Role of interventional pulmonology in the management of complicated parapneumonic pleural effusions and empyema

Abstract

Pleural infection is a major problem that affects 80 000 cases per year in the UK and USA. It is increasing in incidence, and in an ageing population, it presents a complex challenge that requires a combination of medical therapies and may lead to the need for surgery. This article focuses on the role of the interventional pulmonologist in the diagnosis and management of pleural infection. In particular, we examine the role of pleural ultrasound in diagnostics, thoracocentesis and real-time guided procedures, and the current management strategies, including the controversial role of medical thoracoscopy.

Year in review 2014: Lung cancer, pleural diseases, respiratory infections and tuberculosis, bronchoscopic intervention and imaging

“…All patients with community‐acquired parapneumonic effusions or empyema should receive empirical antibiotics covering Gram‐positive cocci and anaerobes, but usually not atypical bacterial pathogens such as Legionella or Mycoplasma . The optimal duration of antibiotic therapy is unknown, although a period of 4 to 6 weeks is not uncommon . Nutritional supplementation is advised if poor nutrition is a concern.…”

“…The rationale is that if no fluid re‐accumulates, no additional therapy will be necessary. Alternatively, when indicators for pleural drainage exist, small‐bore chest drains placed under ultrasound guidance are the procedure of choice . The rightful place for intrapleural fibrinolytics remains a matter of intense debate.…”

“…The next review of the series evaluated CT, ultrasound, drainage procedures, fibrinolytics and thoracoscopy in the management of complicated parapneumonic pleural effusions and empyema . CT allows for structural assessment such as endobronchial obstruction, oesophageal rupture, malignant disease, pleural thickening, split pleural sign, pleural enhancement and differentiates loculated pleural collections from lung abscesses .…”

“…A review described the role of interventional pulmonology in the management of bacterial infections of the pleural space. 27 All patients with community-acquired parapneumonic effusions or empyema should receive empirical antibiotics covering Gram-positive cocci and anaerobes, but usually not atypical bacterial pathogens such as Legionella or Mycoplasma. The optimal duration of antibiotic therapy is unknown, although a period of 4 to 6 weeks is not uncommon.…”

Interventional pulmonology: The tipping point

“…[3][4][5][6][7] Modern approaches to lung cancer management demand that systematic algorithms be followed to ensure that, in addition to establishing the diagnosis, accurate clinical staging is attained efficiently and sufficient samples are acquired for ancillary testing to guide individualized management. 5 Ongoing communication between proceduralists and histo-and cyto-pathologists is paramount to adapt sampling techniques to local specimen processing methodologies and allow for appropriate molecular testing.…”