Treatment of Complicated Parapneumonic Effusion With Fibrinolytic Therapy Versus VATs Decortication

The treatment of parapneumonic infections (infection in the pleural space) at the Denver Health Medical Center is not standardized, and timing for advanced interventions such as fibrinolytic therapy or surgical decortication remain unclear. The definitive treatment strategy in these patients may be sub-optimal, and lead to prolonged hospitalization and morbidity. This is concerning as the mortality rate of community acquired pneumonia triples in the presence of a parapneumonic process (5-15%) and can reach over 25% if it becomes bilateral(1). Prompt recognition of pleural space infections is essential for reducing morbidity and mortality. This is attributable to the progression of the disease from a simple fluid collection amenable to pleural space drainage, to necrotizing empyema requiring thoracotomy decortication and open drainage. The keys to management of parapneumonic effusions are early diagnosis, appropriate therapeutic intervention, and recognition of failure of conservative management. The investigators propose that a standardized pathway for identifying and treating parapneumonic effusions will be an important quality improvement. A key gap in the literature remains if patients with parapneumonic infections that cannot be drained with a chest tube should undergo a trial in intrapleural fibrinolytic therapy, or if they should go directly to video assisted thoracic surgery (VATS) for decortication of all infectious material.

Inclusion criteria

• 18 years old and older
• Admitted with pleural effusion that undergoes thoracentesis by medical/pulmonary service
• Pleural fluid pH <7.3
• SICU placed chest tube
• Subsequent transfer to SICU

Exclusion criteria

• Existing malignancy
• Malignant cells from initial pleural fluid sample
• End stage liver disease (Child's B or greater)
• Coagulopathy
• Unable to tolerate surgical procedure
• Frank purulent drainage (needs OR regardless)
• Recent surgery of abdomen or thorax precluding the use of tPA
• Baseline neurologic impairment requiring a proxy for consent