acid levels are increased in complicated parapneumonic pleural effusions

Hyaluronic acid (HA) is a component of extracellular matrix and may play a role in the pleural inflammation which is implicated in parapneumonic effusions.The aim of the current study was to investigate HA levels in serum and pleura in patients with parapneumonic effusions. We prospectively studied pleural and serum levels of HA in 58 patients with pleural effusions due to infection (complicated and uncomplicated parapneumonic effusions), malignant effusions and transudative effusions due to congestive heart failure. In addition to HA, TNF-alpha and IL-beta levels were determined in pleural fluid and serum by ELISA. The median +/- SD HA levels (pg/ml) in pleural fluid of patients with complicated effusions (39.058 +/- 11.208) were significantly increased (p < 0.005), compared to those with uncomplicated parapneumonic effusions (11.230 +/- 1.969), malignant effusions (10.837 +/- 4.803) or congestive heart failure (5.392 +/- 3.133). There was no correlation between pleural fluid and serum HA values. Pleural fluid TNF-alpha levels (146 +/- 127 pg/mL) and IL-1beta levels (133.4 +/- 156 pg/mL) were significantly higher in patients with complicated parapneumonic effusions compared to patients with other types of effusion (p < 0.05). No significant association between HA and TNF-alpha or IL-1beta was found. CONCLUSIONS. HA may play a significant role in the inflammatory process which characterises exudative infectious pleuritis. Further investigation might reveal whether HA is a useful marker in the management of parapneumonic effusions.

Management of parapneumonic effusions and empyema.

Pleural infection remains a common and serious respiratory condition with important implications for patients and health-care services. This review will cover the management of pleural infection including medical treatment, the role of intrapleural agents and surgical treatment. We discuss the directions that future research in this important area might take. Increasing incidence of pleural infection has been reported worldwide without a clear explanation. The pathogens responsible for pleural infection differ from those in pneumonia. Proper antibiotic selection and pleural fluid drainage remain the cornerstones of treatment. There is no evidence in adult pleural infection to support the routine use of intrapleural fibrinolytics to alter clinically meaningful outcomes; however, combined intrapleural tissue plasminogen activator (tPA) and deoxyribonuclease (DNase) therapy may have a future role. The role of medical thoracoscopy remains unproven. Surgical referral should be considered in patients who fail to respond to standard medical management after 5 to 7 days. Despite advances in microbiology, medical management, and surgery, the mortality of pleural infection at one year remains approximately 20% for the last two decades. Future studies are required to validate predictive scores for patients' stratification (RAPID score) and the role of fibrinolytics (combination of tPA plus DNase). Surgical drainage remains a vital treatment option, but ongoing research is required to define the group of patients who would benefit most and when, in the disease course, this treatment should be offered.

PO-0233 Evaluation Of Hospital Management For Parapneumonic Effusion In Children

Aim To evaluate the initial management of children with parapneumonic effusion admitted to all French university hospitals. Methods A nationwide survey of all university hospitals (n = 35) took place in 2011 to assess practices for children with parapneumonic effusion, through a hypothetical clinical vignette and a standardized questionnaire. Two to four paediatricians per hospital were interviewed and asked about their initial management, probabilistic antibiotic therapy and its adaptation to microbiological results, additional treatment, and action in the absence of improvement. Answers of paediatricians working in emergency departments, intensive care units, and conventional paediatric units were compared. Results Of the 100 paediatricians contacted, 95 responded: 98% would order an initial blood test, and 70% diagnostic thoracentesis. All would start immediate antibiotic therapy: 31% with a single drug, 67% with 2 drugs, and 2% with 3 drugs. The most frequent initial choices were third-generation cephalosporin alone (17%) or combined with rifampicin (33%) or vancomycin (24%). Adaptation varied according to drug used, dose, and duration, especially when the microorganism was not S. pneumoniae . Practices did not differ significantly among the different groups of paediatricians. Conclusion Standardized management of parapneumonic effusion, including routine thoracentesis and more consistent prescription of antibiotics, is needed.

The value of total protein in guiding management of infectious parapneumonic effusion by using matrix-assisted laser desorption/ionization time-of-flight mass spectrometry

Infectious parapneumonic effusion (PE) contains proteins originating from circulation as well as proteins locally released by inflammatory pulmonary cells. The purpose of this study was to investigate the value of total protein analysis in guiding management of infectious PE by using matrix-assisted laser desorption/ionization time-of-flight mass spectrometry. Fifty-seven children with pneumonia followed by PE were consecutively enrolled into our study. Protein profiles generated by matrix-assisted laser desorption/ionization time-of-flight mass spectrometry after fractionating samples with functionalized magnetic beads (C8) were used for differentiating complicated PE (CPE) from non-CPE. A training set was used to generate classification models and the clinical efficacy of these models in detecting CPE and the need for intervention was then evaluated in an independent set. The MS spectra derived from PE were analyzed, and classification models were constructed in the training set. A total of 123 mass/charge (m/z) values were identified and 23 m/z values which were significant with p < 0.05 were used as classifiers. An optimized genetic algorithm model containing enforced selection of three significant downregulated m/z values (2127, 2232, and 2427) was able to classify CPE with 100% positive predictive value and predict the need of aggressive therapeutic intervention with 77% positive predictive value. A diagnostic model construction comprising three potential biomarkers can predict CPE and need for surgical intervention rapidly and precisely. Pleural fluid proteins downregulated during the progression of pneumonia could potentially guide the management of infectious PE.

Intrapleural Fibrinolytic Therapy for Treatment of Adult Parapneumonic Effusions and Empyemas: A Systematic Review and Meta-analysis

Background The purpose of our study was to conduct a systematic review and meta-analysis of all randomized controlled trials to date comparing fibrinolytics with placebo to clarify their current role in the management of parapneumonic effusions and empyemas. Methods MEDLINE, EMBASE, PapersFirst, and the Cochrane Collaboration and the Cochrane Register of controlled trials were searched. All searches were inclusive as of October 2011. Two investigators independently reviewed articles and extracted data. Quality was assessed with the Cochrane concealment of allocation approach and the Jadad criteria. Results Seven randomized controlled studies (total number of patients, 801) comparing fibrinolytic therapy with placebo were included in the meta-analysis. Fibrinolytic therapy was beneficial for the outcomes of treatment failure (surgical intervention or death) (risk ratio [RR], 0.50; 95% CI, 0.28-0.87) and surgical intervention alone (RR, 0.61; 95% CI, 0.45-0.82). There was no difference in mean duration of hospital stay (standard mean difference, −0.69; 95% CI, −1.54-0.16) or death (RR, 1.14; 95% CI, 0.74-1.74). Conclusions This meta-analysis does reveal that fibrinolytic therapy is potentially beneficial in the management of parapneumonic effusions and empyemas in the adult population. Although there is insufficient evidence to support the routine use of this therapy for all parapneumonic effusions/empyemas, fibrinolytic therapy may be considered in patients with loculated pleural effusions, because it may prevent the need for surgical intervention. Further randomized controlled trials with adequate power are needed to definitively address the effect of fibrinolytics and the combination of fibrinolytics and deoxyribonuclease on the clinical outcomes outlined in this analysis in patients with parapneumonic effusions/empyemas. The purpose of our study was to conduct a systematic review and meta-analysis of all randomized controlled trials to date comparing fibrinolytics with placebo to clarify their current role in the management of parapneumonic effusions and empyemas. MEDLINE, EMBASE, PapersFirst, and the Cochrane Collaboration and the Cochrane Register of controlled trials were searched. All searches were inclusive as of October 2011. Two investigators independently reviewed articles and extracted data. Quality was assessed with the Cochrane concealment of allocation approach and the Jadad criteria. Seven randomized controlled studies (total number of patients, 801) comparing fibrinolytic therapy with placebo were included in the meta-analysis. Fibrinolytic therapy was beneficial for the outcomes of treatment failure (surgical intervention or death) (risk ratio [RR], 0.50; 95% CI, 0.28-0.87) and surgical intervention alone (RR, 0.61; 95% CI, 0.45-0.82). There was no difference in mean duration of hospital stay (standard mean difference, −0.69; 95% CI, −1.54-0.16) or death (RR, 1.14; 95% CI, 0.74-1.74). This meta-analysis does reveal that fibrinolytic therapy is potentially beneficial in the management of parapneumonic effusions and empyemas in the adult population. Although there is insufficient evidence to support the routine use of this therapy for all parapneumonic effusions/empyemas, fibrinolytic therapy may be considered in patients with loculated pleural effusions, because it may prevent the need for surgical intervention. Further randomized controlled trials with adequate power are needed to definitively address the effect of fibrinolytics and the combination of fibrinolytics and deoxyribonuclease on the clinical outcomes outlined in this analysis in patients with parapneumonic effusions/empyemas.

Current evidence for the management of paediatric parapneumonic effusions

Background:Parapneumonic effusions (PPE) and empyema, secondary to bacterial pneumonia, are relatively uncommon but their prevalence is increasing lately. Even if their prognosis is generally good, they may still cause significant morbidity. The traditional treatment of PPE has been intravenous antibiotics and, when necessary, chest tube drainage. Open thoracotomy with decortication has usually been applied in case of failure of the traditional approach. Lately, the use of fibrinolysis and/or video-assisted thoracoscopic surgery (VATS) are utilized in the management of PPE; however, there is still little consensus on the most effective primary treatment.Scope:In this article our goal was to summarize, based on up-to-date evidence, all the management options for PPE available to physicians and weigh the benefits and risks of the most popular ones, in an effort to figure out which one is superior as a first-line approach in children.Findings:A literature search of randomized and retrospective studies that pinpoint methods of evaluation and treatment of PPE was carried out in Medline and Scopus databases. Chest X-ray, ultrasound as well as microbiology and biochemical characteristics of the pleural fluid will facilitate decision-making. Small uncomplicated effusions resolve with antibiotics alone, larger ones require small-bore chest tube drainage and in case of complicated loculated PPE, fibrinolysis or VATS should be considered. Both methods promote faster drainage, reduce hospital stay and obviate the need for further interventions when used as first-line approach. However, primary treatment with VATS is not advised by the majority of studies as a first choice intervention, unless medical treatment has failed.Conclusion:The main steps in treatment are diagnostic thoracocentesis and imaging, small percutaneous drainage, and considering fibrinolysis in complicated PPE. In case of failure, VATS should be the surgical method to be applied.

Intrapleural therapy in management of complicated parapneumonic effusions and empyema

Empyema thoracis causes high mortality, and its incidence is increasing in both children and adults. Parapneumonic effusions (PPEs) develop in about one-half of patients hospitalized with pneumonia, and their presence increases mortality by about four-fold. PPEs can be divided into simple PPEs, complicated PPEs, and frank empyema. Two guideline statements on the management of PPEs in adults have been published by the British Thoracic Society (BTS) and the American College of Chest Physicians; a third guideline statement published by the BTS focused on management of PPEs in children. The two adult guideline statements recommend drainage of the pleural space in complicated PPEs and frank empyema. They also recommend the use of intrapleural fibrinolysis in those who do not show improvement. The pediatric guideline statement recommends adding intrapleural fibrinolysis to those treated by tube thoracostomy if they have loculated pleural space or thick pus. Published guideline statements on the management of complicated PPEs and empyema in adults and children recommend the use of intrapleural fibrinolysis in those who do not show improvement after pleural space drainage. However, published clinical trial reports on the use of intrapleural fibrinolysis for the treatment of pleural space sepsis suffer from major design and methodologic limitations. Nevertheless, published reports have shown that the use of intrapleural fibrinolysis does not reduce mortality in adults with parapneumonic effusions and empyema. However, intrapleural fibrinolysis enhances drainage of infected pleural fluid and may be used in patients with large collections of infected pleural fluid causing breathlessness or respiratory failure, but a proportion of these patients will ultimately need surgery for definite cure. Intrapleural streptokinase and urokinase seem to be equally efficacious in enhancing infected pleural fluid drainage in adults. In most of the published studies in adults, the use of intrapleural fibrinolysis was not associated with serious side effects. There is emerging evidence that the combination of intrapleural tissue plasminogen activator (tPA) and deoxyribonuclease (DNase) is significantly superior to tPA or DNase alone or placebo in improving pleural fluid drainage in patients with pleural space infection. In children, intrapleural fibrinolysis has not been shown to reduce mortality, but has been shown to enhance drainage of the pleural space and was safe. In addition, two prospective, randomized trials have shown that intrapleural fibrinolysis is as effective as video-assisted thoracoscopic surgery for the treatment of childhood empyema and is a more cost-effective treatment and therefore should be the primary treatment of choice.

Empyema Thoracis

Epmyema thoracis is associated with high mortality ranging between 6% to 24%. The incidence of empyema is increasing in both children and adults; the cause of this surge is unknown. Most cases of empyema complicate community- or hospital-acquired pneumonia but a proportion results from iatrogenic causes or develops without pneumonia. Parapneumonic effusions (PPE) develop in about one half of the patients hospitalized with pneumonia and their presence cause a four-fold increase in mortality. Three stages in the natural course of empyema have long been described: the exudative, fibrinopurulent, and organizing phases. Clinically, PPE are classified as simple PPE, complicated PPE, and frank empyema. Simple PPE are transudates with a pH > 7.20 whereas complicated PPE are exudates with glucose level <2.2 mmol/l and pH < 7.20. Two guidelines statements on the management of PPE in adults have been published by the American College of Chest Physicians (ACCP) and the British Thoracic Society (BTS). Although they differ in their approach on how to manage PPE, they agree on drainage of the pleural space in complicated PPE and frank empyema. They also recommend the use of intrapleural fibrinolysis and surgical intervention in those who do not show improvement, but the level of evidence for the use of intrapleural fibrinolysis is not high highlighting the need for more research in this area. A recently published large randomized trial has shown no survival advantage with the use of intrapleural streptokinase in patients with pleural infection. However, streptokinase enhances drainage of infected pleural fluid and may still be used in patients with large collection of infected pleural fluid causing breathlessness or ventilatory failure. There is emerging evidence that the combination of intrapleural tPA/DNase is significantly superior to tPA or DNase alone, or placebo in improving pleural fluid drainage in patients with pleural space infection. A guideline statement on the management of PPE in children has been published by the BTS. It recommends the use of antibiotics in all patients with PPE in addition to either video-assisted thoracoscopic surgery (VATS) or tube thoracostomy and intrapleural fibrinolysis. Prospective randomized trials have shown that intrapleural fibrinolysis is as effective as VATS for the treatment of childhood empyema and is a more economic treatment and therefore, should be the primary treatment of choice.

Diagnosis and Management of Parapneumonic Effusions

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.

Management of parapneumonic effusion and pleural empyema

Etwa 50.000 Patienten entwickeln jahrlich in Deutschland einen parapneumonischen Pleuraerguss. Die Prognose der Pneumonien wird dadurch ungunstig beeinflusst. Eine rasche Diagnose mittels bildgebender Verfahren und diagnostischer Pleurapunktion ist daher erforderlich. Basierend auf diagnostischen Kriterien lasst sich der parapneumonische Erguss in eine unkomplizierte und eine komplizierte Verlaufsform sowie das Pleuraempyem unterteilen. Therapeutische Strategien umfassen die parallele Einleitung einer empirischen antimikrobiellen Therapie unter Einschluss grampositiver, gramnegativer und anaerober Erreger und die rasche und vollstandige Entfernung der infizierten Pleuraflussigkeit. Adaquate Verfahren zur Ergussentfernung schliesen die (wiederholte) Pleurapunktion, die Saugdrainage, die intrapleurale Fibrinolyse und thoraxchirurgische Verfahren ein. Ihre Anwendung erfolgt nach individueller Risikostratifizierung unter Berucksichtigung diagnostischer Kriterien wie Ausdehnung und Aussehen des Ergusses, mikrobiologischem Erregernachweis und biochemischer Parameter.

Management of parapneumonic effusions in pediatrics: Current practice

Pneumonia with associated complex pleural disease is a cause of significant morbidity among hospitalized children. The management of this patient population continues to be a challenge and varies even among single institutions. The article presented here reviews the management goals for pediatric patients hospitalized with complex parapneumonic effusions and provides updated summaries of both medical and surgical therapies.