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Pleural Effusions at First ED Encounter Predict Worse Clinical Outcomes in Patients With Pneumonia
Nathan C Dean1, Paula P Griffith2, Jeffrey S Sorensen3
1Division of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, UT; Department of Medicine, University of Utah School of Medicine, Salt Lake City, UT.
Insights
Pneumonia patients with pleural effusions in the emergency department face worse outcomes, including higher mortality and longer hospital stays. Further research is needed to understand why and to explore tailored management strategies.
Area of Science:
- Emergency Medicine
- Pulmonology
- Critical Care
Background:
- Pleural effusions complicate 15-44% of pneumonia hospitalizations.
- The impact of effusions on emergency department (ED) presentation outcomes is unclear.
Purpose of the Study:
- To investigate if pleural effusions at ED presentation influence patient outcomes.
- To determine if patients with pneumonia and effusions require different management.
Main Methods:
- Retrospective study of adult ED patients with pneumonia or related conditions.
- Pleural effusions identified via radiographic imaging.
- Analysis of patient demographics, comorbidities, and clinical outcomes.
Main Results:
- 14.5% of pneumonia patients presented with pleural effusions.
- Effusions were associated with higher comorbidity scores, BNP, bilirubin, and age.
- The CURB-65 score underestimated mortality in patients with effusions.
- Patients with effusions had higher admission rates, longer hospital stays, and increased 30-day mortality.
Conclusions:
- Pleural effusions at ED presentation are linked to adverse outcomes in pneumonia patients.
- The reasons for these adverse outcomes require urgent investigation.
- Optimal management strategies for pneumonia with pleural effusions need further study.
Background:
Pleural effusions are present in 15% to 44% of hospitalized patients with pneumonia. It is unknown whether effusions at first presentation to the ED influence outcomes or should be managed differently.
Methods:
We studied patients in seven hospital EDs with International Statistical Classification of Disease and Health Related Problems-Version 9 codes for pneumonia, or empyema, sepsis, or respiratory failure with secondary pneumonia. Patients with no confirmatory findings on chest imaging were excluded. Pleural effusions were identified with the use of radiographic imaging.
Results:
Over 24 months, 4,771 of 458,837 adult ED patients fulfilled entry criteria. Among the 690 (14.5%) patients with pleural effusions, their median age was 68 years, and 46% were male. Patients with higher Elixhauser comorbidity scores (OR, 1.13 [95% CI, 1.09-1.18]; P < .001), brain natriuretic peptide levels (OR, 1.20 [95% CI, 1.12-1.28]; P < .001), bilirubin levels (OR, 1.07 [95% CI, 1.00-1.15]; P = .04), and age (OR, 1.15 [95% CI, 1.09-1.21]; P < .001) were more likely to have parapneumonic effusions. In patients without effusion, electronic version of CURB-65 (confusion, uremia, respiratory rate, BP, age ≥ 65 years accurately predicted mortality (4.7% predicted vs 5.0% actual). However, eCURB underestimated mortality in those with effusions (predicted 7.0% vs actual 14.0%; P < .001). Patients with effusions were more likely to be admitted (77% vs 57%; P < .001) and had a longer hospital stay (median, 2.8 vs 1.3 days; P < .001). After severity adjustment, the likelihood of 30-day mortality was greater among patients with effusions (OR, 2.6 [CI, 2.0-3.5]; P < .001), and hospital stay was disproportionately longer (coefficient, 0.22 [CI, 0.14-0.29]; P < .001).
Conclusions:
Patients with pneumonia and pleural effusions at ED presentation in this study were more likely to die, be admitted, and had longer hospital stays. Why parapneumonic effusions are associated with adverse outcomes, and whether different management of these patients might improve outcome, needs urgent investigation.
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