Pleural Disease

Pleural Infections

Covers imaging and microbiology, RAPID score risk stratification, tube management, intrapleural tPA/DNase protocols, and team-based management of complex infection.

Empyema staging • Drainage algorithms • IET protocolsReading time · 24mWord count · 2,947

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Exam mapping & scope

This chapter covers the evaluation and management of pleural space infections across the spectrum from complicated parapneumonic effusions to empyema. It emphasizes risk stratification (RAPID), chest tube selection, intrapleural enzyme therapy, saline irrigation, surgical escalation, and special populations. Guidance reflects contemporary society statements and pragmatic pathways tested in trials summarized in the provided materials.

Focus this round

RAPID score use
Drain troubleshooting
Escalation criteria

High-yield pearls

Terminology: "Pleural infection" encompasses complicated parapneumonic effusion (CPPE) and empyema; management principles are aligned.
Epidemiology: Incidence and hospitalizations have increased; older adults bear a disproportionate rise and higher mortality.
Don’t delay: Progression from "simple" to "complicated" can occur rapidly—act decisively.
Imaging: Thoracic ultrasound (TUS) reliably identifies septations/loculations and guides safe access; CT helps delineate anatomy and demonstrates the "split pleura" sign.
Chemistry that matters: pH ≤7.20 (obtained correctly) → place a chest tube if safe. If pH 7.21–7.39, integrate LDH (>900 IU/L), glucose (≤4 mmol/L ≈ 72 mg/dL), and imaging to decide. Purulence, positive Gram stain/culture, or glucose <60 mg/dL also strengthen the case for drainage.
Drain choice: Small-bore (≤14F) tubes are preferred (less pain, similar efficacy). Flush regularly to maintain patency.
Reassess at ~48 h: If persistent collection plus systemic inflammation → escalate (CT, intrapleural therapy, or surgery).
Intrapleural enzyme therapy (IET): Use tPA 10 mg + DNase 5 mg twice daily for up to 3 days; clamp ~1 hour each dose. Consider tPA 5 mg with standard DNase in high bleeding risk. Avoid fibrinolytic monotherapy.

Related chapters

Study notes

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