Pneumonia, Community-Acquired — Evaluation and Management of Pleural Effusion — Clinical Pathway: All Settings

Community Acquired Pneumonia Clinical Pathway — All Settings

Evaluation and Management of Pleural Effusion

Concern for effusion or empyema
US pleural space1
Free flowing fluid, with or without septations
Significant loculations, concern for empyema
Consult general surgery for non-PICU patients, call ICU Admit Fellow for patients being admitted to the PICU
Consult general surgery1
Consider chest tube placement; if indicated, place within 24 hours 2,3
Consider thorascopic drainage of empyema; if indicated, perform within
48 hours 2,3
  1. US is the recommended initial study for most patients to evaluate for presence of effusion or empyema. The need for additional imaging (including CT scan) should be determined on a case-by-case basis with surgery for patients in whom surgery is being considered.
  2. Effusions/empyemas that may require drainage or surgical intervention are those that are:
    • Significantly impairing pulmonary function (e.g., large effusions)
    • Concern for inadequate source control (e.g., poor response to antibiotics or septic shock)
    The goal of these drainage procedures is to correct tension physiology, restore functional residual capacity (FRC, thereby improving oxygenation), and free trapped lung lobes to speed recovery by improving lung excursion and mobilization.
    Thoracoscopic drainage may reduce length of hospital stay relative to medical management for patients with empyemas.
  3. Delaying operative drainage risks missing a window of clinical stability, increasing risks of operation. Clinically unstable patients (e.g., those with respiratory failure or tension physiology) should receive urgent intervention.