From the Guidelines
The presence of a loculated post-pneumonia effusion on CT scan necessitates prompt drainage, preferably via thoracentesis or chest tube placement, accompanied by antibiotics and potentially intrapleural fibrinolytics, to prevent complications such as trapped lung and to improve patient outcomes. This approach is supported by recent guidelines and studies, including the American College of Radiology's appropriateness criteria for the workup of pleural effusion or pleural disease 1. The use of CT chest with IV contrast is recommended for initial imaging in cases of suspected parapneumonic effusion or empyema, as it helps identify key findings such as pleural enhancement, pleural thickening, loculation, extrapleural fat proliferation, and increased attenuation of the extrapleural fat, which are crucial for diagnosing empyema and guiding management decisions 1.
Key considerations in the management of loculated post-pneumonia effusions include:
- The size of the effusion, with those less than 2.5 cm in anteroposterior dimension potentially being managed without thoracentesis 1
- The presence of symptoms such as fever, chest pain, or shortness of breath, which typically necessitate drainage
- The use of antibiotics, which should be continued based on culture results or empirically with coverage for common pneumonia pathogens
- The potential need for surgical intervention with video-assisted thoracoscopic surgery (VATS) if drainage procedures fail
- The importance of follow-up imaging to ensure resolution of the effusion and to rule out underlying conditions that might have contributed to the pneumonia and subsequent effusion
In terms of specific treatment protocols, the combination of intrapleural fibrinolytics like tissue plasminogen activator (tPA) and dornase alfa may be beneficial for very thick or septated fluids, and antibiotics such as ceftriaxone and azithromycin can provide coverage for common pneumonia pathogens 1. However, the most recent and highest quality evidence should always guide clinical decision-making, with the goal of minimizing morbidity, mortality, and improving quality of life for patients with loculated post-pneumonia effusions.
From the Research
CT Findings Consistent with Loculated Post Pneumonia Effusion
- Loculated post pneumonia effusion is a complication of pneumonia where fluid accumulates in the pleural space and becomes trapped by fibrinous adhesions 2, 3, 4
- CT findings consistent with loculated post pneumonia effusion include:
- Presence of fluid in the pleural space
- Fibrinous adhesions or loculations
- Enhanced CT scan may show increased density of the fluid due to presence of pus or debris
- Management of loculated post pneumonia effusion involves:
- Therapeutic thoracentesis to drain the fluid
- Insertion of a chest tube and administration of thrombolytic agents if the fluid cannot be drained due to loculations 2, 4
- Use of intrapleural fibrinolytic therapy (IPFT) in conjunction with thoracostomy for loculated effusions 3, 4
- Surgical referral may be necessary in cases where medical therapy fails or in late-stage disease 3, 4
Diagnostic Evaluation
- Diagnostic evaluation of pleural fluid includes:
- Gram stain and culture
- Analysis of glucose, pH, LDH, white blood cells, and differential cell count
- Repeat diagnostic evaluations of the pleural fluid if the fluid recurs after initial therapeutic thoracentesis 2
- Biochemical, microbiological, and radiological characteristics of the pleural fluid can guide treatment and separate parapneumonic effusions into distinct categories 3
Treatment Options
- Treatment options for loculated post pneumonia effusion include:
- Antibiotic therapy with coverage for Gram-positive, Gram-negative, and anaerobic organisms
- Use of levofloxacin as a monotherapy or in combination with other antibiotics for community-acquired pneumonia 5, 6
- Intrapleural fibrinolytic therapy (IPFT) and thoracostomy for loculated effusions
- Surgical referral for cases where medical therapy fails or in late-stage disease 3, 4