eMedicine Specialties > Pulmonology > Pleural Disorders

Parapneumonic Pleural Effusions and Empyema Thoracis: Follow-up

Author: Atikun Limsukon, MD, Instructor, Department of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Thailand
Coauthor(s): Guy W Soo Hoo, MD, MPH, Clinical Professor of Medicine, Geffen School of Medicine at the University of California at Los Angeles; Director, Medical Intensive Care Unit, Pulmonary and Critical Care Section, West Los Angeles Healthcare Center, Veteran Affairs Greater Los Angeles Healthcare System
Contributor Information and Disclosures

Updated: Sep 17, 2009

Follow-up

Further Inpatient Care

  • Patients require hospitalization for antibiotic therapy, drainage of pleural space, thrombolytic therapy (possibly), and surgery (in patients in whom medical therapy is unsuccessful).

Further Outpatient Care

  • Often, prolonged antibiotic therapy is required, particularly in patients who have anaerobic infections. The length of antibiotic therapy is generally dictated by the response to antibiotics and clinical and radiologic resolution.

Inpatient & Outpatient Medications

  • Extended treatment with antibiotics may be required. See Medication for the antibiotic list.

Transfer

  • If specialty services are not available (interventional radiologist and/or thoracic surgeon), some patients may require transfer to a hospital that is able to provide these services.

Deterrence/Prevention

  • Early diagnosis and intervention (thoracentesis and/or drainage procedure), may obviate the need for surgical treatment.

Complications

  • Complications are related to adverse events related to incomplete drainage of infected pleural fluid. These include chronic, indolent infections, chest tube site infections, trapped lung, bronchopleural fistulas, and pneumothoraces.
  • Untreated infections may lead to sepsis, septic shock, and death.

Prognosis

  • Most patients recover, but the mortality rate remains approximately 10%.
  • Appropriate antibiotic therapy and early drainage of pleural fluid are crucial for recovery.
  • Approximately 15-25% of patients require surgical intervention, including decortication and/or an open drainage procedure.

Patient Education

Miscellaneous

Medicolegal Pitfalls

  • Thoracentesis in patients with pneumonia and pleural effusions of sufficient size is mandatory to allow differentiation of uncomplicated from complicated pleural effusions or empyemas.
  • The pleural fluid pH has the highest diagnostic accuracy in the assessment of uncomplicated or complicated pleural effusions.27
  • Drainage procedures are essential in patients with complicated parapneumonic effusions to prevent adverse events associated with the infection.
  • Indications for fibrinolytic and surgical treatment remain undefined. Consultation with a specialist is advised, and each patient should be managed on a case-by-case basis.

Special Concerns

  • In patients with empyema and bronchopleural fistula, pleural fluid may drain internally and cause an overwhelming pneumonia. In patients who produce large amounts of sputum when in a specific position (eg, supine, decubitus), suspect a bronchopleural fistula.
    • Radiologically, a bronchopleural fistula is suggested by the presence of an air-fluid level in the pleural space. To differentiate the air-fluid level from the lung abscess, ultrasonography or CT scanning may be helpful.
    • The presence of bronchopleural fistula in conjunction with infected pleural fluid is a medical emergency. Immediately institute drainage, and promptly start appropriate antibiotics.
  • An empyema distal to an obstructed bronchus such as an obstructing endobronchial carcinoma creates a unique management problem.
    • The underlying lung does not expand, but the empyema must be drained to control the infection. This results in either the need for a long-standing indwelling chest tube or an open chest wound for drainage. Patients require long-term antibiotics.
    • Radiation therapy or laser therapy of the affected bronchus may allow lung re-expansion.
  • Postpneumonectomy empyemas account for approximately 25% of empyemas. The prevalence of postpneumonectomy empyema is 2-10%, and approximately half of these patients have bronchopleural or esophagopleural fistulas.
    • After a pneumonectomy, a characteristic evolution of radiologic findings develops. Deviations from this suggest the possibility of postpneumonectomy empyema.
    • In the postoperative period, if the volume of air increases or the mediastinum shifts toward the midline or contralateral side, strongly consider postpneumonectomy empyema.
    • Diagnosis is further established by thoracentesis demonstrating bacteria on the Gram stain of the pleural fluid. The usual bacteria responsible for infection are gram-negative organisms or Staphylococcus aureus.
    • Treat all patients with postpneumonectomy empyema with a chest tube and appropriate antibiotics. If the patient does not have a bronchopleural fistula, antibiotic irrigation of the pleural space also appears to be effective in most patients.
    • An alternate approach to postpneumonectomy empyema is the creation of a skin-lined fistula that allows drainage (and irrigation if desired) of pleural fluid. This is often referred to an Eloesser flap and permits outpatient management. Prolonged antibiotics are an essential component of treatment.
    • A similar approach may be required to manage a persistent bronchopleural fistula. If surgical closure or the fistula is not possible, an Eloesser flap along with extended antibiotic therapy may be required.
 
Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the contributions of previous author, Sat Sharma, MD, FRCPC, to the development and writing of this article.



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References
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References

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Further Reading

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Keywords

empyema thoracis, pleural effusions, pleural effusion, parapneumonic pleural effusion, pleuropulmonary empyema, complicated parapneumonic pleural effusion, uncomplicated parapneumonic effusion, thoracic empyema, thoracoplasty, decortication, pneumonia, parapneumonic effusion, esophageal perforation, trauma, surgical procedure on pleural space, septicemia

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Contributor Information and Disclosures

Author

Atikun Limsukon, MD, Instructor, Department of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Thailand
Atikun Limsukon, MD is a member of the following medical societies: American College of Chest Physicians, American Thoracic Society, and California Thoracic Society
Disclosure: Nothing to disclose.

Coauthor(s)

Guy W Soo Hoo, MD, MPH, Clinical Professor of Medicine, Geffen School of Medicine at the University of California at Los Angeles; Director, Medical Intensive Care Unit, Pulmonary and Critical Care Section, West Los Angeles Healthcare Center, Veteran Affairs Greater Los Angeles Healthcare System
Guy W Soo Hoo, MD, MPH is a member of the following medical societies: American Association for Respiratory Care, American College of Chest Physicians, American College of Physicians, American Thoracic Society, California Thoracic Society, and Society of Critical Care Medicine
Disclosure: Nothing to disclose.

Medical Editor

Michael Peterson, MD, Chief of Medicine, Vice-Chair of Medicine, University of California at San Francisco; Endowed Professor of Medicine, University of California at San Francisco-Fresno
Michael Peterson, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, and American Thoracic Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Om Prakash Sharma, MD, FRCP, FCCP, DTM&H, Professor, Department of Medicine, Division of Pulmonary and Critical Care Medicine, University of Southern California Keck School of Medicine
Om Prakash Sharma, MD, FRCP, FCCP, DTM&H is a member of the following medical societies: American Academy of Allergy Asthma and Immunology, American College of Chest Physicians, American College of Physicians, American Federation for Medical Research, American Osler Society, American Thoracic Society, New York Academy of Medicine, and Royal Society of Medicine
Disclosure: Keck School of Medicine, USC None None

CME Editor

Timothy D Rice, MD, Associate Professor, Departments of Internal Medicine and Pediatrics and Adolescent Medicine, Saint Louis University School of Medicine
Timothy D Rice, MD is a member of the following medical societies: American Academy of Pediatrics and American College of Physicians
Disclosure: Nothing to disclose.

Chief Editor

Zab Mosenifar, MD, Director, Division of Pulmonary and Critical Care Medicine, Director, Women's Guild Pulmonary Disease Institute, Executive Vice Chair, Department of Medicine, Cedars Sinai Medical Center; Professor of Medicine, David Geffen School of Medicine at UCLA
Zab Mosenifar, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, American Federation for Medical Research, and American Thoracic Society
Disclosure: Nothing to disclose.

 
 
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