Update: Management of Parapneumonic Effusions

Whenever a patient with a pleural effusion is evaluated, the possibility of a parapneumonic effusion should be considered. When the diaphragms cannot be completely visualized or loculated pleural fluid appears to be present, the possibility of pleural fluid should be assessed with ultrasound or lateral decubitus radiographs. If there is more than a minimal amount of pleural fluid, the fluid should be sampled to determine if there are any poor prognostic factors present (pus, positive gram stain, glucose less than 40 mg/dL, pH less than 7.20, positive culture or lactate dehydrogenase greater than 3 times the upper limit of normal for serum). The fluid is best sampled with a therapeutic thoracentesis. If the fluid recurs, a second therapeutic thoracentesis is performed if any of the poor prognostic factors were present at the first thoracentesis. If the fluid cannot be removed with the therapeutic thoracentesis, either tube thoracostomy with the instillation of fibrinolytics or thoracoscopy should be performed. If the lung does not expand with thoracoscopy, thoracotomy with decortication should be performed. Many decortications are now being done via thoracoscopy. Open drainage procedures are reserved for those patients who are too ill to undergo thoracoscopy or thoracotomy. The definitive procedure should be performed within 10 days of the patient’s initial hospitalization.