What is the diagnosis and treatment for parapneumonic effusion?

From the Guidelines

Parapneumonic effusion should be treated with antibiotics and drainage, if necessary, to prevent progression to complicated effusion or empyema, with the choice of drainage procedure depending on local expertise and the size and complexity of the effusion, as recommended by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America 1.

Diagnosis and Treatment

The diagnosis of parapneumonic effusion involves confirming the presence of pneumonia and evaluating the size and characteristics of the effusion.

• Small, uncomplicated effusions may be treated with antibiotic therapy alone, while larger or complicated effusions require drainage via thoracentesis or chest tube placement.
• The choice of drainage procedure depends on local expertise and the size and complexity of the effusion, with options including chest tube alone, chest tube with fibrinolytics, or video-assisted thoracoscopic surgery (VATS) 1.

Antibiotic Treatment

Antibiotic treatment for parapneumonic effusion typically involves a beta-lactam (such as amoxicillin-clavulanate or ceftriaxone) plus a macrolide (such as azithromycin) for 7-14 days, with the duration of treatment depending on the adequacy of drainage and clinical response 1.

Drainage Procedures

• Chest tube drainage with fibrinolytic agents, such as urokinase or tissue plasminogen activator, is an effective treatment for complicated, loculated effusions 1.
• VATS is also a viable option for multiloculated effusions or those with thick pus, and may be necessary for patients who do not respond to chest tube drainage alone 1.

Key Considerations

• Early intervention is crucial to prevent long-term complications like pleural fibrosis and trapped lung.
• Thoracic ultrasound should guide drainage procedures to ensure accurate placement of chest tubes or other drainage devices.
• The development of parapneumonic effusions occurs when inflammation from pneumonia increases capillary permeability in the pleura, allowing fluid to accumulate and potentially become infected 1.

From the Research

Diagnosis of Parapneumonic Effusion

• The diagnosis of parapneumonic effusion is based on the specific characteristics of pleural fluid, computed tomography or ultrasound findings, or direct visualization of loculations during the surgical procedure 2
• Imaging (i.e., chest radiograph, ultrasound and computed tomography) and pleural fluid analysis (i.e., pH, glucose, lactate dehydrogenase, bacterial cults) provide essential information for patient management 3
• All parapneumonic effusions should be aspirated for diagnostic purposes, which may require image-guidance if the effusion is small or heavily loculated 3

Treatment of Parapneumonic Effusion

• The key components of the treatment of complicated parapneumonic effusion and empyema are the use of appropriate antibiotics, provision of nutritional support, and drainage of the pleural space 3
• The treatment options for drainage of the pleural space include therapeutic thoracentesis, tube thoracostomy, intrapleural fibrinolytics, thoracoscopy with breakdown of adhesions or thoracotomy with decortication 3
• The routine use of intrapleural fibrinolytic therapy remains controversial, but its use according to guidelines was associated with survival and reduced mortality in some studies 3, 4
• Early concordant antibiotic treatment, intrapleural fibrinolytics, and input from a pulmonologist were associated with improved outcomes in patients with complicated parapneumonic effusion and empyema 4
• A 14-day treatment with amoxicillin with/without clavulanic acid confirmed or modified by microbiological findings from pleural tap resulted in full recovery in >95% of children with parapneumonic effusion or pleural empyema 5

Criteria for Drainage of Parapneumonic Effusion

• Any parapneumonic effusion that fulfills at least one of the following criteria should be drained:
  • size > or = 1/2 of the hemithorax
  • loculations
  • pleural fluid pH < 7.20 (or alternatively pleural fluid glucose < 60 mg/dl)
  • positive pleural fluid Gram stain or culture
  • purulent appearance 3