Related Experiment Video
Updated: Jul 6, 2026
Point-of-Care Lung Ultrasound in Adults: Image Acquisition
Published on: March 3, 2023
Parapneumonic pleural effusion and empyema
Coenraad F N Koegelenberg1, Andreas H Diacon, Chris T Bolliger
1Division of Pulmonology, Department of Medicine, University of Stellenbosch and Tygerberg Academic Hospital, Cape Town, South Africa. coeniefn@sun.ac.za
Abstract:
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.
Insights
Many pneumonia patients develop pleural effusion, but few need intervention. Complicated effusions require drainage via tube thoracostomy, sometimes with controversial fibrinolytics or thoracoscopy, to manage pleural sepsis.
Area of Science:
- Pulmonology
- Thoracic Surgery
- Infectious Diseases
Background:
- Pleural effusion complicates at least 40% of pneumonia cases.
- A minority of patients with pneumonia-associated pleural effusion develop complicated parapneumonic effusion or empyema requiring intervention.
Purpose of the Study:
- To review current management strategies for parapneumonic effusion and empyema.
- To highlight recent developments and controversies in the treatment of pleural infections.
Main Methods:
- Review of medical literature on parapneumonic effusion and empyema management.
- Discussion of diagnostic criteria and treatment options including antibiotics, drainage, fibrinolytics, thoracoscopy, and surgery.
Main Results:
- Antibiotics are standard for all patients.
- Drainage via tube thoracostomy is indicated for empyema, large/loculated effusions, or parapneumonic effusions with specific biochemical or microbiological criteria.
- Fibrinolytics and thoracoscopy offer alternatives for complicated effusions, with choices dependent on local expertise and patient factors.
Conclusions:
- Management of complicated parapneumonic effusion and empyema requires timely drainage.
- The role of fibrinolytics and thoracoscopy is evolving, with decisions guided by clinical judgment and resource availability.
- Open surgery may be necessary for refractory cases or to address chest mechanics.
Related Concept Videos
01:28Pleural Effusion II: Symptoms and Management
A pleural effusion is the abnormal collection of fluid between the parietal and visceral pleura layers of tissue that form the lining of the lungs and chest cavity. It can occur independently or due to surrounding parenchymal diseases, such as infection, malignancy, or inflammatory conditions.
Clinical Manifestations:
01:25Pleural Effusion I: Introduction
There are two main types of pleural effusion: transudative and exudative. They are differentiated using Light's criteria,...
01:30Pleural Disorders: Types and Brief Description
01:13Pleura of the Lungs
01:29Pneumonia I: Introduction
01:30Pneumonia I: Introduction
Risk Factors
Various factors influence the likelihood of developing pneumonia. Age plays a crucial role, with infants, children under two, and individuals over 65 at increased risk due to their...