Critical Care Medicine-Pulmonary Disorders>>>>>Pulmonary Infections
Question 5#

A 65-year-old man with acute myeloid leukemia is admitted to the ICU with worsening hypoxemia while receiving induction chemotherapy on the oncology ward. His chest radiograph reveals bibasilar opacities, and he is started on treatment with vancomycin and cefepime. His hypoxemia improves by day 3 of treatment, however his fevers continue. On day 5 of treatment, chest radiograph reveals opacification of the right lower lung fields with loss of visualization of the right hemidiaphragm and costophrenic angle. A thoracic ultrasound demonstrates a pleural effusion, and diagnostic thoracentesis is performed with removal of 60 mL of fluid. Pleural fluid analysis demonstrates:

cloudy tan fluid

• pH 7.1
• glucose 30 mg/dL
• lactate dehydrogenase (LDH) 2000 U/L
• cholesterol 85 mg/dL
• protein 4.5 g/dL

Gram stain and cultures are pending.

What is the next best step in management?

A. Broaden antibiotic coverage and await results of gram stain and culture
B. Perform tube thoracostomy and continue antibiotic therapy
C. Continue antibiotic therapy with serial imaging, drainage if no response
D. Repeat thoracentesis to drain pleural space
E. Perform video-assisted thoracoscopic surgery to clear pleural space

Correct Answer is B

Comment:

Correct Answer: B

This patient presents with continued fevers while being treated of pneumonia and is found to have a pleural effusion with diagnostic tests highly suggestive of an empyema—these include frankly purulent pleural fluid, an LDH greater than 1000, low pH, and low glucose. The first step in management of empyema is the placement of the tube thoracostomy to completely drain the pleural space (answer B is correct). Delay in drainage may lead to increased morbidity and mortality (answer A and answer C are incorrect). Drainage with thoracentesis alone is not recommended because of the likelihood of fluid reaccumulating, making ongoing drainage necessary (answer D is incorrect). When drainage cannot be achieved through thoracostomy, thoracic surgical intervention may be necessary but is not usually the initial management strategy (answer E is incorrect). 

References:

1. Light RW. Parapneumonic effusions and empyema. Proc Am Thorac Soc. 2006;3(1):75-80.
2. Colice GL, Curtis A, Deslauriers J, et al. Medical and surgical treatment of parapneumonic effusions: an evidence-based guideline. Chest. 2000;118(4):1158.
3. Shen KR, Bribriesco A, Crabtree T, et al. The American Association for thoracic surgery consensus guidelines for the management of empyema. J Thorac Cardiovasc Surg. 2017;153(6):e129.