Parapneumonic Pleural Effusion and Empyema

At least 40% of all patients with pneumonia will have an associated pleural effusion, although a minority will require an intervention for a complicated parapneumonic effusion or empyema. All patients require medical management with antibiotics. Empyema and large or loculated effusions need to be formally drained, as well as parapneumonic effusions with a pH <7.20, glucose <3.4 mmol/l (60 mg/dl) or positive microbial stain and/or culture. Drainage is most frequently achieved with tube thoracostomy. The use of fibrinolytics remains controversial, although evidence suggests a role for the early use in complicated, loculated parapneumonic effusions and empyema, particularly in poor surgical candidates and in centres with inadequate surgical facilities. Early thoracoscopy is an alternative to thrombolytics, although its role is even less well defined than fibrinolytics. Local expertise and availability are likely to dictate the initial choice between tube thoracostomy (with or without fibrinolytics) and thoracoscopy. Open surgical intervention is sometimes required to control pleural sepsis or to restore chest mechanics. This review gives an overview of parapneumonic effusion and empyema, focusing on recent developments and controversies.