Treatment of complicated parapneumonic effusion and empyema

IV: intravenous; CT: computed tomography; tPA: tissue plasminogen activator; DNase: deoxyribonuclease; VATS: video-assisted thoracoscopic surgery.
* Chest tube or catheter thoracostomy drainage is best suited for patients with free-flowing or uniloculated effusions (ie, effusions without internal septae), but is also frequently used to drain complex effusions (ie, effusions with internal septations or locules). In general, we prefer small-bore tubes (10 to 14 French [Fr]) but some experts prefer larger-bore tubes in patients with effusions that have multiple locules to enhance the efficacy of drainage. However, in practice the choice may be dependent upon factors including physician and patient preference, institutional policy, and available expertise.
¶ Failure to improve or worsening after antibiotics and tube thoracostomy drainage (eg, the effusion worsens, fever persists or new fever develops, persistent or worsening leukocytosis) may indicate that antibiotic coverage and/or drainage is inadequate.
Δ Placing drainage tubes under image guidance helps decrease the frequency of tube misplacement and increases the likelihood of draining locules suspected to be infected.
◊ Choosing among the drainage options is often provider-specific. Factors that influence the decision include the clinician's specialty, expertise availability, patient values, patient prognosis from comorbidities, and candidacy for select surgical procedures as well as the number and size of locules and degree of pleural thickening on chest CT. However, most experts administer intrapleural tPA/DNase and give consideration to placing a second (or third) chest tube or catheter before resorting to VATS. Exceptions include patients with empyema from a bronchopleural fistula who should preferably undergo VATS repair after an adequate course of antibiotics, and patients who have clear evidence of significant organization/fibrothorax (eg, no pleural fluid, excessively thickened pleura on chest CT with or without calcification) or patients with evidence of unexpandable lung (air replaces fluid after drainage); in such cases proceeding directly to VATS for decortication rather than attempting a trial of tPA/DNase is appropriate.
§ Patients should be followed clinically. Some patients can be discharged with a mechanism in place for continued drainage. Imaging is generally obtained at approximately three to four weeks after discharge to ensure continued resolution of the effusion. Antibiotics may be continued for several weeks (eg, 2 to 3 weeks for a complicated parapneumonic effusion and 4 to 6 weeks for empyema).