What is the diagnosis and treatment for parapneumonic effusion?

From the Guidelines

Parapneumonic effusion should be treated with antibiotics alone for small, uncomplicated effusions, while larger effusions require drainage, which can be done via thoracentesis, chest tube placement, or video-assisted thoracoscopic surgery (VATS) depending on the size and loculation of the effusion. The management of parapneumonic effusion involves confirming the diagnosis of pneumonia and parapneumonic effusion, categorizing the size of the effusion, and treating with antibiotics, with the option of drainage depending on the size and complexity of the effusion 1.

Diagnosis and Treatment

The diagnosis of parapneumonic effusion is based on clinical presentation, imaging studies, and pleural fluid analysis. Treatment begins with appropriate antibiotics targeting the underlying pneumonia, typically a combination of a beta-lactam and a macrolide for 7-14 days depending on clinical response. Small, uncomplicated effusions can often be managed with antibiotics alone, while larger effusions, especially those with pH <7.2, glucose <60 mg/dL, LDH >1000 IU/L, or positive gram stain/culture require drainage 1.

Drainage Options

Drainage options include thoracentesis, chest tube placement, and VATS. The choice of drainage procedure depends on local expertise and the size and loculation of the effusion. Both chest tube drainage with the addition of fibrinolytic agents and VATS have been demonstrated to be effective methods of treatment, with decreased morbidity compared to chest tube drainage alone 1. For patients with moderate to large effusions that are free flowing, placement of a chest tube without fibrinolytic agents is a reasonable first option.

Monitoring and Follow-up

Patients should be monitored with serial chest imaging to ensure resolution of both the effusion and underlying pneumonia. The development of parapneumonic effusions relates to increased vascular permeability from the inflammatory response to infection, allowing fluid to accumulate in the pleural space, which can become infected if bacteria invade this space 1.

• Key points to consider in the management of parapneumonic effusion include:
  • Prompt evaluation and management to prevent progression to complicated effusion or empyema
  • Treatment with antibiotics targeting the underlying pneumonia
  • Drainage options depending on the size and loculation of the effusion
  • Monitoring with serial chest imaging to ensure resolution of both the effusion and underlying pneumonia
  • Consideration of local expertise and available resources in choosing a drainage procedure.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Diagnosis of Parapneumonic Effusion

• Parapneumonic pleural effusion should be considered in all patients with pneumonia as antibiotic therapy is being initiated 2
• Diagnostic tools include chest radiographs, lateral decubitus radiograph, ultrasonography, and computerized tomography scan 2
• Pleural fluid analysis provides diagnostic information and guides therapy, including gram-stain, culture, glucose, pH, LDH, white blood cells, and differential cell count 3

Treatment of Parapneumonic Effusion

• Early antibiotic treatment usually prevents the development of a parapneumonic effusion and its progression to a complicated effusion and empyema 4
• Therapeutic thoracentesis should be performed if more than a minimal amount of pleural fluid is present 3
• If the fluid cannot be drained because of loculations, a chest tube should be inserted and thrombolytic agents administered 3
• Intrapleural fibrinolytics may be effective during the early fibrinolytic stage and may make surgical drainage unnecessary 4
• Video-assisted thoracic surgery should be performed without delay if pleural space drainage is ineffective 4
• Decortication should be performed without delay if the lung does not reexpand completely with thoracoscopy 2

Management Options

• Management options include thoracentesis, tube thoracostomy, adjunctive intrapleural fibrinolytic therapy, and surgical drainage 5
• The methods of surgical drainage include thoracoscopy, thoracotomy, and decortication 5
• An aggressive approach with early surgical drainage results in shorter hospital stays and may be more cost-effective than conservative management 5