- Does the patient need a diagnostic thoracentesis?
- Does he need a chest tube?
- What is the difference between Uncomplicated parapneumonic effusion vs Comlicated parapneumonic effusion vs Empyema?
What is the difference between Uncomplicated parapneumonic effusion vs Comlicated parapneumonic effusion vs Empyema?
- An uncomplicated parapneumonic effusion has "exudative" chemistries, normal pH and glucose, and negative cultures.
- A complicated parapneumonic effusion typically has "exudative" chemistries, a low pleural pH (pH <7.20), a low glucose, and is often loculated.
- Empyema fluid typically looks like pus and organisms are visible on Gram stain, although cultures may be negative
Who would qualify for a diagnostic thoracentesis?
- In general, all parapneumonic effusions, EXCEPT those that are free flowing and layer less than 10 mm on a lateral decubitus film, should be sampled (diagnostic) by thoracentesis.
Who would qualify for a Chest tube placement?
- In patients with a large, loculated, or complicated parapneumonic effusion or empyema.
- CT or ultrasound-guided placement of multiple tubes may be needed when pleural loculations prevent adequate drainage by a single tube.
- In patients with a thoracic empyema - tube thoracostomy and video-assisted thoracoscopic surgery (VATS) with debridement are acceptable. The latter may be preferred in patients with multiple loculations and a thick pleural peel.
- When tube thoracostomy is used for initial drainage of an empyema, a chest CT scan should be obtained within 24 hours after chest tube placement to document appropriate placement of the tube and assess drainage.
- For patients who do not have good drainage of empyema fluid from a well-placed chest tube, administer a combination of TPA 10 mg and deoxyribonuclease (DNase) 5 mg, twice daily for three days. IR team does a different regimen that is not effective and not evidence based. So do not let IR team manage the fibrinolytics.
- The only pleural effusion with a trasudative chemistry but low pH : URINOTHORAX.
- Red tinged effusion is likely a hemothorax when the pleural fluid hematocrit / blood hematocrit ratio is >50%
- Chylothorax - triglyceride level >110.
- Lights criteria can be false positive when a patient with transudative effusion gets lasix.