Management of Parapneumonic Pleural Effusion in Adults

Infective Pleural Effusions-A Comprehensive Narrative Review Article

Infective pleural effusions are mainly represented by parapneumonic effusions and empyema. These conditions are a spectrum of pleural diseases that are commonly encountered and carry significant mortality and morbidity rates reaching upwards of 50%. The causative etiology is usually an underlying bacterial pneumonia with the subsequent seeding of the infectious culprit and inflammatory agents to the pleural space leading to an inflammatory response and fibrin deposition. Radiographical evaluation through a CT scan or ultrasound yields high specificity and sensitivity, with features such as septations or pleural thickening indicating worse outcomes. Although microbiological yields from pleural studies are around 56% only, fluid analysis assists in both diagnosis and prognosis by evaluating pH, glucose, and other biomarkers such as lactate dehydrogenase. Management centers around antibiotic therapy for 2-6 weeks and the drainage of the infected pleural space when the effusion is complicated through tube thoracostomies or surgical intervention. Intrapleural enzymatic therapy, used to increase drainage, significantly decreases treatment failure rates, length of hospital stay, and surgical referrals but carries a risk of pleural hemorrhage. This comprehensive review article aims to define and delineate the progression of parapneumonic effusions and empyema as well as discuss pathophysiology, diagnostic, and treatment modalities with aims of broadening the generalist's understanding of such complex disease by reviewing the most recent and relevant high-quality evidence.

Comparison of central venous catheter thoracic drainage and traditional closed thoracic drainage following minimally invasive surgery for esophageal carcinoma: a retrospective analysis

OBJECTIVE

To compare the effectiveness and safety of central venous catheter thoracic drainage (CVCTD) with traditional closed thoracic drainage (TCTD) after minimally invasive surgery for esophageal cancer.

METHODS

We conducted a retrospective investigation of 103 patients who underwent minimally invasive esophageal cancer surgery at our institution between January 2017 and December 2019. Among them, 44 patients underwent CVCTD, while 59 received TCTD. We compared the following outcomes between the two cohorts: drainage volume, duration of drainage, postoperative complications (including pleural effusion, pulmonary infection, atelectasis, anastomotic leakage, etc.), length of hospital stay, and postoperative pain assessment.

RESULTS

No significant differences were observed between the experimental and control groups regarding postoperative thoracic drainage, the timing of postoperative tube removal, or postoperative complications. However, significant disparities were noted in the duration of postoperative hospitalization, drainage tube healing time, and pain threshold among the esophageal cancer patients in both cohorts (p < 0.05).

CONCLUSION

CVCTD is a secure and potent alternative to TCTD following minimally invasive surgery for esophageal carcinoma. It potentially contributes to reducing the incidence of postoperative complications while curtailing the duration of hospitalization. Additional research is warranted to substantiate these findings.

Analysis of clinical characteristics and risk factors of community-acquired pneumonia complicated by parapneumonic pleural effusion in elderly patients

BACKGROUND

Community-acquired pneumonia (CAP) patients usually present with parapneumonic pleural effusion (PPE), which complicates the treatment of pneumonia. This study aims to investigate the clinical characteristics and risk factors of elderly CAP patients hospitalised with PPE.

METHODS

The clinical data of 132 elderly patients with CAP were retrospectively analysed. A total of 54 patients with PPE (PPE group) and 78 patients without PPE (NPPE group) were included in this study. Clinical data, laboratory examinations, treatments and other relevant indicators were collected. Univariate analysis and multivariate logistic regression analysis will be used to explore the possible risk factors for PPE.

RESULTS

The proportion of PPE in elderly patients with CAP was 40.9%. PPE patients were significantly more likely to be older, have comorbid neurological diseases, experience chest tightness, and have a lasting fever (P < 0.05). In contrast to NPPE patients, the total number of lymphocytes, serum albumin and blood sodium levels in the PPE group were significantly lower (P < 0.05). The blood D-dimer, C-reactive protein and CURB-65 score of PPE patients were significantly higher (P < 0.05) than those of NPPE patients. Multivariate logistic regression identified chest tightness (OR = 3.964, 95% CI: 1.254-12.537, P = 0.019), long duration of fever (OR = 1.108, 95%CI: 1.009-1.217, P = 0.03), low serum albumin (OR = 0.876, 95%CI: 0.790- 0.971, P = 0.012) or low blood sodium (OR = 0.896, 95%CI: 0.828-0.969, P = 0.006) as independently associated with the development of parapneumonic pleural effusion in the elderly.

CONCLUSION

This study has identified several clinical factors, such as chest tightness, long duration of fever, low serum albumin, and low blood sodium, as risk factors for the development of pleural effusion in elderly patients with CAP. Early identification and prompt management of these patients can prevent inappropriate treatment and reduce morbidity and mortality.

Targeting the PAI-1 Mechanism with a Small Peptide Increases the Efficacy of Alteplase in a Rabbit Model of Chronic Empyema

The incidence of empyema is increasing and associated with a mortality rate of 20% in patients older than 65 years. Since 30% of patients with advanced empyema have contraindications to surgical treatment, novel, low-dose, pharmacological treatments are needed. A Streptococcus pneumoniae-induced rabbit model of chronic empyema recapitulates the progression, loculation, fibrotic repair, and pleural thickening of human disease. Treatment with single chain (sc) urokinase (scuPA) or tissue type (sctPA) plasminogen activators in doses 1.0-4.0 mg/kg were only partially effective in this model. Docking Site Peptide (DSP; 8.0 mg/kg), which decreased the dose of sctPA for successful fibrinolytic therapy in acute empyema model did not improve efficacy in combination with 2.0 mg/kg scuPA or sctPA. However, a two-fold increase in either sctPA or DSP (4.0 and 8.0 mg/kg or 2.0 and 16.0 mg/kg sctPA and DSP, respectively) resulted in 100% effective outcome. Thus, DSP-based Plasminogen Activator Inhibitor 1-Targeted Fibrinolytic Therapy (PAI-1-TFT) of chronic infectious pleural injury in rabbits increases the efficacy of alteplase rendering ineffective doses of sctPA effective. PAI-1-TFT represents a novel, well-tolerated treatment of empyema that is amenable to clinical introduction. The chronic empyema model recapitulates increased resistance of advanced human empyema to fibrinolytic therapy, thus allowing for studies of muti-injection treatments.

Significance of pleural effusion detected by metagenomic next-generation sequencing in the diagnosis of aspiration pneumonia

Objective

Using metagenomic next-generation sequencing (mNGS) to profile the bacterial pathogen of pleural infection in aspiration pneumonia for therapeutic decision-making.

Methods

Collection and analysis of the clinical and laboratory data of aspiration pneumonia patients who underwent mNGS detection of pleural effusion at the Second Hospital of Jilin University from November 2020 and March 2022.

Results

Nine males and one female were included, aged 33 to 69 years. All patients had chest pain, fever, cough, and hypoxemia symptoms; 90% had expectoration. The laboratory tests revealed that all patients had elevated white blood cell, neutrophil, and C-reactive protein (CRP) levels. Furthermore, erythrocyte sedimentation rate (ESR) increased in 8 patients, and procalcitonin increased in only one patient. Chest CT indicated different degrees of lobar pneumonia and pleural effusion in all patients, and biochemical results implied exudative effusion according to Light criteria. Most routine culture results were negative. Among bacteria identified by mNGS, Fusobacterium nucleatum (n=9) was the most common, followed by Parvimonas micra (n=7) and Filifactor alocis (n=6). Three patients underwent surgical treatment after applying targeted antibiotics, thoracic puncture and drainage, and fibrinolytic septum treatment. After the adjusted treatment, the number of white blood cells, neutrophils, and lymphocytes decreased significantly, indicating the eradication of the infection.

Conclusions

Improving the vigilance of atypical people suffering from aspiration pneumonia is essential. The mNGS detection of pleural effusion clarified the microbial spectrum of aspiration pneumonia, allowing targeted antibiotic administration.

Analysis of antibiotic use and clinical outcomes in adults with known and suspected pleural empyema

Background

There is not a prevailing consensus on appropriate antibiotic choice, route, and duration in the treatment of bacterial pleural empyema after appropriate source control. Professional society guidelines note the lack of comparative trials with which to guide recommendations. We assessed clinical outcomes in the treatment of known and suspected empyema based upon three aspects of antibiotic use: (1) total duration, (2) duration of intravenous (IV) antibiotics, and (3) duration of anti-anaerobic antibiotics.

Methods

We performed a hypothesis-generating retrospective chart review analysis of 355 adult inpatients who had pleural drainage, via either chest tube or surgical intervention, for known or suspected empyema. The primary outcome variable was clinician assessment of resolution or lack thereof. The secondary outcomes were death within 90 days, hospital readmission within 30 days for empyema, and all-cause hospital readmission within 30 days. Mann-Whitney U test was used to compare outcomes with regard to these variables.

Results

None of the independent variables was significantly associated with a difference in clinical resolution rate despite trends for total antibiotic duration and anti-anaerobic antibiotic duration. None of the independent variables was associated with mortality. Longer total antibiotic duration was associated with lower readmission rate for empyema (median 17 [interquartile range 11–28] antibiotic days in non-readmission group vs. 13 [6-15] days in readmission group), with a non-significant trend for all-cause readmission rate (17 [11–28] days vs. 14 [9–21] days). IV antibiotic duration was not associated with a difference in any of the defined outcomes. Longer duration of anti-anaerobic antibiotics was associated with both lower all-cause readmission (8.5 [0–17] vs. 2 [0–11]) and lower readmission rate for empyema (8 [0–17] vs. 2 [0–3]).

Conclusion

Our data support the premise that routine use of anti-anaerobic antibiotics is indicated in the treatment of pleural empyema. However, our study casts doubt on the benefits of extended IV rather than oral antibiotics in the treatment of empyema. This represents a target for future investigation that could potentially limit complications associated with the excessive use of IV antibiotics.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-022-07759-8.

Predictors of outcome of chest tube drainage of non-purulent exudative pleural effusions

Background

Although chest tube drainage is the primary management method for many pleural effusions, it has a failure rate of 9.4–48%. In this study, we examined the factors that predict the outcome of management of nonpurulent exudative effusions. The aim of this study was to determine the predictors of outcomes of chest tube drainage of pleural effusions.

Methodology

Consecutive patients who had a chest tube drainage of nonpurulent exudative pleural effusions were followed up in a prospective observational cohort study until extubation and discharge. Data on the management of the patients were recorded, analysed and compared between groups of patients with good and poor outcomes.

Results

Of the 52 patients studied, 38 had good outcomes, while 14 had poor outcomes. The mean±sd age was 39.7±15.9 years. Multivariate analysis demonstrated that empyema thoracis complicating drainage was an independent predictor of a poor outcome, while the duration of drainage ≤14 days and duration of illness before presentation <30 days were predictive of a good outcome.

Conclusion

Our results show that the development of empyema thoracis during drainage, a long duration of drainage and a prolonged period of illness before presentation are predictive of the outcome of chest tube drainage.

This study of predictors of outcome of chest drainage of nonpurulent pleural effusions found that the development of empyema, a prolonged duration of drainage and a prolonged duration of illness are predictive of a poor outcome of drainagehttps://bit.ly/3tpK39Y

Uncertainty-guided graph attention network for parapneumonic effusion diagnosis

Parapneumonic effusion (PPE) is a common condition that causes death in patients hospitalized with pneumonia. Rapid distinction of complicated PPE (CPPE) from uncomplicated PPE (UPPE) in Computed Tomography (CT) scans is of great importance for the management and medical treatment of PPE. However, UPPE and CPPE display similar appearances in CT scans, and it is challenging to distinguish CPPE from UPPE via a single 2D CT image, whether attempted by a human expert, or by any of the existing disease classification approaches. 3D convolutional neural networks (CNNs) can utilize the entire 3D volume for classification: however, they typically suffer from the intrinsic defect of over-fitting. Therefore, it is important to develop a method that not only overcomes the heavy memory and computational requirements of 3D CNNs, but also leverages the 3D information. In this paper, we propose an uncertainty-guided graph attention network (UG-GAT) that can automatically extract and integrate information from all CT slices in a 3D volume for classification into UPPE, CPPE, and normal control cases. Specifically, we frame the distinction of different cases as a graph classification problem. Each individual is represented as a directed graph with a topological structure, where vertices represent the image features of slices, and edges encode the spatial relationship between them. To estimate the contribution of each slice, we first extract the slice representations with uncertainty, using a Bayesian CNN: we then make use of the uncertainty information to weight each slice during the graph prediction phase in order to enable more reliable decision-making. We construct a dataset consisting of 302 chest CT volumetric data from different subjects (99 UPPE, 99 CPPE and 104 normal control cases) in this study, and to the best of our knowledge, this is the first attempt to classify UPPE, CPPE and normal cases using a deep learning method. Extensive experiments show that our approach is lightweight in demands, and outperforms accepted state-of-the-art methods by a large margin. Code is available at https://github.com/iMED-Lab/UG-GAT.

Comparison of clinical manifestation among Australian Indigenous and non- Indigenous patients presenting with pleural effusion

BACKGROUND

There is sparse evidence in the literature in relation to the nature and causes of pleural effusion among Australian Indigenous population.

METHODS

In this retrospective study, Indigenous and non-Indigenous adults diagnosed to have pleural effusion over a two-year study period were included for comparative analysis.

RESULTS

Of the 314 patients, 205 (65%) were non-Indigenous and 52% were males. In comparison to non-Indigenous, the Indigenous patients were younger (50 years (IQR 39,60) vs 63 years (IQR 52,72), p<0.001), females (61% vs 41%, p=0.001), have higher prevalence of renal and cardiovascular disease and tend to have exudative effusion (93% vs 76%, p=0.032). Infections was judged to be the most common cause for effusion in both groups, more so among the Indigenous cohort. Effusion secondary to renal disease was higher (13% vs 1%, p<0.001) among Indigenous Australians, in contrast malignant effusions were higher (13% vs 4%, p=0.004) among non-Indigenous. Length of hospital stay was longer for Indigenous patients (p=0.001), and a greater proportion received renal dialysis (13% vs 1%, p<0.001). Intensive care unit (ICU) admissions rates were higher with infective etiology of pleural effusion (82% vs. 53% Indigenous & 44% vs. 39% non-Indigenous respectively). Re-presentations to hospital were higher among Indigenous patients (46% vs 33%, p=0.046) and were associated with renal and cardiac disease and malignancy in non-Indigenous.

CONCLUSION

There are significant differences in the way pleural effusion manifests among Australian Indigenous patients. Understanding these differences may facilitate approaches to the management and to implement strategies to reduce morbidity and mortality in this population. This article is protected by copyright. All rights reserved.

Medical Thoracoscopy for the Management of Exudative Pleural Effusion: A Retrospective Study

Objective

The aim of this study was to evaluate the efficacy of medical thoracoscopy in the diagnosis and treatment of exudative pleural effusion.

Methods

A total of 82 patients with exudative pleural effusion underwent medical thoracoscopy under local anesthesia and mild sedation. The clinical characteristics, pleural fluid routine and biochemical tests, pleural biopsy, and outcomes were retrospectively evaluated.

Results

Among 82 patients, the color and transparency of pleural fluid and the levels of white blood cells (WBC), lactate dehydrogenase (LDH), neutrophil proportion, lymphocyte proportion, adenosine deaminase (ADA), and glucose were different among tuberculosis (TB), malignant (M), acute and chronic inflammation (ACI), and purulent (P) cases. Furthermore, 70% of M cases had a low positive rate of exfoliated cells in the sputum and pleural fluid, and more than 90% of TB cases had low positive rates of anti-tuberculosis antibodies and acid-fast bacilli in the sputum and pleural fluid. Pleural biopsy showed that 11% of cases were M, 74.4% were TB, 11% were ACI, and 3.6% were P. Medical thoracoscopy showed that 66.7% of ACI cases had pleural adhesions, 34.4% of TB cases had moderate and 34.4% of TB cases had severe pleural adhesions, 100% of M and TB cases had pleural surface nodules and 77.8% of ACI cases had pleural surface nodules, 49.2% of TB cases showed encapsulated pleural effusion, and 33.3% of M cases showed encapsulated pleural effusion.

Conclusion

Medical thoracoscopy has high feasibility and accuracy in the diagnosis and treatment of exudative pleural effusion.

Diagnostic Value of C-Reactive Protein in Discrimination between Uncomplicated and Complicated Parapneumonic Effusion

Objectives: The role of serum C-reactive protein (CRPs) and pleural fluid CRP (CRPpf) in discriminating uncomplicated parapneumonic effusion (UCPPE) from complicated parapneumonic effusion (CPPE) is yet to be validated since most of the previous studies were on small cohorts and with variable results. The role of CRPs and CRPpf gradient (CRPg) and of their ratio (CRPr) in this discrimination has not been previously reported. The study aims to assess the diagnostic efficacy of CRPs, CRPpf, CRPr, and CRPg in discriminating UCPPE from CPPE in a relatively large cohort. Methods: The study population included 146 patients with PPE, 86 with UCPPE and 60 with CPPE. Levels of CRPs and CRPpf were measured, and the CRPg and CRPr were calculated. The values are presented as mean ± SD. Results: Mean levels of CRPs, CRPpf, CRPg, and CRPr of the UCPPE group were 145.3 ± 67.6 mg/L, 58.5 ± 38.5 mg/L, 86.8 ± 37.3 mg/L, and 0.39 ± 0.11, respectively, and for the CPPE group were 302.2 ± 75.6 mg/L, 112 ± 65 mg/L, 188.3 ± 62.3 mg/L, and 0.36 ± 0.19, respectively. Levels of CRPs, CRPpf, and CRPg were significantly higher in the CPPE than in the UCPPE group (p < 0.0001). No significant difference was found between the two groups for levels of CRPr (p = 0.26). The best cut-off value calculated by the receiver operating characteristic (ROC) analysis for discriminating UCPPE from CPPE was for CRPs, 211.5 mg/L with area under the curve (AUC) = 94% and p < 0.0001, for CRPpf, 90.5 mg/L with AUC = 76.3% and p < 0.0001, and for CRPg, 142 mg/L with AUC = 91% and p < 0.0001. Conclusions: CRPs, CRPpf, and CRPg are strong markers for discrimination between UCPPE and CPPE, while CRPr has no role in this discrimination.

Performance of procalcitonin in diagnosing parapneumonic pleural effusions: A clinical study and meta-analysis

BACKGROUND

Parapneumonic pleural effusion (PPE) is a common complication of pneumonia. The accurate diagnosis of PPE remains a challenge. Recent studies suggest that procalcitonin (PCT) emerges as a potential biomarker for PPE. Our study aimed to determine the diagnostic value of PCT for PPE by a clinical study and summarize the overall diagnostic performance of PCT through a meta-analysis.

METHODS

Demographic and clinical data of the patients with PPE and controls were collected in our clinical study. The diagnostic performances of serum PCT (s-PCT) were analyzed via receiver operating characteristic (ROC) curve analysis, using area under the curve (AUC) as a measure of accuracy. Literature databases were systematically searched for the studies examining the accuracy of PCT for diagnosing PPE. Data on sensitivity, specificity, positive/negative likelihood ratio (PLR/NLR), and diagnostic odds ratio (DOR) were pooled. Summary ROC curves and AUC were used to evaluate overall test performance.

RESULTS

In our clinical study, 47 patients with PPE and 101 controls were included. The s-PCT levels were significantly increased in the setting of PPE (5.44 ± 9.82 ng/mL) compared with malignant PE (0.15 ± 0.19 ng/mL), tuberculous PE (0.18 ± 0.16 ng/mL), and transudates (0.09 ± 0.03 ng/mL) (P < .001). Using a cutoff value of 0.195 ng/mL, the sensitivity and specificity of s-PCT in diagnosing PPE were 0.83 and 0.80, respectively, and AUC was 0.89. In addition, 11 studies were included in our meta-analysis. Summary performance estimates for s-PCT in diagnosing PPE were as follows: sensitivity, 0.78 (95% CI: 0.71-0.84); specificity, 0.74 (95% CI: 0.69-0.78); PLR, 3.46 (95% CI: 2.09-5.74); NLR, 0.27 (95% CI: 0.14-0.54); DOR, 12.37 (95% CI: 4.34-41.17); and AUC, 0.84. The corresponding estimates for p-PCT were as follows: sensitivity, 0.62 (95% CI: 0.57-0.67); specificity, 0.71 (95% CI: 0.68-0.75); PLR 2.31 (95% CI: 1.81-2.95); NLR, 0.47 (95% CI: 0.35-0.63); DOR, 5.48 (95% CI: 3.07-9.77); and AUC, 0.80.

CONCLUSION

Both s-PCT and p-PCT might have modest performance in diagnosing PPE. However, more studies on a large scale should be performed to confirm our findings.

A review of the management of complex para-pneumonic effusion in adults

A complex para-pneumonic effusion is a descriptive term for exudative effusions, which complicate or are likely to complicate the anatomy of the pleural space after pneumonia. We performed an online search was performed using the resources PubMed and Google Scholar to provide an update on the management of such effusions based on review of published literature. Search terms including pleural effusion (PE), parapneumonic effusion, and empyema were used. Relevant studies were identified and original articles were studied, compared and summarized. References in these articles were examined for relevance and included where appropriate. Studies involving pediatric patients were excluded. Management of para-pneumonic PE has changed tremendously over the last decade. As we accumulate more evidence in this area, approach to pleural fluid drainage is becoming more specific and guideline based. An example of a practice changing study in this aspect is the Multi-center Intrapleural Streptokinase Trial (MIST) 2 trial which demonstrated that a combination of intra-pleural tPA and DNAse improved outcomes in pleural infections compared to DNase or t-PA alone. More randomized control trials are needed to describe the role of surgical techniques like VATS (video-assisted thoracoscopic surgery) when MIST 2 protocol fails; this combination has revolutionized the management of empyema in recently.

Factors associated with recurrent bacterial empyema thoracis

BACKGROUND

Empyema thoracis (ET) is one of the common thoracic diseases frequently found in developing countries. In the past, only a few studies have analyzed recurrent ET, and none had clearly identified the prognostic factors for recurrence. The aim of this study is to identify the prognostic factors of recurrent ET in Northern Thailand.

METHODS

A retrospective cohort study was conducted. All patients diagnosed with Stage II and III ET at Maharaj Nakorn Chiang Mai Hospital (a tertiary-care hospital in northern Thailand) between January 1, 2007 and November 31, 2012 were enrolled in this study. All clinical data were extracted from the medical recording system. The primary outcome was recurrent disease. Multivariable Cox's proportion hazard model was used to identify the independent prognostic factors for recurrence.

RESULTS

There were 382 patients enrolled in this study, and 34 patients (8.9%) had recurrent disease. The most common gram-positive and gram-negative pathogens found were Staphylococcus aureus and Acinetobacter baumannii, respectively. Three independent prognostic factors for recurrent disease were nonsepsis status prior to the surgery [hazard ratio (HR) = 12.3; 95% confidence interval (CI), 4.25-35.43], nonperforming decortication (HR = 5.4; 95% CI, 1.82-15.92), and persistent pleural spaces (HR = 4.1; 95% CI, 1.93-8.68).

CONCLUSIONS

Clinical characteristics, surgical procedure, and persistent pleural spaces were independent prognostic factors for ET recurrence in this study. Decortication and early thoracoplasty in patients who had persistent pleural space should be considered. Large cohort studies are warranted to support these findings.

Efficacy of ultrasound-guided thoracentesis catheter drainage for pleural effusion

The factors influencing the efficacy of ultrasound-guided thoracentesis catheter drainage were investigated in the present study. A retrospective analysis of clinical data from 435 patients who presented with a pleural effusion was performed. Patients were divided into a control group and an intervention group. Thirty-seven patients in the control group were given standard care using pleural puncture to draw the excess fluid. The 398 patients in the intervention group were treated using ultrasound-guided thoracentesis catheter drainage. The rate of successful drainage of a pleural effusion was significantly higher (P<0.05), while the rate of complication was lower, in the ultrasound-guided thoracentesis cases compared to standard care treatment. In conclusion, ultrasound-guided thoracentesis catheter drainage is an efficient, safe and minimally invasive procedure to alleviate pleural effusion. The efficacy of the procedure is related to the separation of pleural effusion, drainage tube type and tube diameter.