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* From the Pulmonary and Respiratory Services, Washington Hospital Center, Washington, DC (Drs. Colice and Yusen); Department of Radiology, Yale University School of Medicine (Dr. Curtis); Thoracic Surgery Department, Centre de Pneumo-logie de l’Hôpital Laval (Dr. Deslauriers); Department of Medicine, University of South Carolina (Drs. Heffner and Sahn); Department of Medicine, Vanderbilt University (Dr. Light); Department of Medicine, University of Vermont (Dr. Littenberg); and Department of Medicine, Rush Medical College (Dr. Weinstein).
Correspondence to: Gene L. Colice, MD, FCCP, Pulmonary and Respiratory Services, Washington Hospital Center, 110 Irving St N.W., Washington, DC 20010; e-mail: gxc8{at}mhg.edu
Evidence: The literature review revealed 24 articles eligible for full review by the panel, 19 of which dealt with the primary management approach to PPE and 5 with a rescue approach after a previous approach had failed. Of the 19 involving the primary management approach to PPE, there were 3 randomized, controlled trials, 2 historically controlled series, and 14 case series. The number of patients included in the randomized controlled trials was small; methodologic weaknesses were found in the 19 articles describing the results of primary management approaches to PPE. The proportion and 95% CI of patients suffering each of the two relevant outcomes (death and need for a second intervention to manage the PPE) were calculated for the pooled data for each management approach from the 19 articles on the primary management approach. The pooled proportion of deaths was higher for the no drainage (6.6%), therapeutic thoracentesis (10.3%), and tube thoracostomy management approaches (8.8%) than for the fibrinolytic (4.3%), VATS (4.8%), and surgery (1.9%) approaches, but the 95% CI showed considerable overlap among all six possible primary management approaches. The pooled proportion of patients needing a second intervention to manage the PPE was also higher for the no drainage (49.2%), therapeutic thoracentesis (46.3%), and tube thoracostomy (40.3%) management approaches than the fibrinolytic (14.9%), VATS (0%), and surgery (10.7%) approaches; there was no overlap in the 95% CI between the first three and the last three management approaches, indicating a nonrandom difference.
Recommendations: The studies identified through a careful literature review as relevant to the medical and surgical management of PPE have significant methodological limitations. Despite these limitations in the data, there did appear to be consistent and possibly clinically meaningful trends for the pooled data and the results of the randomized, controlled trials and the historically controlled series on the primary management approach to PPE. Based on these trends and consensus opinion, the panel recommends the following approach to managing PPE: • In all patients with acute bacterial pneumonia, the presence of a PPE should be considered. Recommendation based on level C evidence. • In patients with PPE, the estimated risk for poor outcome, using the panel recommended approach based on pleural space anatomy, pleural fluid bacteriology, and pleural fluid chemistry, should be the basis for determining whether the PPE should be drained. Recommendation based on level D evidence. • Patients with category 1 or category 2 risk for poor outcome with PPE may not require drainage. Recommendation based on level D evidence. • Drainage is recommended for management of category 3 or 4 PPE based on pooled data for mortality and the need for second interventions with the no drainage approach. Recommendation based on level C evidence. • Based on the pooled data for mortality and the need for second interventions, therapeutic thoracentesis or tube thoracostomy alone appear to be insufficient treatment for managing most patients with category 3 or 4 PPE. Recommendation based on level C evidence. However, the panel recognizes that in the individual patient, therapeutic thoracentesis or tube thoracostomy, as planned interim steps before a subsequent drainage procedure, may result in complete resolution of the PPE. Careful evaluation of the patient for several hours is essential in these cases. If resolution occurs, no further intervention is necessary. Recommendation based on level D evidence. • Fibrinolytics, VATS, and surgery are acceptable approaches for managing patients with category 3 and category 4 PPE based on cumulative data across all studies that indicate that these interventions are associated with the lowest mortality and need for second interventions. Recommendation based on level C evidence. (CHEST 2000, 18:1158–1171)
Key Words: empyema • fibrinolytics • parapneumonic effusion • thoracentesis
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