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Parapneumonic effusion and empyema
Guidelines
Key sources
The following summarized guidelines for the evaluation and management of parapneumonic effusion and empyema are prepared by our editorial team based on guidelines from the British Thoracic Society (BTS 2023), the Consensus Group on Pleural Empyema (PE-CG 2021), the American Association for Thoracic Surgery (AATS 2017), the Infectious Diseases Society of America (IDSA 2011,2007), and the Infectious Diseases Society of ...
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Classification and risk stratification
Risk assessment: as per BTS 2023 guidelines, use the RAPID score for risk-stratifying adult patients with pleural infection to inform discussions regarding potential outcomes from infection.
B
RAPID score for pleural infection
Calculator
When to use
Blood urea nitrogen
< 14 mg/dL [5 mmol/L]
14-23 mg/dL [5-8 mmol/L]
> 23 mg/dL [8 mmol/L]
Age, years
< 50
50-70
> 70
Purulence of pleural fluid
Purulent
Non-purulent
Infection source
Community-acquired
Hospital-acquired
Serum albumin
≥ 2.7 g/dL [27 g/L]
< 2.7 g/dL [27 g/L]
Calculation
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Diagnostic investigations
Indications for evaluation
As per AATS 2017 guidelines:
Evaluate for the presence of pleural effusion in all patients presenting with signs and symptoms of pneumonia or unexplained sepsis.
B
Evaluate for the presence of pleural effusion in patients with community- or healthcare-associated pneumonia not responding to appropriate antibiotic therapy.
B
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Diagnostic imaging
Laboratory tests
Diagnostic procedures
Pleural fluid analysis: as per BTS 2023 guidelines, obtain immediate pH analysis in patients with parapneumonic effusion or suspected pleural infection if diagnostic aspiration does not identify frank pus.
A
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Pleural fluid culture
Medical management
Antibiotic therapy: as per AATS 2017 guidelines, take into account the patient's clinical history, local antimicrobial resistance patterns, institutional antibiotic stewardship, and pharmacologic characteristics of the antibiotics to decide on appropriate empiric antibiotic therapy in patients with acute pleural empyema.
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Therapeutic procedures
Pleural fluid drainage, tube thoracostomy, indications: as per AATS 2017 guidelines, perform tube thoracostomy, followed by surgical intervention when appropriate, for the management of empyema (established based on the presence of pus, positive Gram stain, or culture in the pleural fluid).
B
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Pleural fluid drainage (tube thoracostomy, technical considerations)
Pleural fluid drainage (thoracoscopy and surgical drainage)
Intrapleural fibrinolytic therapy
Intrapleural saline irrigation
Surgical interventions
Indications for surgery, general principles
As per BTS 2023 guidelines:
Ensure that the surgical technique can facilitate the optimal clearance of infected material and achieve lung reexpansion where appropriate when selecting surgical access for the management of pleural infection.
E
Tailor the extent of surgery according to the patient and empyema stage when the lung is not completely trapped (drainage versus debridement).
E
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Indications for surgery (video-assisted thoracoscopic surgery)
Indications for surgery (decortication)
Specific circumstances
Pediatric patients, evaluation: as per IDSA/PIDS 2011 guidelines, obtain a CXR (posteroanterior and lateral) to assess for complications of pneumonia, including parapneumonic effusion, in pediatric patients with community-acquired pneumonia not responding to initial antibiotic therapy.
B
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Pediatric patients (antibiotic therapy)
Pediatric patients (drainage and fibrinolytic therapy)
Pediatric patients (monitoring)
Patients with chronic empyema
Patients with postresectional empyema
Patients with bronchopleural fistulas