Chest
Volume 118, Issue 4, October 2000, Pages 1158-1171
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Consensus Statement
Medical and Surgical Treatment of Parapneumonic Effusions: An Evidence-Based Guideline

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Evidence:

The literature review revealed 24 articleseligible for full review by the panel, 19 of which dealt with theprimary management approach to PPE and 5 with a rescue approach after aprevious approach had failed. Of the 19 involving the primarymanagement approach to PPE, there were 3 randomized, controlled trials,2 historically controlled series, and 14 case series. The number of patients included in the randomized controlled trials was small;methodologic weaknesses were found in the 19 articles describing theresults of primary management approaches to PPE. The proportion and95% CI of patients suffering each of the two relevant outcomes (deathand need for a second intervention to manage the PPE) were calculatedfor the pooled data for each management approach from the 19 articleson the primary management approach. The pooled proportion of deaths washigher for the no drainage (6.6%), therapeutic thoracentesis (10.3%),and tube thoracostomy management approaches (8.8%) than for thefibrinolytic (4.3%), VATS (4.8%), and surgery (1.9%) approaches, butthe 95% CI showed considerable overlap among all six possible primarymanagement approaches. The pooled proportion of patients needing asecond intervention to manage the PPE was also higher for the nodrainage (49.2%), therapeutic thoracentesis (46.3%), and tubethoracostomy (40.3%) management approaches than the fibrinolytic(14.9%), VATS (0%), and surgery (10.7%) approaches; there was nooverlap in the 95% CI between the first three and the last threemanagement approaches, indicating a nonrandom difference.

Recommendations:

The studies identified through a carefulliterature review as relevant to the medical and surgical management of PPE have significant methodological limitations. Despite theselimitations in the data, there did appear to be consistent and possiblyclinically meaningful trends for the pooled data and the results of therandomized, controlled trials and the historically controlled series onthe primary management approach to PPE. Based on these trends andconsensus opinion, the panel recommends the following approach tomanaging PPE:

• In all patients with acute bacterial pneumonia, thepresence of a PPE should be considered. Recommendation based on level Cevidence.

In patients with PPE, the estimated risk for pooroutcome, using the panel recommended approach based on pleural spaceanatomy, pleural fluid bacteriology, and pleural fluid chemistry, should be the basis for determining whether the PPE should be drained. Recommendation based on level D evidence.

• Patients withcategory 1 or category 2 risk for poor outcome with PPE may not requiredrainage. Recommendation based on level D evidence.

• Drainageis recommended for management of category 3 or 4 PPE based on pooleddata for mortality and the need for second interventions with the nodrainage approach. Recommendation based on level C evidence.

• Based on the pooled data for mortality and the need for secondinterventions, therapeutic thoracentesis or tube thoracostomy aloneappear to be insufficient treatment for managing most patients withcategory 3 or 4 PPE. Recommendation based on level C evidence. However, the panel recognizes that in the individual patient, therapeuticthoracentesis or tube thoracostomy, as planned interim steps before asubsequent drainage procedure, may result in complete resolution of the PPE. Careful evaluation of the patient for several hours is essentialin these cases. If resolution occurs, no further intervention isnecessary. Recommendation based on level D evidence.

• Fibrinolytics, VATS, and surgery are acceptable approaches formanaging patients with category 3 and category 4 PPE based oncumulative data across all studies that indicate that theseinterventions are associated with the lowest mortality and need forsecond interventions. Recommendation based on level Cevidence.

Section snippets

Choice of Topic, Panel, and Objectives

The HSP is charged by the ACCP Board of Regents to makerecommendations on issues of clinical policy and to oversee preparationof clinical practice guidelines. The HSP solicits nominations fortopics for clinical practice guidelines through an annual survey of the ACCP membership. Criteria for selecting nominated topics are: topicsthat are controversial or have conflicting data; topics that have widevariability in practice; conditions in which diagnosis and managementof disease could be

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    Support for the development of this clinical practice guideline hasbeen provided solely by the American College of Chest Physicians.

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