• Exudative, predominantly neutrophilic effusions reflecting
increasing passage of interstitial fluid as a result of
inflammation associated with pneumonia.
• cloudy or even clear, without any organisms noted on
Gram stain or culture.
• They resolve with appropriate antibiotic treatment of the
Complicated Parapneumonic effusions
• Bacterial invasion into the pleural space
• Increased number of neutrophils, decreased glucose
levels, pleural fluid acidosis, and an elevated lactic
• Often are sterile.
• Classified as complicated because it requires drainage
• Frank pus accumulates in the pleural space
• Bacterial, viral,Atypical
• Aerobic gram-positive –S pneumoniae
Staphylococcus aureus , streptococcus milleri
• Aerobic gram-negative
coli, and Haemophilus
• Anaerobic -Bacteroides and Peptostreptococcus
• Patients with pneumonia due to Legionella species
• The pleural fluid originates in the interstitial spaces of the
lung and in the capillaries of the visceral pleura because
of increased permeability.
• Sterile pleural fluid
• Low WBC count and LDH level
• Glucose and pH levels are normal
• Resolve with antibiotic therapy, and chest tube insertion
is not required.
• 2-5 days from the onset of pneumonia.
• Bacterial invasion of the pleural space
• Accumulation of neutrophils, bacteria, and cellular
• A tendency toward loculation and septation
• pleural fluid pH (< 7.20) and glucose levels are lower (<
60 mg/dL), and the LDH level increases.
• Bacteriological stains or cultures of the pleural fluid can
be positive for microorganisms.
• 5-10 days after pneumonia onset.
• Fibroblasts grow into the exudates from both the visceral
and parietal pleural surfaces and forms inelastic
membrane called pleural peel.
• Pleural fluid is thick.
• In an untreated patient, pleural fluid may drain
spontaneously through the chest wall (empyema
• Take 2-3 weeks to develop.
Risk factors for Empyema thoracis
• Age -children and elderly persons
• Rheumatoid arthritis
• Gastroesophageal reflux disease
• Intravenous drug abuse
• Depend on aerobic or anaerobic infection.
• Aerobic infections are more acute in onset
• Anaerobic infections can be indolent
• Patients present with an acute febrile illness with chest
pain, cough with sputum production, and dyspnoea.
• A complicated parapneumonic effusion is suggested by
the presence of a fever lasting more than 48 hours after
the initiation of antibiotic therapy.
Anaerobic bacterial infection
• Usually subacute illness.
• Most have symptoms for more than 7 days
• a/i Poor oral hygiene,alcoholism, and factors predispose
to recurrent aspiration.
• Febrile with Tachypnea and tachycardia
• Decreased tactile fremitus and VR
• Dullness to percussion
• Decreased or absent breath sounds
• Tracheal shift possible with large effusions
• In areas in which pneumonia and lung consolidation are
adjacent and more extensive than pleural fluid-crackles
,bronchial breath sounds ,egophony.
• BLOOD-leukocytosis may be present (>12,000/µL
• Sputum for Gram stain &culture.
• PA , Lateral and Decubitus view
Chest radiograph of a 63-year-old woman with
left lower lobe pneumonitis
The patient developed a large leftsided
pleural effusion despite 5 days of oral antibiotic therapy
• Localize fluid for a thoracentesis
• Distinguish loculated pleural fluid from an infiltrate.
Sonographic study of the pleural space showed marked
septation throughout the fluid collection
• Pleural enhancement can be seen in patients with active
• “split pleura sign”
• Distinguish pleural from parenchymal abnormalities
• Determine the precise location and extent
• Detect loculations
• Find airway and parenchymal abnormalities that may be
relevant to the etiology of the pleural infection.
• When parapneumonic pleural effusion is greater than or
equal to 10 mm thick on a lateral decubitus chest
• Appearance -clear yellow liquid to an opaque turbid fluid
to grossly purulent thick, viscous, foul-smelling
• WBC count
• Total protein
Complicated pleural effusion or
• LDH value of greater than 1000 U/L
• Glucose level of less than 40 mg/d
• pH of less than 7.20.
Category 1 (parapneumonic effusion)
• Minimal free-flowing fluid, smaller than 10 mm on
• Culture, Gram stain, and pH unknown
• No thoracentesis needed; treatment with antibiotics
(uncomplicated parapneumonic effusion)
• Larger than 10 mm fluid and less than half the
hemithorax on decubitus films
• Gram stain and culture negative
• pH higher than 7.20
• Treatment with antibiotics alone
(complicated parapneumonic effusion)
• Large free-flowing effusion, more than half the
• pH lower than 7.20, LDH level greater than 1000 U/L and
glucose level less than 40 mg/dL
• Gram stain or culture positive
• Treatment with tube thoracostomy and antibiotics
• Multiloculated effusions may require multiple tubes
• Thrombolytics may help resolution
Category 4 (empyema)
• Large free-flowing effusion, greater than equal to half the
• Loculated effusion or effusion with thickened pleura
• Gross pus on aspiration
• Treatment with tube thoracostomy
• Thrombolytics may help resolution
• May require decortication
• selection of an appropriate antibiotic
• Assessment of need for drainage of pleural fluid
• Community-acquired pneumonia : second- or third-
generation cephalosporins in addition to a macrolide.
• severe community-acquired pneumonia-initiate treatment
with a macrolide plus a third-generation cephalosporin
with antipseudomonal activity.
• If aspiration is evident or suspected, oral anaerobes
should also be covered.
• In the absence of a positive gram stain, coverage
for Legionella species and Chlamydia pneumoniae
should be added
• For nosocomial infections, broader antibiotic coverage
for gram-negative organisms is recommended
Duration of antibiotic therapy
• antibiotics are continued until:
• (1) the patient is afebrile and the white blood cell count is
• (2) the tube thoracostomy drainage yields less than 50
ml of fluid daily
• (3) the radiograph shows considerable clearing.
• Typically, 3 to 6 weeks of antibiotic therapy is required to
• achieve these results.
Pleural space drainage.
• If the diagnostic thoracentesis yields thick pus(
empyema thoracis ) definitive pleural drainage is
• If the pleural fluid is not thick pus, then results of pleural
fluid Gram stain or culture, pleural fluid pH and glucose
levels, and the presence or absence of pleural fluid
loculations should guide the course of action
Indications for drainage
• Prolonged pneumonia symptoms, co morbid disease
• Failure to respond to antibiotic therapy
• Presence of anaerobic organisms
• Chest radiograph –Effusion involving >50% of the
hemothorax , loculation, and an air-fluid level.
• Aspiration of pus, a putrid odor associated with an
anaerobic infection, a positive Gram stain or culture
result, pH <7.20, a glucose level <40 mg/dL, and an LDH
level >1000 IU/L
• USG-Stranding or septation
• CT-marked pleural enhancement, pleural thickening, and
the split pleura sign
Pleural space drainage
• Repeated thoracentesis
• Use of a standard chest tube
• An image-guided insertion of a small-bore catheter.
Intrapleural thrombolytic agents
• Most effective in the early fibrinolytic stage
• streptokinase,streptodornase,urokinase, and tPA
• occluded small-bore catheter,
• multiloculated pleural space
• as a trial before committing the patient to surgery.
• Video-assisted thoracic surgery (VATS),
• Standard thoracotomy
• Open drainage
• When Tube thoracostomy has been ineffective in
controlling the pleural infection.
• Empyema that has been present for several days to
weeks and that has multiple loculations
• Patients with impaired pulmonary function and
debilitation can be treated effectively with VATS
• Recommended for persistent pleural sepsis and failure
of less invasive procedures
• When VATS cannot adequately access the pleural space
• optimal method for successful debridement and
• Decortication (i.e., stripping of the visceral pleural peel)
can be performed early to control pleural sepsis and late
(3–6 months after the onset of empyema or CPPE) to
treat a symptomatic, restrictive ventilatory defect.
• Patients with empyema enter a catabolic state ; hence
,good nutrition is vital
• The outcome of a PPE depends on the point in the
clinical course when the patient presents to the
physician, co morbidities, and efficient clinical
• Early antibiotic therapy prevents the development of a
PPE and progression to a CPPE and empyema.