Management of parapneumonic effusions

When a patient with pneumonia and pleural effusion is first evaluated, a therapeutic thoracentesis should be performed. If the fluid recurs after an initial successful therapeutic thoracentesis, a repeat therapeutic thoracentesis is indicated. If the fluid recurs after a second therapeutic thoracentesis, tube thoracostomy should be performed. If the fluid cannot be evacuated because of loculations, a chest tube should be placed and intrapleural thrombolytics administered. Thoracoscopy with the breakdown of adhesions and debridement of the pleural space is indicated if tube thoracostomy plus thrombolytics is unsuccessful. Thoracotomy with decortication should be performed if thoracoscopy is unsuccessful or if the patient has a chronic empyema.