Medical and surgical treatment of parapneumonic effusions - An evidence-based guideline

Objective: A panel was convened by the Health and Science Policy Committee of the American College of Chest Physicians to develop a clinical practice guideline on the medical and surgical treatment of parapneumonic effusions (PPE) using evidence-based methods. Options and outcomes considered: Based on consensus of clinical opinion, th e expert panel developed an annotated table for evaluating the risk for poo r outcome in patients with PPE. Estimates of the risk for poor outcome were based on the clinical judgment that, without adequate drainage of the pleu ral space, the patient,vith PPE would be likely to have any or all of the f ollowing: prolonged hospitalization, prolonged evidence of systemic toxicit y, increased morbidity from any drainage procedure, increased risk for resi dual ventilatory impairment, increased risk for local spread of the inflamm atory reaction, and increased mortality. Three variables, pleural space ana tomy, pleural fluid bacteriology, and pleural fluid chemistry, were used in this annotated table to categorize patients into four separate risk levels for poor outcome: categories 1 (very low risk), 2 (low risk), 3 (moderate risk), and (high risk). The panel's consensus opinion supported drainage fo r patients with moderate (category 3) or high (category 4) risk for a poor outcome, but not for patients with very low (category 1) or low (category 2 ) risk for a poor outcome. The medical literature was reviewed to evaluate the effectiveness of medica l and surgical management approaches for patients with PPE at moderate or h igh risk for poor outcome. The panel grouped PPE management approaches into six categories: no drainage performed, therapeutic thoracentesis, tube tho racostomy, fibrinolytics, video-assisted thoracoscopic surgery (VATS), and surgery (including thoracotomy with or without decortication and rib resect ion). The fibrinolytic approach required tube thoracostomy for administrati on of drug, and VATS included postprocedure tube thoracostomy. Surgery may have included concomitant lung resection and always included postoperative tube thoracostomy. All management approaches included appropriate treatment of the underlying pneumonia, including systemic antibiotics. Criteria for including articles in the panel review were adequate data provided for grea ter than or equal to 20 adult patients with PPE to allow evaluation of at l east one relevant outcome (death or need for a second intervention to manag e the PPE); reasonable assurance provided that drainage was clinically appr opriate (patients receiving drainage were either category 3 or category 4) and drainage procedure was adequately described; and original data were pre sented. The strength of panel recommendations on management of PPE was base d on the following approach: level A, randomized, controlled trials with co nsistent results or individual randomized, controlled trial with narrow con fidence interval (CI); level B, controlled cohort and case control series; level C, historically controlled series and case series; and level D, exper t ol,inion without explicit critical appraisal or based on physiology, benc h research, or "first principles."