Sepsis pp 152-165 | Cite as

Management of Pleural Effusion in the Pulmonary Sepsis

  • Yubiao Guo
  • Richard W. Light


Whenever a pulmonary sepsis patient with a pleural effusion is evaluated, the possibility of a parapneumonic effusion should be considered. If there is more than a minimal amount of pleural fluid, the fluid should be sampled with a therapeutic thoracentesis to determine if any poor prognostic factors are present (pus, positive Gram stain, glucose less than 40 mg/dL, pH less than 7.20, positive culture or LDH greater than three times the upper limit of normal for serum). It is important to administer appropriate antibiotics. The antibiotic is selected on the basis of the results of blood, sputum, or pleural fluid cultures. 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. 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.

An estimated 750,000 cases of severe sepsis occur annually in the United States, and the mortality rate is about 30%. Bacterial pneumonia is one of the most important causes of pulmonary sepsis.1 Bacterial pneumonia leads to significant morbidity and mortality despite the availability of potent antimicrobial agents. The annual incidence of bacterial pneumonia in the United States is estimated to be 4 million, with approximately 20% of patients requiring hospitalization.2 Approximately 20% to 40% of hospitalized patients with bacterial pneumonia have an accompanying pleural effusion.3, 4 The morbidity and mortality rates for patients with pneumonia and pleural effusions are higher than those for patients with pneumonia alone. In one study of patients with community-acquired pneumonia (CAP), patients with bilateral pleural effusions had a relative mortality risk 7.0 times higher than patients without a pleural effusion. Patients with a unilateral pleural effusion of moderate or greater size had a relative risk 3.4 times higher than patients without effusion.5 In assessing risks of patients with CAP, the presence of a pleural effusion is given the same weight as a PO2 of less than 60 mmHg.6

Most pleural effusions associated with pneumonia resolve without any specific therapy directed toward the pleural fluid,3 but about 10% require operative intervention for their resolution. Delay in instituting proper therapy for these effusions is responsible for a significant percentage of the increased morbidity and mortality associated with parapneumonic effusions.7


Pleural Effusion Pleural Fluid Poor Prognostic Factor Pleural Space Tube Thoracostomy 
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  1. 1.
    Angus DC, Linde-Zwirble WT, Lidicker J, et al. Epideminology of severe sepsis in the United States: Analysis of incidence, outcome, and associated costs of care. Crit Care Med 2001; 29: 1303–10.PubMedCrossRefGoogle Scholar
  2. 2.
    Neiderman MS, Bass JB, Campbell GD, et al. Guidelines for the initial management of adults with community-acquired pneumonia: diagnosis, assessment of severity, and initial antimicrobial therapy. Am Rev Respir Dis 1993; 148: 1418–26.Google Scholar
  3. 3.
    Light RW, Girard WM, Jenkinson SG. Parapneumonic effusions. Am J Med 1980; 69: 507–511.PubMedCrossRefGoogle Scholar
  4. 4.
    Musher DM, Alexandraki I, Graviss EA. Bacteremic and nonbacteremic pneumococcal pneumonia. A prospective study. Medicine (Baltimore) 2000; 79: 210–21.CrossRefGoogle Scholar
  5. 5.
    Hasley PB, Albaum MN, Li Y-H, et al. Do pulmonary radiographic findings at presentation predict mortality in patients with community-acquired pneumonia? Arch Intern Med 1996; 156: 2206–12.PubMedCrossRefGoogle Scholar
  6. 6.
    Fine MJ, Auble TE, Yealy DM, et al. A prediction rule to identify low-risk patients with community-acquired pneumonia. JAMA 1996; 275: 1341.CrossRefGoogle Scholar
  7. 7.
    Broaddus VC. Infections in the pleural space. An update on pathogenesis and management. Semin Respir Crit Card Med 1995; 16: 303–14.CrossRefGoogle Scholar
  8. 8.
    Light RW, MacGregor MI, Ball WC Jr. Diagnostic significance of pleural fluid pH and PCO2. Chest 1973; 64: 591–6.PubMedCrossRefGoogle Scholar
  9. 9.
    Andrews NC, Parker EF, Shaw RR, et al. Management of nontuberculous empyema. Am Rev Respir Dis 1962; 85: 935–6.Google Scholar
  10. 10.
    Wiener-Kronish JP, Sakuma T, Kudoh I. Alveolar epithelial injury and pleural empyema in acute P. aeruginosa pneumonia in anesthetized rabbits. J Appl Physiol 1993; 75: 1661–9.PubMedGoogle Scholar
  11. 11.
    Light RW. Pleural diseases, 4th ed. Philadelphia: Lippincott, Williams and Wilkins, 2001.Google Scholar
  12. 12.
    Colice GL, Curtis A, Deslauriers J. Medical and surgical treatment of parapneumonic effusions: An evidence-based guideline. Chest 2000; 118: 1158–71.PubMedCrossRefGoogle Scholar
  13. 13.
    Cheng D-S, Rodriguez RM, Rogers J. Comparison of pleural fluid pH values obtained using blood gas machine, pH meter, and pH indicator strip. Chest 1998; 114: 1368–72.PubMedCrossRefGoogle Scholar
  14. 14.
    Falguera M, Lopez A, Nogues A. Evaluation of the polymerase chain reaction method for detection of Streptococcus pneumoniae DNA in pleural fluid samples. Chest 2002; 122: 2212–6.PubMedCrossRefGoogle Scholar
  15. 15.
    Teixeira LR, Sasse SA, Villarino MA. Antibiotics levels in empyemic pleural fluid. Chest 2000; 117: 1734–9.PubMedCrossRefGoogle Scholar
  16. 16.
    Bartlett JG, Dowell SF, Mandell LA. Practice guidelines for the management of community-acquired pneumonia in adults. Infectious Diseases Society of America. Clin Infect Dis 2000; 31: 347–82.PubMedCrossRefGoogle Scholar
  17. 17.
    Bowditch HI. Paracentesis thoracic: An analysis of 25 cases of pleuritic effusion. Am Med Monthly 1853;pp 3–45.Google Scholar
  18. 18.
    Snider GL, Saleh SS. Empyema of the thorax in adults: review of 105 cases. Chest 1968; 54: 12–7.Google Scholar
  19. 19.
    Sasse S, Nguyen T, Teixeira LR. The utility of daily therapeutic thoracentesis for the treatment of early empyema. Chest 1999; 116: 1703–8.PubMedCrossRefGoogle Scholar
  20. 20.
    Storm HKR, Krasnik M, Bang K. Treatment of pleural empyema secondary to pneumonia: thoracocentesis regimen versus tube drainage. Thorax 1992; 47: 821–4.PubMedCrossRefGoogle Scholar
  21. 21.
    Simmers TA, Jie C, Sie B Minimally invasive treatment of thoracic empyema. Thorac Cardiovasc Surg 1999; 47: 77–81.PubMedCrossRefGoogle Scholar
  22. 22.
    Shankar S, Gulati M, Kang M Image-guided percutaneous drainage of thoracic empyema: Can sonography predict the outcome? Eur Radiol 2000; 10: 495–9.PubMedCrossRefGoogle Scholar
  23. 23.
    Ali I, Unruh H. Management of empyema thoracis. Ann Thorac Surg 1990; 50: 355–9.PubMedCrossRefGoogle Scholar
  24. 24.
    Ashbaugh DG. Empyema thoracis. Factors influencing morbidity and mortality. Chest 1991; 99: 1162–5.PubMedCrossRefGoogle Scholar
  25. 25.
    Tillett WS, Sherry S, Read CT. The use of streptokinase-streptodornase in the treatment of postpneumonic empyema. J Thorac Surg 1951; 21: 275–97.PubMedGoogle Scholar
  26. 26.
    Light RW, Nguyen T, Mulligan ME. The in vitro efficacy of varidase versus streptokinase or urokinase for liquefying thick purulent exudative material from loculated empyema. Lung 2000; 178: 13–8.PubMedCrossRefGoogle Scholar
  27. 27.
    Bergh NP, Ekroth R, Larsson S. Intrapleural streptokinase in the treatment of haemothorax and empyema. Scand J Thorac Cardiovasc Surg 1977; 11: 265–8.PubMedGoogle Scholar
  28. 28.
    Bouros D, Schiza S, Patsourakis G. Intrapleural streptokinase versus urokinase in the treatment of complicated parapneumonic effusions: A prospective, double-blind study. Am J Respir Crit Care Med 1997; 155: 291–5.PubMedGoogle Scholar
  29. 29.
    Jerjes-Sanchez C, Ramirez-Rivera A, Elizalde JJ, et al. Intrapleural fibrinolysis with streptokinase as an adjunctive treatment in heroothorax and empyema: A multicenter trial. Chest 1996; 109: 1514–9.PubMedCrossRefGoogle Scholar
  30. 30.
    Laisaar T, Puttsepp E, Laisaar V. Early administration of intrapleural streptokinase in the treatment of multiloculated pleural effusions and pleural empyemas. Thorac Cardiovasc Surg 1996; 44: 252–6.PubMedCrossRefGoogle Scholar
  31. 31.
    Ternes RT, Follis F, Kessler RM. Intrapleural fibrinolytics in management of empyema thoracis. Chest 1996; 110: 102–6.CrossRefGoogle Scholar
  32. 32.
    Moulton JS, Moore PT, Mencini RA. Treatment of loculated pleural effusions with transcatheter intracavitary urokinase. AJR 1989; 153: 941–5.PubMedGoogle Scholar
  33. 33.
    Laisaar T, Pullerits T. Effect of intrapleural streptokinase administration on antistreptokinase antibody level in patients with loculated pleural effusions. Chest 2003; 123: 432–5.PubMedCrossRefGoogle Scholar
  34. 34.
    Davies CW, Lok S, Davies RI. The systemic fibrinolytic activity of intrapleural streptokinase. Am J Respir Crit Care Med 1998; 157: 328–30.PubMedGoogle Scholar
  35. 35.
    Chin NK, Lim TK. Controlled trial of intrapleural streptokinase in the treatment of pleural empyema and complicated parapneumonic effusions. Chest 1997; 111: 275–9.PubMedCrossRefGoogle Scholar
  36. 36.
    Davies RJO, Traill ZC, Gleeson FV. Randomized controlled trial of intrapleural streptokinase in community acquired pleural infection. Thorax 1997; 52: 416–21.PubMedCrossRefGoogle Scholar
  37. 37.
    Bouros D, Schiza S, Tzanakis N. Intrapleural urokinase versus normal saline in the treatment of complicated parapneumonic effusions and empyema. A randomized, double-blind study. Am J Respir Crit Care Med 1999; 159: 37–42.Google Scholar
  38. 38.
    Tuncozgur B, Ustunsoy H, Sivrikoz MC. Intrapleural urokinase in the management of parapneumonic empyema: A randomized controlled trial. Int J Clin Pract 2001; 55: 65–860.Google Scholar
  39. 39.
    Lim TK, Chin NK Empirical treatment with fibrinolysis and early surgery reduces the duration of hospitalization in pleural sepsis. Eur Respir J 1999; 13: 514–8.PubMedCrossRefGoogle Scholar
  40. 40.
    Simpson G, Roomes D, Heron M. Effects of streptokinase and deoxyribonuclease on viscosity of human surgical and empyema pus. Chest 2000; 117: 1728–33.PubMedCrossRefGoogle Scholar
  41. 41.
    Silen ML, Naunheim KS. Thoracoscopic approach to the management of empyema thoracis. Indications and results. Chest Surg Clin N Am 1996; 6: 491–9.PubMedGoogle Scholar
  42. 42.
    Landreneau RI, Keenan RI, Hazelrigg SR. Thoracoscopy for empyema and hemothorax. Chest 1995; 109: 18–24.CrossRefGoogle Scholar
  43. 43.
    Cassina PC, Hauser M, Hillejan L. Video-assisted thoracoscopy in the treatment of pleural empyema: Stage-based management and outcome. J Thorac Cardiovasc Surg 1999; 117: 234–8.PubMedCrossRefGoogle Scholar
  44. 44.
    Lawrence DR, Ohri SK, Moxon RE. Thoracoscopic debridement of empyema thoracis. Ann Thorac Surg 1997; 64: 1448–50.PubMedCrossRefGoogle Scholar
  45. 45.
    Striffeler H, Gugger M, Im Hof V. Video-assisted thoracoscopic surgery for fibrinopurulent pleural empyema in 67 patients. Ann Thorac Surg 1998; 65: 319–23.PubMedCrossRefGoogle Scholar
  46. 46.
    Wait MA, Sharma S, Hohn J. A randomized trial of empyema therapy. Chest 1997; 111: 1548–51.PubMedCrossRefGoogle Scholar
  47. 47.
    Thurer RJ. Decortication in thoracic empyema. Indications and surgical technique. Chest Surg Clin N Am 1996; 6: 461–90.PubMedGoogle Scholar
  48. 48.
    Pothula V, Krellenstein DJ. Early aggressive surgical management of parapneumonic empyemas. Chest 1994; 105: 832–6.PubMedCrossRefGoogle Scholar
  49. 49.
    Angelillo Mackinlay TA, Lyons GA, Chimondeguy DJ. VATS debridement versus thoracotomy in the treatment of loculated postpneumonia empyema. Ann Thorac Surg 1996; 61: 1626–30.CrossRefGoogle Scholar
  50. 50.
    Neff CC, van Sonnenberg E, Lawson DW. CT follow-up of empyemas: pleural peels resolve after percutaneous catheter drainage. Radiology 1990; 176: 195–7.PubMedGoogle Scholar
  51. 51.
    Rzyman W, Skokowski J, Romanowicz G. Decortication in chronic pleural empyema—effect on lung function. Eur J Cardiothorac Surg 2002; 21: 502–7.PubMedCrossRefGoogle Scholar
  52. 52.
    Maruyama R, Ondo K, Mikami K. Clinical course and management of patients undergoing open window thoracostomy for thoracic empyema. Respiration 2001; 68: 60610.CrossRefGoogle Scholar
  53. 53.
    Deslauriers J, Jacques LF, Gregoire J. Role of Eloesser flap and thoracoplasty in the third millennium. Chest Surg Clin N Am 2002; 12: 605–23.PubMedCrossRefGoogle Scholar
  54. 54.
    Empyema Commission. Cases of empyema at Camp Lee, Virginia. JAMA 1918; 71: 36673.Google Scholar
  55. 55.
    Bartlett JG, Finegold SM. Anaerobic infections of the lung and pleural space. Am Rev Respir Dis 1974; 110: 56–77.PubMedGoogle Scholar
  56. 56.
    Cameron RJ. Management of complicated parapneumonic effusions and thoracic empyema. Intern Med J 2002; 32: 408–14.PubMedCrossRefGoogle Scholar
  57. 57.
    Waller DA, Rengarajan A. Thoracoscopic decortication: a role for video-assisted surgery in chronic postpneumonic pleural empyema. Ann Thorac Surg 2001; 71: 1813–6.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2004

Authors and Affiliations

  • Yubiao Guo
  • Richard W. Light

There are no affiliations available

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