Management of infectious processes of the pleural space: a review

Abstract

Pleural effusions can present in 40% of patients with pneumonia. Presence of an effusion can complicate the diagnosis as well as the management of infection in lungs and pleural space. There has been an increase in the morbidity and mortality associated with parapneumonic effusions and empyema. This calls for employment of advanced treatment modalities and development of a standardized protocol to manage pleural sepsis early. There has been an increased understanding about the indications and appropriate usage of procedural options at clinicians' disposal.

Figure 1

A series of CT images done in patient with parapneumonic effusions. (a) CT image showing a free flowing pleural effusion (r) with a meniscus formation (arrow). There is also some fluid in the fissure on the left side (L). (b) A loculated pleural effusion with loculations seen in the pleural space (arrows). (c) A chronic pleural effusion showing marked pleural thickening (arrows).

Figure 2

CT images after chest tube drainage. (a) Image shows placement of pigtail catheter (arrow) in the posterior recess confirmed with CT. (b) Placement of small-bore pigtail catheter (arrowheads) in the small loculated effusion with the help of CT guidance.

Figure 3

A pictorial representation of a chronic indwelling catheter (Aspira) which is tunneled beneath the skin to enter the pleural cavity at a distant site. This assembly prevents introduction of infection in the pleural cavity and can provide long term drainage of infected pleural effusion.

Figure 4

Thoracoscopic views of a complicated parapneumonic effusion. Multiple pleural adhesions (black arrowheads) are seen which prevent lungs from re-expanding. There are also seen inflamed pleura (white arrowheads) which represent nonresolving infection.

Figure 5

A schematic flow chart summarizing the various treatment modalities available for managing pleural infection and various stages where each of them may be used. Decisions regarding timing of each treatment option may vary according to institutional expertise. *Empyema or effusions with either gram stain or culture positive, pH < 7.2, glucose < 60 mg/dL, LDH < 1000.