Evaluation and Management of Pleural Effusion and Empyema

Guideline · Aug 2019 · 1 min read

In brief

Clinical approach to diagnosing and treating pleural effusions and empyema, covering diagnostic workup, imaging interpretation, drainage procedures, and management strategies for infected pleural space.

Written by the GCMD Library team from the guideline.

Observation Criteria and Management

Small effusions (<10mm) or resolving effusions in stable patients on antibiotics can be managed with observation alone. Baseline CRP should be obtained and repeated in 24 hours, with follow-up chest X-ray if clinically indicated. This conservative approach is appropriate for patients without respiratory distress.

Indications for Drainage Procedures

Drainage is indicated for large effusions causing respiratory compromise or when fluid characterization is needed for diagnosis. The decision to drain depends on clinical presentation, respiratory status, and the need to identify pathogens or rule out alternative diagnoses such as malignancy.

Diagnostic Thoracentesis

Diagnostic tap is performed by pulmonology or interventional radiology in patients not yet on antibiotics with mild respiratory distress or atypical presentations. Pleural fluid should be analyzed for pH, glucose, LDH, cell count with differential, gram stain, and culture to guide further management.

Chest Tube Placement

Chest tube insertion is indicated for patients in respiratory distress or when effusion is staged as complicated by ultrasound or pleural fluid indices. Both interventional radiology and surgery should be consulted, with comprehensive pleural fluid analysis performed at the time of placement.

Management of Non-Loculated Effusions

When ultrasound review shows no significant loculations, chest tube placement by interventional radiology is appropriate. If drainage is adequate, the tube can be removed in 24-48 hours; inadequate drainage prompts consideration of fibrinolytic therapy or surgical intervention.

Fibrinolytic Therapy Protocol

For significantly loculated effusions, tissue plasminogen activator (TPA) should be initiated within 6 hours of chest tube placement and administered every 12 hours for up to 6 doses. Treatment success is defined as >75% effusion resolution, absence of oxygen requirement, or fever resolution within 72 hours of first TPA dose.

Surgical Intervention Criteria

Video-assisted thoracoscopic surgery (VATS) or thoracotomy is considered when fibrinolytic therapy fails to achieve adequate drainage or clinical improvement. Surgical consultation should be obtained early in cases with significant loculations, with the surgeon documenting specific indications for operative intervention.

Statements in this guideline

Effusions smaller than 10 mm are too small to drain and should be observed.
RecommendationCriteria for Observation Only
Drainable effusions in patients on antibiotics without respiratory distress and with resolving effusion on serial chest X-ray should be observed.
RecommendationCriteria for Observation Only
Baseline C-reactive protein should be obtained and repeated in 24 hours during observation.
RecommendationPlan
Chest X-ray should be repeated in 24 hours if clinically indicated during observation.
RecommendationPlan
Patients with suspected large effusion and respiratory compromise should have the effusion drained.
RecommendationCriteria to Drain
Drainage should be performed to obtain fluid to further characterize the effusion.
RecommendationCriteria to Drain
Diagnostic tap should be performed by pulmonology or interventional radiology in patients not on antibiotics with mild respiratory distress to identify the pathogen.
RecommendationDiagnostic Tap
Diagnostic tap should be performed when clinical presentation is atypical for parapneumonic effusion to rule out malignancy or clarify exudate versus transudate.
RecommendationDiagnostic Tap
Pleural fluid measurements should include pH, glucose, lactate dehydrogenase, cell count with differential, gram stain, and culture.
RecommendationPlan
Chest tube placement is indicated for patients in respiratory distress.
RecommendationChest Tube Placement
Chest tube placement is indicated when effusion is staged as complicated by ultrasound or pleural fluid indices and is progressing.
RecommendationChest Tube Placement
Interventional radiology and surgery consultations should be obtained for chest tube placement.
RecommendationPlan
Ultrasound should be reviewed with interventional radiology, radiology, or pulmonology to assess the degree of loculations.
RecommendationSurgical Consult
When there are no significant loculations, the chest tube should be removed in 24 to 48 hours if the effusion is drained over 75% in 24 hours.
Recommendation
When significant loculations are present, tissue plasminogen activator should be started within 6 hours of chest tube placement.
Recommendation
Tissue plasminogen activator should be administered every 12 hours for 6 doses.
Recommendation
Tissue plasminogen activator should be stopped and the chest tube removed in 24 hours if there is resolution of greater than 75% of effusion, absence of oxygen requirement, or resolution of fever.
Recommendation
Tissue plasminogen activator should be continued if criteria for stopping are not met at 72 hours since the first dose.
Recommendation
Video-assisted thoracoscopic surgery or thoracotomy should be considered if tissue plasminogen activator does not achieve adequate drainage.
Recommendation
Video-assisted thoracoscopic surgery or thoracotomy may be performed at surgeon discretion with documented reason.
Recommendation

Full text

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.

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