Chest
Volume 149, Issue 6, June 2016, Pages 1509-1515
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Original Research: Chest Infections
Pleural Effusions at First ED Encounter Predict Worse Clinical Outcomes in Patients With Pneumonia

Part of this article has been presented at the American Thoracic Society International Conference, May 19, 2014, San Diego, CA.
https://doi.org/10.1016/j.chest.2015.12.027Get rights and content

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.

Section snippets

Study Population

ED patients with pneumonia seen in seven Intermountain Healthcare Hospitals in the urban corridor of Utah were studied. Patient enrollment occurred during two 12-month periods: December 2009 through November 2010, and December 2011 through November 2012. Most patients in the present study were originally enrolled in a study of the implementation of a pneumonia electronic clinical decision support tool; the gap year between December 2010 and November 2011 was the period of tool deployment.12

All

Results

Of the 458,837 adult patients who were admitted to the study EDs, 4,771 had pneumonia and fulfilled the entry criteria. Among these subjects, 690 (14.5%) had a pleural effusion (Fig 1). The effusions were small in 563 (81.6% of all the patients with effusions), moderate in 101 (14.6%), and large in 26 (3.8%) patients. Pleural effusions were defined by using chest CT scans in 263 (38.1%), 280 (40.6%) by upright CXR imaging, and 147 (21.3%) by supine portable CXR imaging in the EDs. Pleural

Discussion

In this study, patients with pneumonia with radiologically defined pleural effusions at ED presentation were more likely to die by 30 days, more likely to be admitted to the hospital, and had a longer length of stay compared with patients without effusion, even after adjustment for severity of illness. Importantly, eCURB/CURB-65 significantly underestimated the 30-day mortality of patients with pneumonia presenting with a pleural effusion. These data suggest that the presence of a pleural

Conclusions

Patients with pneumonia presenting with a pleural effusion had more comorbid illnesses, experienced higher rates of mortality and hospital admissions, and had longer stays in the hospital. Clinicians must recognize the implication on clinical outcome conferred by the presence of an effusion. Targeted therapies or increased attention to fluid drainage might be needed to improve outcome in this patient population.

Acknowledgments

Author contributions: N. C. D. conceived the original idea for this study, performed critical revision of the manuscript for intellectual content, obtained funding, and is overall responsible for the content of the manuscript, including the data and analysis. P. P. G. performed data acquisition, analysis, and interpretation of data, and drafted the initial manuscript. J. S. S. was primarily responsible for statistical analysis and performed critical revision of the manuscript for intellectual

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