Figure 1. Management of Pneumonia with Parapneumonic Effusion then categorize the size of the effusion
Confirm the Dx of pneumonia and parapneumonic effusion,
Small effusion size: < 10 mm rim or < ¼ thorax opacified
Treat with antibiotics (abx) Do not obtain pleural fluid for culture, and do not
attempt pleural drainage Is the patient
responding to treatment?
YES
Continue abx
effusion size Reassess
effusion still small?
Is the YES
If the effusion is still small, then continue IV abx, and do NOT attempt pleural drainage
If the effusion is now moderate or large, then follow the
algorithm for moderate or large effusion size
NO loculated– "simple" Fluid IS NOT
Options for drainage: > Chest tube alone > Chest tube with fibrinolytics
> VATS
Chest tube with fibrinolytics; if not responding
(approx. 15% of patients), then proceed to VATS
OR
directly to VATS
Proceed 21
Fluid IS loculated– "complicated"
NO chest tube (fibrinolytics)
Treat with IV abx alone, or Obtain chest US and obtain pleural fluid for culture by thoracentesis or by placement of a
worsening despite appropriate IV abx, then proceed to the algorithm for large effusions
If clinical condition is
Moderate effusion size: > ¼ but < ½ thorax opacified
Degree of respiratory compromise
LOW HIGH
algorithm for large effusions
Follow the treatment
Obtain pleural fluid for culture, and drain the pleural space of fluid
Options for drainage
Large effusion size: > ½ thorax opacified
assess effusion size and degree of loculation
Obtain a chest US or CT (US preferred) to
