Parapneumonic effusion and empyema

Diagnosis: The pleural empyema (the complicated parapneumonic effusion) — the recent pneumonia, the persistent fever, the pus, and the pleural fluid of the pH below 7.2 and the glucose below 3.3. The empyema criteria are met (the pus, the pH, the glucose).^[3]

Management:

1. The chest drain (the large-bore, the ultrasound-guided or the CT-guided for the loculated) — the drainage of the pus.
2. The intravenous antibiotics — the broad-spectrum, the cover of the streptococci (the Streptococcus pneumoniae, the milleri), the anaerobes, the Staphylococcus, and the Gram-negatives. The culture-guided.
3. The fluid for the microbiology — the Gram stain, the culture, the AFB (the TB), and the cytology (to exclude the malignancy).
4. The surgical (the VATS) consideration for the loculated, the non-draining, or the refractory — the Cochrane addresses the surgical versus the non-surgical management. The intrapleural thrombolytics (the DNase and the tPA) for the loculated in the selected.
5. The supportive — the oxygen, the analgesia, the nutrition, the physiotherapy.
6. The disposition — the admission, the monitoring of the response (the fever, the drain output, the radiograph), the follow-up imaging for the trapped lung and the pleural thickening.

The cardinal principle: The empyema is the DRAIN. The pH below 7.2 and the pus are the indications. The delayed drainage worsens the outcome.^[3]