Parapneumonic effusion

It is a common complication of bacterial pneumonia (about 40%). Most parapneumonic

effusions are small and resolve with appropriate antibiotic therapy. Thoracentesis should be done
if the effusion layers out to a thickness equal to or greater than 10 mm on the lateral decubitus
chest radiograph to determine as early as possible if a chest tube should be placed.
Pathophysiology:
The spectrum of parapneumonic effusions has been divided into three stages, although they are
not sharply defined and represent a point on a continuous spectrum.
1. The exudative stage which results from a focus of parenchymal infection leading to
increased pulmonary interstitial fluid. Some of this fluid crosses the visceral pleura and
accumulates as a small sterile pleural effusion. The pleural fluid is an exudate with
primarily PMNs, a normal glucose level, and a normal pH level. Antibiotics begun in this
stage will affect resolution of both the pneumonic and pleural process. The initial sterile
free flowing exudative parapneumonic effusions may rapidly progress (within a day) to
the second stage.
2. The fibropurulent stage characterized by infection of sterile pleural fluid. Pleural fluid
further accumulates and contains many PMNs, bacteria, and cellular debris. Fibrin
deposits cover both the visceral and parietal pleura. Fibrin membrane partitions result in
loculated effusion. This loculation makes complete pleural space drainage difficult.
During this stage, the pleural fluid pH and glucose levels become low, LDH levels
increase, and bacterial organisms or frank pus may be present.
3. The organization stage. Fibroblasts grow into the exudate from both the visceral and
parietal pleural surface to produce an inelastic membrane called the pleural peel. These
untreated effusions may also drain spontaneously through the chest wall (empyema
necessitans) or into the lung to produce a bronchopleural fistula.
Bacteriology:
Anaerobic organisms are responsible for the majority of culture-positive empyemas. In a study
by Bartlett et al. (Lancet 1:338-340, 1974), in patients with positive pleural fluid cultures, 35%
had only anaerobic organisms, 41% had both anaerobic and aerobic organisms, and 24% had
only aerobic organisms. Therefore anaerobic cultures should always be obtained.
Approximately 35% of patients with anaerobic pneumonia will have a culture-positive pleural
effusion, whereas fewer than 5% of patients with parapneumonic effusions secondary to
pneumococcal pneumonia will have culture-positive pleural effusions (Light et al. Am. J. Med.
69:507-511, 1980).
Clinical Manifestations
Aerobic bacterial pneumonia with pleural effusion usually presents with an acute febrile illness
consisting of chest pain, sputum production, and elevated WBC count. By contrast, anaerobic

bacterial infections involving the pleural space usually present with a subacute illness. Anaerobic
infections should be considered in patients with a history of alcoholism, an episode of
unconsciousness, or other factors that predispose them to aspiration. The majority of patients
with anaerobic pleuropulmonary infections will have significant weight loss, leukocytosis and
mild anemia.
Diagnosis
In order to state a patient has a parapneumonic effusion, a bacterial pneumonia needs to be
diagnosed. Other possibilities for pulmonary infiltrates and pleural effusions need to be
considered and may include pulmonary embolism, acute pancreatitis, Dressler's syndrome, and
other diseases.
With the involved side dependent, if the thickness exceeds 10 mm, a diagnostic thoracentesis
should be performed immediately. An empyema or complicated pleural effusion can be
identified only by examination of the pleural fluid. Clinical evaluation is inadequate to predict
simple sympathetic effusion from complicated effusion.
Pleural fluid should be examined grossly for color, turbidity, and odor. If pus is present, the
pleural space should be drained via tube thoracostomy. In the absence of gross pus, pleural fluid
is sent for other studies to assist in determining if immediate chest tube placement is required.
These pleural fluid studies should include glucose, LDH, amylase, protein, pH, WBC count plus
differential, Gram stain, aerobic and anaerobic bacterial cultures. Depending on the clinical
setting, fungal and mycobacterial smears and cultures and cytological studies should be done.
Accurate pH measurements requires that the pleural fluid be collected anaerobically in a
heparinized syringe (0.2 ml of 1:1000 heparin is drawn up into the syringe and then flushed to
eliminate any artifact due to low pH of heparin). The syringe is then placed on ice, and the pH
should be measured expeditiously.
Treatment:
Antibiotics after sputum, blood, or pleural fluid cultures obtained.
Thoracentesis is fluid over 1 cm thick.
Chest tube drainage for grossly purulent pleural fluid/empyema. It is to be removed when
drainage becomes serous and < 50 ml per day.
[In the Textbook of Respiratory Medicine by Murray and Nadel (2nd edition), Richard Light offers the following
recommendations for implementing chest tube drainage: 1) purulent pleural fluid, 2) positive pleural fluid Gram
stain, 3) pleural fluid glucose less than 50 mg/dl, 4) pleural fluid pH below 7.00 and 0.15 units lower than arterial
pH. If these four criteria are not met, a chest tube should still be considered if pleural fluid pH is below 7.20 or if
pleural fluid LDH is above 1000 IU/L. ]

Nonetheless, with the guidelines, if the pleural fluid characteristics are borderline for chest tube
placement, repeating a thoracentesis at 12- to 24- hours may be helpful. If the pleural fluid LDH

decreases and the pH and glucose increases, the patient is likely improving. But if the LDH is
increasing and the pH and glucose are decreasing a chest tube should be placed.
Intrapleural Fibrinolytics
One major reason for failed drainage is tube obstruction by organized empyema and multiple
pleural space loculations. If the decision is made to use fibrinolytics, the usual dose of
streptokinase is 250,000 U, in 30 to 60 ml normal saline given intrapleurally via chest tube. The
usual dose of urokinase is 100,000 U diluted in the same manner. It appears that streptokinase
and urokinase are equally effective. The chest tube is clamped for 1 to 2 hours. This treatment
can be repeated for up to 14 days. The decision regarding fibrinolytics versus surgery should be
made in consultation with a thoracic surgeon.
Open Drainage and Empyemectomy/Decortication
Patients in the late fibropurulent or organizational stage may have inadequate pleural drainage
after tube thoracostomy and intrapleural fibrinolytic therapy. An open drainage procedure can be
performed under local anesthesia. Segments of one to three ribs overlying the lower part of the
empyema cavity are resected, and one or more short large-bore tubes are inserted into the cavity.
The cavity is irrigated daily with mild antiseptic solution, and drainage from the tubes can be
collected in a colostomy bag. Open drainage is preferred to decortication only in those patients
who are thought to be too ill to tolerate decortication. With decortication a full thoracotomy is
performed and all fibrous tissue is removed from the pleural surfaces and all pus is evacuated
from the pleural space.