Skip to main content

Main menu

  • Online first
    • Online first
  • Current issue
    • Current issue
  • Archive
    • Archive
  • Submit a paper
    • Online submission site
    • Information for authors
  • About the journal
    • About the journal
    • Editorial board
    • Information for authors
    • FAQs
    • Thank you to our reviewers
      • Thank you to our reviewers
    • American Federation for Medical Research
  • Help
    • Contact us
    • Feedback form
    • Reprints
    • Permissions
    • Advertising
  • BMJ Journals

User menu

  • Login

Search

  • Advanced search
  • BMJ Journals
  • Login
  • Facebook
  • Twitter
JIM

Advanced Search

  • Online first
    • Online first
  • Current issue
    • Current issue
  • Archive
    • Archive
  • Submit a paper
    • Online submission site
    • Information for authors
  • About the journal
    • About the journal
    • Editorial board
    • Information for authors
    • FAQs
    • Thank you to our reviewers
    • American Federation for Medical Research
  • Help
    • Contact us
    • Feedback form
    • Reprints
    • Permissions
    • Advertising

Sonographic septation: a useful diagnostic predictor of complicated parapneumonic effusion

Shan-Yueh Chang, Ying-Chieh Chen, Chen-Liang Tsai, Shih-Wei Wu, Chung-Kan Peng, Chih-Hao Shen, Yu-Ching Chou, Chih-Feng Chian
DOI: 10.1136/jim-2020-001770 Published 25 November 2021
Shan-Yueh Chang
1 Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
2 Graduate Institute of Medical Sciences, National Defense Medical Center, Taipei, Taiwan
3 Hyperbaric Oxygen Center, Division of Pulmonary Medicine and Critical Care Medicine, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • ORCID record for Shan-Yueh Chang
Ying-Chieh Chen
1 Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Chen-Liang Tsai
1 Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Shih-Wei Wu
1 Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
2 Graduate Institute of Medical Sciences, National Defense Medical Center, Taipei, Taiwan
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Chung-Kan Peng
1 Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
3 Hyperbaric Oxygen Center, Division of Pulmonary Medicine and Critical Care Medicine, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Chih-Hao Shen
1 Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
3 Hyperbaric Oxygen Center, Division of Pulmonary Medicine and Critical Care Medicine, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Yu-Ching Chou
4 School of Public Health, National Defense Medical Center, Taipei, Taiwan
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • ORCID record for Yu-Ching Chou
Chih-Feng Chian
1 Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • ORCID record for Chih-Feng Chian
  • Article
  • Figures & Data
  • eLetters
  • Info & Metrics
  • PDF
Loading

Abstract

Sonographic septation is associated with prolonged hospitalization and increased mortality in patients diagnosed with empyema. However, it is unknown whether sonographic septation is associated with complicated parapneumonic effusion (CPPE) or the need for invasive procedures among patients with pneumonia. In this retrospective study, we included 180 patients with non-purulent neutrophilic exudative pleural effusion secondary to pulmonary infections such as pneumonia and lung abscess. We performed univariate and multivariate logistic regression analyses, including baseline clinical characteristics, values from blood samples, and sonographic echogenicity, to identify variables correlated with CPPE and the need for invasive procedures. Seventy of the 180 included patients (38.89%) displayed sonographic septation. Multivariate logistic regression analysis identified that sonographic septation (adjusted OR (AOR)=3.38 (95% CI 1.64 to 6.98), p=0.001) and younger age (AOR=2.63 (95% CI 1.24 to 5.58), p=0.012) were independently associated with CPPE. With regard to treatment strategy, sonographic septation (AOR 9.06 (95% CI 3.71 to 22.11), p<0.001) and total serum protein level (AOR=1.80 (95% CI 1.13 to 2.86), p=0.013) were independently associated with the need for subsequent invasive procedures in patients with CPPE using multivariate logistic regression analysis. Sonographic septation is a useful predictor of CPPE and may imply the need for early invasive procedures.

Significance of this study

What is already known about this subject?

  • 20%–40% of hospitalized patients with pneumonia have parapneumonic effusion (PPE) and the mortality rate of patients with pneumonia and PPE is as high as 15%.

  • Treatment of complicated parapneumonic effusion (CPPE) consists of empiric antibiotic therapy and adequate drainage of the pleural fluid.

  • Diagnosis and timing of drainage for patients with CPPE may be delayed due to similar clinical presentations to uncomplicated PPE, resulting in longer hospital stay and increased healthcare expenditure.

  • Although the biochemical parameters of pleural effusion, Gram stain, and bacterial cultures are used to diagnose CPPE and determine treatment strategy, this process is time-consuming.

What are the new findings?

  • Patients with sonographic septation had a 4.68-fold higher risk of having CPPE compared with those without septation (OR=4.68, 95% CI 2.45 to 8.91) using univariate logistic regression analysis.

  • In multivariate logistic regression analysis, sonographic septation and younger age remained significantly correlated with CPPE.

  • In multivariate logistic regression analysis, sonographic septation and total serum protein level were independently associated with invasive procedures.

Significance of this study

How might these results change the focus of research or clinical practice?

  • Sonographic septation is a useful predictor of CPPE.

  • Chest sonography may adjudicate on the decision of invasive procedures in patients with non-purulent PPE.

  • Further studies are needed to investigate the association between sonographic septation and invasive procedures and its influence on prognosis in patients with non-purulent PPE.

Introduction

Pneumonia remains a major cause of death, even after years of research and the development of a broad spectrum of antibiotics.1 In 2005, there were more than 60,000 people aged 15 years and above who died from pneumonia in the USA.2 Parapneumonic effusion (PPE) is a type of effusion which usually occurs in patients with pneumonia or a lung abscess. It has been reported that 20%–40% of hospitalized patients with pneumonia have PPE and that the mortality rate of patients with pneumonia and PPE is as high as 15%.3 Additionally, 20% of patients with PPE require hospitalization for more than 1 month.4 Furthermore, a higher mortality rate has been reported in patients with bilateral PPE compared with those with unilateral PPE.5 Complicated parapneumonic effusion (CPPE) is defined as PPE which only resolves after an invasive procedure, such as tube thoracostomy, or yields a positive Gram stain or bacterial culture.6 Treatment of CPPE consists of empiric antibiotic therapy and adequate drainage of the pleural fluid. Several guidelines have been proposed to accurately and rapidly diagnose CPPE to improve the outcomes by the early application of adequate drainage.

The American College of Chest Physicians (ACCP) and the British Thoracic Society (BTS) have proposed criteria to differentiate CPPE from non-CPPE and guide treatment.7–9 The ACCP guidelines use plain chest radiograph of the pleural space, biochemical parameters, and bacteriology of the pleural effusion to categorize patients into four categories. Categories 3 and 4 are defined as moderate and high risk groups, respectively, and adequate drainage is recommended for these patients. The BTS guidelines use biochemical parameters of the pleural effusion and bacteriology to classify patients as having uncomplicated parapneumonic effusion (UPPE), CPPE, and empyema. Patients with empyema are recommended to receive empiric antibiotics as well as invasive procedures such as pigtail catheter drainage, chest tube thoracostomy, or video-assisted thoracoscopic surgery (VATS) to promptly control pleural infections. Importantly, the diagnosis and timing of drainage for patients with CPPE may be delayed due to similar clinical presentations to UPPE, resulting in longer hospital stay and increased healthcare expenditure.10 Therefore, it is very important to accurately identify CPPE as early as possible. Although the biochemical parameters of pleural effusion, Gram stain, and bacterial cultures are used to diagnose CPPE and determine treatment strategy, this process is time-consuming.

Few studies have focused on identifying the predictive factors for CPPE/empyema. Falguera et al 11 identified five independent baseline characteristics, including age, alcoholism, pleuritic pain, tachycardia, and leukocytosis, in 882 patients diagnosed with community-acquired pneumonia with PPE. Although several clinical factors have been reported to predict CPPE/empyema, the application of imaging studies such as chest sonography has never been reported. Transthoracic sonography is a useful method to safely guide thoracentesis and the placement of a chest tube.12 13 In patients with empyema, sonographic septation has been associated with longer hospital stay, longer duration of chest tube drainage, and higher probability of a need for fibrinolytic therapy or surgical interventions.14 However, whether sonographic septation is a predictor of CPPE or a guideline for pleural drainage has never been investigated. Therefore, this study aimed to clarify the clinical significance of sonographic septation in patients with PPE.

Methods

Study subject

All hospitalized patients with exudative pleural effusion secondary to pneumonia or lung abscess who underwent chest sonography and thoracentesis between January 2002 and April 2011 at the Tri-Service General Hospital, a tertiary referral center in Taiwan, were included in this study. All medical records, including the results of the pleural fluid analysis, cultures, biochemical parameters, cell counts, pH, cytology, baseline characteristics, and treatment strategy, from these patients were retrospectively reviewed. The inclusion criteria were age older than 20 years and those with exudative pleural effusion with neutrophil predominance concomitantly with pneumonia or a lung abscess.

The definition of exudate was determined according to Light’s criteria.15 Patients who had PPE were classified into UPPE or CPPE group according to the BTS guidelines (a case is defined as CPPE if it fits any of the following parameters: pleural fluid lactate dehydrogenase (LDH) >1000 IU/L, glucose <40 mg/dL, pH <7.2, positive Gram stain or bacterial culture).7

All patients were treated empirically with antibiotics, consisting of broad-spectrum penicillin with beta-lactamase inhibitor (amoxicillin-clavulanate, ampicillin-sulbactam, piperacillin-tazobactam), cephalosporin (ceftriaxone, ceftazidime, or cefepime), clarithromycin, fluoroquinolone (levofloxacin or moxifloxacin), or carbapenem (imipenem, meropenem, ertapenem). The antibiotics were changed in some cases according to the susceptibility evaluated with bacterial culture. Patients were excluded if the pleural fluid analysis showed transudative effusion, exudative effusion with lymphocyte predominance, malignant pleural effusion, post-traumatic pleural infection, tuberculosis-related effusion, or empyema (pus in the pleural fluid).5 The decision to use invasive procedures or not was left up to the discretion of the attending physician. The most common causes of undergoing tube thoracostomy or VATS in this study were uncontrolled sepsis, large effusion with clinical symptoms such as dyspnea, or multiloculated effusion.

Imaging studies of the chest

The timing of chest ultrasound in this study is after the initial encounter of pneumonia or lung abscess with pleural effusion. All patients received chest ultrasound in an upright seated position or lying in the lateral decubitus position. A real-time ultrasound scanner (Toshiba SSA-340A; Tokyo, Japan) with a 3.75 MHz sector transducer under fixed parameters, such as a gain setting of 80 dB and a transmitted focal depth of 6 cm, was used to evaluate the pleural effusion, followed by a diagnostic thoracentesis if the width of the pleural effusion exceeded 10 mm. All sonographic images of the pleural fluid from the included patients were saved in JPG format. Sonographic septation was determined by two board-certified chest physicians blinded to patients’ clinical information. If any disagreement existed between these two chest physicians, another senior board-certified chest physician was consulted. Sonographic septation was defined as the presence of hyperechoic strands (figure 1A) or web-like, branching fibrinous septa floating in the pleural effusion (figure 1B), as opposed to non-septated pleural effusion (figure 1C).14 16

Figure 1
  • Download figure
  • Open in new tab
  • Download powerpoint
Figure 1

Sonography of chest demonstrated the presence of hyperechoic strands in the pleural fluid (A), branching fibrinous septa floating in the pleural effusion (B), and non-septated anechoic effusion (C). PE, pleural effusion; LT, left side.

Pleural effusion samples obtained with diagnostic thoracentesis were aliquoted into different collecting tubes using aseptic techniques. All specimens were sent to the laboratory for analysis of LDH, total protein, glucose, total leukocyte count, differential leukocyte count, Gram stain, bacterial culture, acid-fast stain, tuberculosis culture, cytology, and pH using a blood gas analyzer.

Statistical analysis

Data were expressed as mean±SEM. Continuous variables were compared between groups using the Student’s t-test, and the χ2 test was used to examine the differences between the two groups with respect to categorical variables. Fisher’s exact test was used to compare differences between categorical variables among groups if the expected count of at least one cell was less than five. The positive predictive value, negative predictive value, sensitivity, and specificity of sonographic septation in predicting CPPE were calculated. OR, adjusted OR (AOR), and corresponding 95% CI of positive sonographic septation in predicting CPPE and invasive management were calculated using univariate and multivariate logistic regression analyses. Potential predictive factors including baseline characteristics which appeared to be significant in the univariate logistic regression analysis were entered into the multivariate logistic regression analysis in order to determine if the factors are independently associated with CPPE and the need for invasive management. Agreement between the two chest physicians in determining sonographic septation of the pleural fluid was evaluated by kappa statistics. All statistical analyses were performed using IBM SPSS Statistics V.22, and a two-tailed p value of less than 0.05 was considered to indicate statistical significance.

Results

Baseline characteristics and comorbidities

We included a total of 180 patients who had PPE and received thoracentesis from January 2002 to April 2011, of whom 97 (53.89%) were diagnosed with UPPE and 83 (46.11%) with CPPE. The baseline clinical characteristics, comorbidities, and sonographic echogenicity are shown in table 1. There were no significant differences in gender, smoking status, and comorbidities between the two groups; however, the CPPE group had a higher percentage of patients less than 60 years age, sonographic septation, and a lower rate of comorbid chronic obstructive pulmonary disease (COPD), compared with the UPPE group.

View this table:
  • View inline
  • View popup
Table 1

Baseline characteristics of the study population

Bacteriology

Of the 180 patients, 21 (11.67%) of the effusion cultures were positive for micro-organisms. These findings consisted of 22 organisms, including 13 aerobic Gram-positive bacteria, 5 aerobic Gram-negative bacteria, and 4 anaerobic bacteria. The most frequently isolated bacteria were Streptococcus viridans (n=5) and methicillin-resistant Staphylococcus aureus (n=3). The incidence of bacteria isolated from pleural effusion was much higher in the sonographic septated group than in the non-septated group (20% vs 4.5%, p=0.004).

Laboratory findings and sonographic septation

Table 2 shows the laboratory characteristics of pleural effusions with and without sonographic septation. The glucose level (p<0.001) and pH (p<0.001) of the pleural effusions were significantly lower in the sonographic septation group than in the non-septated group, whereas total protein level (p<0.001), LDH (p=0.024), and the percentage of neutrophils (p=0.001) were significantly higher in the sonographic septation group. The interobserver agreement of sonographic septation reached a κ of 0.77 between the two chest physicians.

View this table:
  • View inline
  • View popup
Table 2

Correlations between sonographic features and laboratory characteristics of pleural effusion and serum

Sonographic septation predicted CPPE

Patients with sonographic septation had a 4.68-fold higher risk of having CPPE compared with those without septation (OR=4.68, 95% CI 2.45 to 8.91) using univariate logistic regression analysis. In addition, CPPE was significantly associated with younger age, lower rate of COPD, and high serum total protein level in univariate logistic regression analysis. In multivariate logistic regression analysis, sonographic septation and younger age remained significantly correlated with CPPE (table 3).

View this table:
  • View inline
  • View popup
Table 3

Univariate and multivariate logistic regression analyses for predictors of CPPE

Sonographic septation correlated with invasive procedures

In total, 101 patients received invasive procedures including tube thoracostomy (n=59) and VATS (n=42). Among the 70 patients with a septated effusion, 88.6% (62 of 70) received invasive procedures, compared with 35.5% (39 of 110) of those without sonographic evidence of septation. Using sonographic septation as the predictor of invasive procedures, the sensitivity, specificity, positive predictive value, and negative predictive value were 61.4%, 89.9%, 88.6%, and 64.5%, respectively. The potential predictors of invasive procedures in univariate logistic regression analysis were sonographic septation (OR=14.11, CI 6.13 to 32.47, p<0.001), male gender (OR=2.16, CI 1.06 to 4.38, p=0.033), absence of COPD (OR=0.37, CI 0.16 to 0.86, p=0.021), absence of malignancy (OR=0.44, CI 0.21 to 0.94, p=0.035), and serum total protein level (OR=1.73, CI 1.17 to 2.57, p=0.007). In multivariate logistic regression analysis, sonographic septation and total serum protein level were independently associated with invasive procedures (table 4).

View this table:
  • View inline
  • View popup
Table 4

Univariate and multivariate logistic regression analyses for predictors of invasive procedures

Discussion

In the current study, we demonstrated that the sonographic findings of septation were useful for predicting CPPE and strongly correlated with subsequent invasive procedures such as tube thoracostomy or VATS. Patients with CPPE were significantly younger, had a lower rate of COPD, and a higher rate of sonographic septation than those with UPPE. Furthermore, we also demonstrated that sonographic septation was significantly associated with higher LDH, total protein level, percentage of neutrophils, and lower glucose and pH in the pleural effusion, compared with the non-septated group. Sonographic evidence of septation suggests the presence of overwhelming inflammation in the pleural fluid, which correlates with the fibropurulent stage of PPE. Importantly, patients with septated PPE had a significantly increased risk of receiving invasive procedures in our study subjects. The above findings suggest that sonographic septation is strongly correlated with CPPE and predicts the application of tube thoracostomy or VATS in patients with pneumonia and pleural effusion.

At baseline, our patients with CPPE were younger, had a higher rate of sonographic septation, and a lower rate of COPD compared with the patients with UPPE. Also, age younger than 60 years was an independent predictor of CPPE, and the AOR was 2.63. The relationship between younger age and CPPE may be related to the changes in innate immunity associated with aging; however, the exact mechanism remains unknown.17 18

Falguera et al 11 reported that leukocytosis was an important predictor of CPPE or empyema in a patient diagnosed with community-acquired pneumonia. Nevertheless, sonographic echogenicity was not included in previous studies as a possible predictor of CPPE. In the current study, leukocytosis was not significantly associated with CPPE when analyzed using univariate logistic analysis. We found that sonographic septation and age were better predictors of CPPE compared with COPD and leukocytosis. Moreover, the AOR was higher for sonographic septation than for age (AOR 3.38 vs 2.63).

The incidence of pleural space infection is increasing despite continuous improvements in diagnostic and therapeutic modalities.19 Accurate diagnosis and appropriate antibiotic treatment can prevent progression from UPPE to CPPE.10 However, the most commonly used scoring systems to assess the severity of pneumonia, such as the Pneumonia Severity Index, CURB-65 (consciousness, urea nitrogen, respiratory rate, blood pressure, and age (above or below 65)), and Acute Physiology and Chronic Health Evaluation (APACHE II), are of no prognostic value for the development of CPPE.20 The imbalance of fibrinogenesis and fibrinolysis increases fibrin deposition and septum formation, which then envelops the infected area and leads to regional heterogeneity in the composition of the pleural fluid. Chest sonography allows for better characterization of a pleural fluid collection with septation than CT.21 Based on our findings, we suggest that chest sonography can be used to detect pleural fluid septation, which can be considered to represent the formation of CPPE and the risk of invasive procedures.

Early treatment with antibiotics has been reported to prevent the development of UPPE and progression to empyema in patients with pneumonia.10 Conversely, delayed pleural drainage for patients with CPPE has been reported to result in prolonged hospital stays and increased medical costs.22 Feller-Kopman and Light23 pointed out that in patients with septated or loculated PPE, early VATS should be considered if the patient is a good surgical candidate, or alternatively treated with 14-French chest tube thoracostomy or tissue plasminogen activator and deoxyribonuclease (t-PA-DNase) in a poor surgical candidate after multidisciplinary discussion. Our results disclosed that sonographic septation has good specificity (89.9%) and a high positive predictive value (88.6%) in predicting the need for invasive procedures in patients with infectious lung diseases and pleural effusion, which were in line with the statement of Feller-Kopman and Light.23 For the decision of chest tube placement, it is very challenging without biochemical analysis of the pleural effusion during the initial thoracentesis. Our results suggest that it is possible to consider an early chest tube placement during the initial thoracentesis in patients with clinically suspected PPE and sonographic septation.

There are several limitations to the current study. First, this study focused on the correlation between clinical parameters and sonographic septation with the development of CPPE and the subsequent need for an invasive procedure. We did not investigate the influence of treatment such as antibiotics on clinical outcomes in this study. Second, although we found that physicians performed invasive procedures more frequently for patients with sonographic septation, we still could not conclude that the clinical application of sonographic septation may affect the prognosis. Further studies are needed to investigate the association between sonographic septation and invasive procedures and its influence on prognosis in patients with non-purulent PPE.

In conclusion, sonographic septation is a useful predictor of CPPE. Chest sonography may adjudicate on the decision of invasive procedures in patients with non-purulent PPE.

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information.

Ethics statements

Patient consent for publication

Not required.

Ethics approval

This study was approved by the Tri-Service General Hospital Institutional Review Board (TSGHIRB: 2-103-05-108).

Footnotes

  • Contributors S-YC wrote the first draft of this article. All authors contributed to acquisition, analysis, and interpretation of data. The principal author takes full responsibility for the data presented in this study, analysis of data, conclusions, and conduct of the research.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

References

  1. ↵
    1. Musher DM ,
    2. Thorner AR
    . Community-acquired pneumonia. N Engl J Med 2014;371:1619–28.doi:10.1056/NEJMra1312885 pmid:http://www.ncbi.nlm.nih.gov/pubmed/25337751
    OpenUrlCrossRefPubMed
  2. ↵
    1. File TM ,
    2. Marrie TJ
    . Burden of community-acquired pneumonia in North American adults. Postgrad Med 2010;122:130–41.doi:10.3810/pgm.2010.03.2130 pmid:http://www.ncbi.nlm.nih.gov/pubmed/20203464
    OpenUrlCrossRefPubMed
  3. ↵
    1. Davies CW ,
    2. Kearney SE ,
    3. Gleeson FV , et al
    . Predictors of outcome and long-term survival in patients with pleural infection. Am J Respir Crit Care Med 1999;160:1682–7.doi:10.1164/ajrccm.160.5.9903002 pmid:http://www.ncbi.nlm.nih.gov/pubmed/10556140
    OpenUrlCrossRefPubMedWeb of Science
  4. ↵
    1. Maskell NA ,
    2. Davies CWH ,
    3. Nunn AJ , et al
    . U.K. controlled trial of intrapleural streptokinase for pleural infection. N Engl J Med 2005;352:865–74.doi:10.1056/NEJMoa042473 pmid:http://www.ncbi.nlm.nih.gov/pubmed/15745977
    OpenUrlCrossRefPubMedWeb of Science
  5. ↵
    1. Light RW
    . Parapneumonic effusions and empyema. Proc Am Thorac Soc 2006;3:75–80.doi:10.1513/pats.200510-113JH pmid:http://www.ncbi.nlm.nih.gov/pubmed/16493154
    OpenUrlCrossRefPubMed
  6. ↵
    1. Light RW ,
    2. Girard WM ,
    3. Jenkinson SG , et al
    . Parapneumonic effusions. Am J Med 1980;69:507–12.doi:10.1016/0002-9343(80)90460-X pmid:http://www.ncbi.nlm.nih.gov/pubmed/7424940
    OpenUrlCrossRefPubMedWeb of Science
  7. ↵
    1. Colice GL ,
    2. Curtis A ,
    3. Deslauriers J , et al
    . Medical and surgical treatment of parapneumonic effusions : an evidence-based guideline. Chest 2000;118:1158–71.doi:10.1378/chest.118.4.1158 pmid:http://www.ncbi.nlm.nih.gov/pubmed/11035692
    OpenUrlCrossRefPubMedWeb of Science
  8. ↵
    1. Davies CWH ,
    2. Gleeson FV ,
    3. Davies RJO , et al
    . Bts guidelines for the management of pleural infection. Thorax 2003;58 Suppl 2:18ii–28.doi:10.1136/thorax.58.suppl_2.ii18 pmid:http://www.ncbi.nlm.nih.gov/pubmed/12728147
    OpenUrlPubMed
  9. ↵
    1. Davies HE ,
    2. Davies RJO ,
    3. Davies CWH , et al
    . Management of pleural infection in adults: British Thoracic Society Pleural Disease Guideline 2010. Thorax 2010;65 Suppl 2:ii41–53.doi:10.1136/thx.2010.137000 pmid:http://www.ncbi.nlm.nih.gov/pubmed/20696693
    OpenUrlPubMed
  10. ↵
    1. Sahn SA
    . Diagnosis and management of parapneumonic effusions and empyema. Clin Infect Dis 2007;45:1480–6.doi:10.1086/522996 pmid:http://www.ncbi.nlm.nih.gov/pubmed/17990232
    OpenUrlCrossRefPubMedWeb of Science
  11. ↵
    1. Falguera M ,
    2. Carratalà J ,
    3. Bielsa S , et al
    . Predictive factors, microbiology and outcome of patients with parapneumonic effusion. Eur Respir J 2011;38:1173–9.doi:10.1183/09031936.00000211 pmid:http://www.ncbi.nlm.nih.gov/pubmed/21565916
    OpenUrlAbstract/FREE Full Text
  12. ↵
    1. Diacon AH ,
    2. Brutsche MH ,
    3. Solèr M
    . Accuracy of pleural puncture sites: a prospective comparison of clinical examination with ultrasound. Chest 2003;123:436–41.doi:10.1378/chest.123.2.436 pmid:http://www.ncbi.nlm.nih.gov/pubmed/12576363
    OpenUrlCrossRefPubMedWeb of Science
  13. ↵
    1. Feller-Kopman D
    . Ultrasound-Guided Thoracentesis. Chest 2006;129:1709–14.doi:10.1378/chest.129.6.1709 pmid:http://www.ncbi.nlm.nih.gov/pubmed/16778292
    OpenUrlCrossRefPubMed
  14. ↵
    1. Chen KY ,
    2. Liaw YS ,
    3. Wang HC , et al
    . Sonographic septation: a useful prognostic indicator of acute thoracic empyema. J Ultrasound Med 2000;19:837–43.doi:10.7863/jum.2000.19.12.837 pmid:http://www.ncbi.nlm.nih.gov/pubmed/11127008
    OpenUrlAbstract
  15. ↵
    1. Light RW ,
    2. Macgregor MI ,
    3. Luchsinger PC , et al
    . Pleural effusions: the diagnostic separation of transudates and exudates. Ann Intern Med 1972;77:507–13.doi:10.7326/0003-4819-77-4-507 pmid:http://www.ncbi.nlm.nih.gov/pubmed/4642731
    OpenUrlCrossRefPubMedWeb of Science
  16. ↵
    1. Yang PC ,
    2. Luh KT ,
    3. Chang DB , et al
    . Value of sonography in determining the nature of pleural effusion: analysis of 320 cases. AJR Am J Roentgenol 1992;159:29–33.doi:10.2214/ajr.159.1.1609716 pmid:http://www.ncbi.nlm.nih.gov/pubmed/1609716
    OpenUrlCrossRefPubMedWeb of Science
  17. ↵
    1. Gomez CR ,
    2. Nomellini V ,
    3. Faunce DE , et al
    . Innate immunity and aging. Exp Gerontol 2008;43:718–28.doi:10.1016/j.exger.2008.05.016 pmid:http://www.ncbi.nlm.nih.gov/pubmed/18586079
    OpenUrlCrossRefPubMedWeb of Science
  18. ↵
    1. Kim S-K ,
    2. Kang CU ,
    3. Song SH , et al
    . Factors predictive of the failure of medical treatment in patients with pleural infection. Korean J Intern Med : 2014;29:603. doi:10.3904/kjim.2014.29.5.603 pmid:http://www.ncbi.nlm.nih.gov/pubmed/25228836
    OpenUrlPubMed
  19. ↵
    1. Farjah F ,
    2. Symons RG ,
    3. Krishnadasan B , et al
    . Management of pleural space infections: a population-based analysis. J Thorac Cardiovasc Surg 2007;133:346–51.doi:10.1016/j.jtcvs.2006.09.038 pmid:http://www.ncbi.nlm.nih.gov/pubmed/17258562
    OpenUrlCrossRefPubMedWeb of Science
  20. ↵
    1. Chalmers JD ,
    2. Singanayagam A ,
    3. Murray MP , et al
    . Risk factors for complicated parapneumonic effusion and empyema on presentation to hospital with community-acquired pneumonia. Thorax 2009;64:592–7.doi:10.1136/thx.2008.105080 pmid:http://www.ncbi.nlm.nih.gov/pubmed/19131449
    OpenUrlAbstract/FREE Full Text
  21. ↵
    1. Kearney SE ,
    2. Davies CW ,
    3. Davies RJ , et al
    . Computed tomography and ultrasound in parapneumonic effusions and empyema. Clin Radiol 2000;55:542–7.doi:10.1053/crad.1999.0480 pmid:http://www.ncbi.nlm.nih.gov/pubmed/10924379
    OpenUrlCrossRefPubMedWeb of Science
  22. ↵
    1. Heffner JE ,
    2. McDonald J ,
    3. Barbieri C , et al
    . Management of parapneumonic effusions. An analysis of physician practice patterns. Arch Surg 1995;130:433-8.doi:10.1001/archsurg.1995.01430040095021 pmid:http://www.ncbi.nlm.nih.gov/pubmed/7710346
    OpenUrlPubMed
  23. ↵
    1. Feller-Kopman D ,
    2. Light R
    . Pleural disease. N Engl J Med 2018;378:740–51.doi:10.1056/NEJMra1403503 pmid:http://www.ncbi.nlm.nih.gov/pubmed/29466146
    OpenUrlCrossRefPubMed
PreviousNext
Back to top
Vol 69 Issue 8 Table of Contents
Journal of Investigative Medicine: 69 (8)
  • Table of Contents
  • Table of Contents (PDF)
  • About the Cover
  • Index by author
  • AFMR Highlights
  • Front Matter (PDF)
Email

Thank you for your interest in spreading the word on JIM.

NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. We do not capture any email address.

Enter multiple addresses on separate lines or separate them with commas.
Sonographic septation: a useful diagnostic predictor of complicated parapneumonic effusion
(Your Name) has sent you a message from JIM
(Your Name) thought you would like to see the JIM web site.
CAPTCHA
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
Print
Alerts
Sign In to Email Alerts with your Email Address
Citation Tools
Sonographic septation: a useful diagnostic predictor of complicated parapneumonic effusion
Shan-Yueh Chang, Ying-Chieh Chen, Chen-Liang Tsai, Shih-Wei Wu, Chung-Kan Peng, Chih-Hao Shen, Yu-Ching Chou, Chih-Feng Chian
Journal of Investigative Medicine Dec 2021, 69 (8) 1447-1452; DOI: 10.1136/jim-2020-001770

Citation Manager Formats

  • BibTeX
  • Bookends
  • EasyBib
  • EndNote (tagged)
  • EndNote 8 (xml)
  • Medlars
  • Mendeley
  • Papers
  • RefWorks Tagged
  • Ref Manager
  • RIS
  • Zotero
Cite This
  • APA
  • Chicago
  • Endnote
  • MLA
Loading
Sonographic septation: a useful diagnostic predictor of complicated parapneumonic effusion
Shan-Yueh Chang, Ying-Chieh Chen, Chen-Liang Tsai, Shih-Wei Wu, Chung-Kan Peng, Chih-Hao Shen, Yu-Ching Chou, Chih-Feng Chian
Journal of Investigative Medicine Dec 2021, 69 (8) 1447-1452; DOI: 10.1136/jim-2020-001770
Download PDF

Share
Sonographic septation: a useful diagnostic predictor of complicated parapneumonic effusion
Shan-Yueh Chang, Ying-Chieh Chen, Chen-Liang Tsai, Shih-Wei Wu, Chung-Kan Peng, Chih-Hao Shen, Yu-Ching Chou, Chih-Feng Chian
Journal of Investigative Medicine Dec 2021, 69 (8) 1447-1452; DOI: 10.1136/jim-2020-001770
Reddit logo Twitter logo Facebook logo Mendeley logo
Respond to this article
  • Tweet Widget
  • Facebook Like
  • Google Plus One
  • Article
    • Abstract
    • Introduction
    • Methods
    • Results
    • Discussion
    • Data availability statement
    • Ethics statements
    • Footnotes
    • References
  • Figures & Data
  • eLetters
  • Info & Metrics
  • PDF

Related Articles

Cited By...

More in this TOC Section

  • Opium may affect coronary artery disease by inducing inflammation but not through the expression of CD9, CD36, and CD68
  • Bronchodilatory effect of higenamine as antiallergic asthma treatment
  • Evaluating reporting of patient-reported outcomes in randomized controlled trials regarding inflammatory bowel disease: a methodological study
Show more Original research

Similar Articles

 

CONTENT

  • Latest content
  • Current issue
  • Archive
  • Sign up for email alerts
  • RSS

JOURNAL

  • About the journal
  • Editorial board
  • Subscribe
  • Thank you to our reviewers
  • American Federation for Medical Research

AUTHORS

  • Information for authors
  • Submit a paper
  • Track your article
  • Open Access at BMJ

HELP

  • Contact us
  • Reprints
  • Permissions
  • Advertising
  • Feedback form

© 2023 American Federation for Medical Research