Evaluation and Management of Pleural Effusion and Empyema

Medical Management of Pneumonia with Pleural Effusion Observation DrainCriteria for Observation Only: •Effusion too small to drain (<10 mm)•Effusion drainable, but pt. on antibiotics, no respiratory distress, effusion resolving on serial CXR Plan: •Baseline CRP , repeat in 24 hours•Repeat CXR in 24 hours if clinically indicated Criteria to Drain: •Patient with suspected “large” effusion and respiratory compromise•To obtain fluid to further characterize effusion Diagnostic TapChest Tube PlacementPatient Scenario:•Patient not on antibiotics and mild respiratory distress (identify pathogen)•Clinical presentation atypical for parapneumonic effusion (r/o malignancy, clarify exudate vs. transudate) Plan: •Tap performed by Pulmor IR•Pleural fluid measurements: pH, glucose, LDH, cell count/differential, gram stain & culture Patient Scenario:•Patient in respiratory distress•Effusion staged as complicated by U/S or pleural fluid indices (and progressing) Plan: •IR Consult•Surgery Consult•Pleural fluid measurements: pH, glucose, LDH, cell count/differential, gram stain & culture See next Page Updated 1/2019 Surgical ConsultReview U/S with Interventional Radiology/Radiology/Pulmonaryto assess degree of loculations No significant loculations Chest tube placed by Interventional Radiology YesRemove tube in 24-48 hoursNo Significant loculations Chest tube placed by Interventional RadiologyStart TPA within 6 hours (Administered Q12H for 6 doses) No Continue TPA Consider VATS/Thoracotomy Yes •Stop TPA•Remove chest tube in 24 hours VATS/Thoracotomy at Surgeon discretion (please document reason) Effusion drained over 75% in 24 hours •Resolution of >75% of effusion•Absence of O2 requirement•Resolution of fever(≥1 of the above)72 hours since 1stTPA dose?Yes Updated 1/2019 No Source:•St. Peter SD, et al. Thoracoscopic decortication vs tube thoracostomy with fibrinolysis for empyema in children: a prospective, randomized trial. J PediatrSurg2009;44:106-111.•Gates RL, et al. Drainage, Fibrinolytics or Surgery: A Comparison of Treatment Options in Pediatric Empyema. J PediatrSurg2004;39:1638-1642.