Pleural effusions and pneumothoraces

On the basis of class C evidence and consensus, ultrasonography should be used preferentially over computed tomography scan for the diagnosis of parapneumonic effusion and empyema. On the basis of class C evidence and consensus, pleural fluid should be drained in patients with large effusions, loculated effusions, and moderate-sized effusions who fail to improve or have worsening symptoms. On the basis of class C evidence and consensus, small-bore chest tubes should be used even when chemical fibrinolytic therapy is planned. On the basis of class A evidence and consensus, even though prospective trials have shown equivalent efficacy of videoassisted thoracoscopic surgery and chest tube insertion with fibrinolytic therapy, chest tube with chemical fibrinolysis should be first-line therapy when resources allow due to decreased resource utilization. On the basis of class B evidence, definitive management with chest tube placement with fibrinolysis should be initiated when empyema is diagnosed. On the basis of class C evidence, primary surgical intervention should be reserved for pediatric patients with recurrent primary spontaneous pneumothoraces and those with persistent air leaks. Additional Resources.