From Chest Wall Resection to Medical Management: The Continued Saga of Parapneumonic Effusion Management and Future Directions

Abstract

Pleural space infections have been described since the time of Hippocrates and to this day remains a significant pathology. Every year in the USA approximately there are one million hospital admissions for pneumonia with 20%-40% associated with some form of pleural space infections leading to pleural effusions with increased morbidity and mortality. Often, management of these effusions mandate combination of medical treatment and surgical drainage with debridement and decortication. There has been a lot of ongoing research regarding the safety and efficacy of intrapleural fibrinolytics in the management of complicated pleural effusions and empyema. Till this day, areas of debate and controversies exist among clinicians treating pleural space infection. Empyema is historically considered a surgical disease. There have been societies and guidelines for the management of infected parapneumonic effusions with antibiotics and chest tube drainage as an initial empiric treatment modality. With the advances in the use of Intrapleural fibrinolytics and minimally invasive procedures such as video-assisted thoracoscopic surgery (VATS), empyema a surgical disease is now more favoring medical management. Surgical option, such as open thoracotomy, is reserved for patients who failed conservative management and chronic empyema. The aim of this comprehensive review is to shed light on the evolution of various management strategies from the era of Hippocrates to current day practice and how there continues to be a paradigm shift in treating empyema as a surgical condition to a medical disease.

Infective Pleural Effusions—A Comprehensive Narrative Review Article

“…A nationwide epidemiological analysis of pleural infections revealed that 64.9% of patients who underwent management with tube thoracostomy did not require a second therapeutic intervention [ 66 ]. However, surgical candidacy should be explored if patients are persistently septic despite chest tube drainage and antibiotics or if there is failure of chest tube drainage, antibiotics, and fibrinolytics [ 67 ]. Overall, surgical treatment is pursued in 36–65% of patients [ 6 ].…”

“…There has been a substantial decrease in healthcare utilization, including inpatient use, length of stay, and costs over the past decade. Furthermore, inpatient mortality also decreased [ 67 ]. Thereafter, patient counseling on realistic prognosis based on clinical factors and response to initial interventions ensures aligned expectations and goals of care.…”

Complicated Management of Left-Sided Loculated Empyema Secondary to Streptococcus intermedius and Prevotella in a 53-Year-Old Male

“…Based on thoracentesis results, parapneumonic effusion is categorized as either uncomplicated effusion, complicated effusion, or empyema. Across all three subtypes, morbidity and mortality rates are high, particularly among elderly and immunocompromised patients [3]. Mortality for patients with empyema reaches as high as 20%, and the need for eventual surgery is a similar 20% [4].…”

Optimization of Surgical Treatment of Chronic Pleural Empyema. Efficacy and Safety of Chemical Pleurodesis With Silver Nitrate Solution

“…Однако между листками плевры присутствует небольшое количество жидкости, примерно 3-30 мл. Парапневмонический выпот -это вторичное накопление жидкости на фоне пневмонии, является ее наиболее частым осложнением и встречается в 57 % случаев инфекции легочной ткани [1]. Парапневмонический выпот, в зависимости от характера жидкости, разделяют на три типа: неосложненный, осложненный и эмпиема плевры.…”

“…Плевральная жидкость при осложненном парапневмоническом выпоте нестерильная, содержит фибрин, в жидкости увеличивается количество нейтрофилов. Такой плевральный выпот не разрешится только на фоне антибиотикотерапии и возникает необходимость в дре- НАУЧНОЕ ОБОЗРЕНИЕ № 4, 2022   МЕДИЦИНСКИЕ НАУКИ  нировании плевральной полости, в ином случае осложненный парапневмонический выпот в короткие сроки трансформируется в эмпиему плевры [1].…”