Pleural effusion in pneumonia means worse prognosis

Short Attention Span Summary

Parapneumonic effusion was associated with increased risk of death, hospitalization, and length of stay in this retrospective study.  The clinical prediction instrument, CURB-65, underestimated mortality risk in patients with parapneumonic effusion: 7% predicted vs. 14% actual.  Why does this matter?  Standard clinical prediction rules to determine inpatient vs. outpatient treatment do not take this into account.  If an ED patient has a parapneumonic effusion, be extra cautious and err on the side of admission.

Speaking of prediction rules, it's hard to keep them all straight.  There is a new evidence-based clinical decision support tool that I use called Evidence Care, developed by an Emergency Physician from University of Virginia.  With authors like Kline, Mattu, Brady, and other heavy hitters, it is well written and well designed.  Best of all, it's free!


Abstract

Chest. 2016 Jun;149(6):1509-15. doi: 10.1016/j.chest.2015.12.027. Epub 2016 Jan 16.

Pleural Effusions at First ED Encounter Predict Worse Clinical Outcomes in Patients With Pneumonia.

Dean NC1, Griffith PP2, Sorensen JS3, McCauley L4, Jones BE5, Lee YC6.

Author information:

1Division of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, UT; Department of Medicine, University of Utah School of Medicine, Salt Lake City, UT. Electronic address: nathan.dean@imail.org.

2Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT.

3Division of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, UT.

4Division of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, UT; Department of Medicine, University of Utah School of Medicine, Salt Lake City, UT.

5Department of Medicine, University of Utah School of Medicine, Salt Lake City, UT; Division of Pulmonary and Critical Care Medicine, Salt Lake City VA Health System, Salt Lake City, UT.

6Pleural Diseases Unit, Sir Charles Gairdner Hospital, University of Western Australia-Perth, Western Australia.

Abstract

BACKGROUND:

Pleural effusions are present in 15% to 44% of hospitalized patients with pneumonia. It is unknown whether effusions at first presentation to the ED influence outcomes or should be managed differently.

METHODS:

We studied patients in seven hospital EDs with International Statistical Classification of Disease and Health Related Problems-Version 9 codes for pneumonia, or empyema, sepsis, or respiratory failure with secondary pneumonia. Patients with no confirmatory findings on chest imaging were excluded. Pleural effusions were identified with the use of radiographic imaging.

RESULTS:

Over 24 months, 4,771 of 458,837 adult ED patients fulfilled entry criteria. Among the 690 (14.5%) patients with pleural effusions, their median age was 68 years, and 46% were male. Patients with higher Elixhauser comorbidity scores (OR, 1.13 [95% CI, 1.09-1.18]; P < .001), brain natriuretic peptide levels (OR, 1.20 [95% CI, 1.12-1.28]; P < .001), bilirubin levels (OR, 1.07 [95% CI, 1.00-1.15]; P = .04), and age (OR, 1.15 [95% CI, 1.09-1.21]; P < .001) were more likely to have parapneumonic effusions. In patients without effusion, electronic version of CURB-65 (confusion, uremia, respiratory rate, BP, age ≥ 65 years accurately predicted mortality (4.7% predicted vs 5.0% actual). However, eCURB underestimated mortality in those with effusions (predicted 7.0% vs actual 14.0%; P < .001). Patients with effusions were more likely to be admitted (77% vs 57%; P < .001) and had a longer hospital stay (median, 2.8 vs 1.3 days; P < .001). After severity adjustment, the likelihood of 30-day mortality was greater among patients with effusions (OR, 2.6 [CI, 2.0-3.5]; P < .001), and hospital stay was disproportionately longer (coefficient, 0.22 [CI, 0.14-0.29]; P < .001).

CONCLUSIONS:

Patients with pneumonia and pleural effusions at ED presentation in this study were more likely to die, be admitted, and had longer hospital stays. Why parapneumonic effusions are associated with adverse outcomes, and whether different management of these patients might improve outcome, needs urgent investigation.

Copyright © 2016 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.

PMID: 26836918 [PubMed - in process]