Summary
Definition
History and exam
Key diagnostic factors
- recent pneumonia
- constitutional symptoms
- pyrexia and rigors
- dullness to percussion
- reduced breath sounds and reduced vocal resonance
- signs of sepsis
Other diagnostic factors
- subacute presentation
- productive cough
- pleuritic chest pain
- dyspnea
Risk factors
- pneumonia
- iatrogenic interventions in the pleural space
- thoracic trauma
- immunocompromised state
- comorbid lung disease
- male sex
- older or young age
Diagnostic investigations
1st investigations to order
- blood cultures
- CRP
- WBC count
- chest x-ray
- thoracentesis: pleural fluid appearance
- thoracentesis: pleural fluid odor
- thoracentesis: pleural fluid pH
- thoracentesis: pleural fluid total protein concentration
- thoracentesis: pleural fluid LDH level
- thoracentesis: pleural fluid glucose concentration
- thoracentesis: pleural fluid white cell differential
- thoracentesis: pleural fluid microscopy, culture, and sensitivity
- thoracic ultrasound
Investigations to consider
- contrast-enhanced thoracic CT
- MRI of thorax
- PET scan
- pleural fluid polymerase chain reaction (PCR)
Treatment algorithm
adults (culture results pending)
children (culture results pending)
adults (culture results available)
children (culture results available)
Contributors
Authors
Athanasia D. Pataka, MRCP
Assistant Professor of Respiratory Medicine
Respiratory Failure Unit
G Papanikolaou Hospital Thessaloniki
Aristotle University of Thessaloniki
Thessaloniki
Greece
Disclosures
ADP declares that she has no competing interests.
Renata L. Riha, BMedSc, MD, FRACP, FRCPE
Respiratory Consultant
Royal Infirmary
Edinburgh
Scotland
UK
Disclosures
RLR declares that she has no competing interests.
Najib M. Rahman, DPhil MSc FRCP
Professor of Respiratory Medicine
Director, Oxford Respiratory Trials Unit
Nuffield Department of Medicine, University of Oxford
Oxford
UK
Disclosures
NMR declares that Roche UK supplied clinical trial supplies and funding for the MIST2 trial that he conducted.
Acknowledgements
Dr Athanasia D. Pataka, Dr Renata L. Riha, and Dr Najib M. Rahman would like to gratefully acknowledge Dr Eleanor K. Mishra, a previous contributor to this topic. EKM declares that she has no competing interests.
Peer reviewers
Steven Sahn, MD
Professor of Medicine and Director
Division of Pulmonary/Critical Care/Allergy/Sleep Medicine
Medical University of South Carolina
Charleston
SC
Disclosures
SS declares that he has no competing interests.
Nicholas Maskell, MD
Senior Lecturer and Consultant Physician
North Bristol Lung Centre
Southmead Hospital
Bristol
UK
Disclosures
NM declares that he has no competing interests.
Y.C. Gary Lee, MBChB, PhD, FCCP, FRACP
Consultant Chest Physician and Senior Lecturer
Oxford Centre for Respiratory Medicine and University of Oxford Churchill Hospital
Oxford
UK
Disclosures
YCGL declares that he has no competing interests.
Differentials
- Pneumonia
- Uncomplicated parapneumonic effusion
- Lung abscess
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- ACR–SIR–SPR practice parameter for specifications and performance of image-guided percutaneous drainage/aspiration of abscesses and fluid collections (PDAFC)
- The American Association for Thoracic Surgery consensus guidelines for the management of empyema
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