title: Pleural Effusions at First ED Encounter Predict Worse Clinical Outcomes in Patients With Pneumonia.
abstract: 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.
  
  
  
  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.
  
  
  
  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).
  
  
  
  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.
authors.affiliation: Division 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.
authors.forename: Nathan C
authors.initials: NC
authors.lastname: Dean
authors.affiliation: Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT.
authors.forename: Paula P
authors.initials: PP
authors.lastname: Griffith
authors.affiliation: Division of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, UT.
authors.forename: Jeffrey S
authors.initials: JS
authors.lastname: Sorensen
authors.affiliation: Division of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, UT; Department of Medicine, University of Utah School of Medicine, Salt Lake City, UT.
authors.forename: Lindsay
authors.initials: L
authors.lastname: McCauley
authors.affiliation: Department 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.
authors.forename: Barbara E
authors.initials: BE
authors.lastname: Jones
authors.affiliation: Pleural Diseases Unit, Sir Charles Gairdner Hospital, University of Western Australia-Perth, Western Australia.
authors.forename: Y C Gary
authors.initials: YC
authors.lastname: Lee
mesh_terms: D000368:Aged; D015897:Comorbidity; D019468:Disease Management; D057286:Electronic Health Records; D005260:Female; D006760:Hospitalization / Q000706:statistics & numerical data; D006801:Humans; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D063868:Patient Outcome Assessment; D010996:Pleural Effusion / Q000175:diagnosis / Q000453:epidemiology / Q000628:therapy; D011014:Pneumonia / Q000175:diagnosis / Q000453:epidemiology / Q000628:therapy; D011379:Prognosis; D013902:Radiography, Thoracic / Q000379:methods; D012307:Risk Factors; D012720:Severity of Illness Index; D016019:Survival Analysis; D014481:United States / Q000453:epidemiology
keywords: brain natriuretic peptide; emergency medicine; pleural effusion; pneumonia
references.citation: Eur Respir J. 2011 Nov;38(5):1173-9
references.pmid: 21565916
references.citation: Trends Ecol Evol. 2009 Mar;24(3):127-35
references.pmid: 19185386
references.citation: BMC Pulm Med. 2014 Sep 22;14:149
references.pmid: 25244961
references.citation: Med Care. 2004 Apr;42(4):355-60
references.pmid: 15076812
references.citation: Arch Intern Med. 1997 Aug 11-25;157(15):1709-18
references.pmid: 9250232
references.citation: Clin Infect Dis. 2007 Mar 1;44 Suppl 2:S27-72
references.pmid: 17278083
references.citation: J Thorac Dis. 2015 Jun;7(6):992-8
references.pmid: 26150912
references.citation: Med Care. 1998 Jan;36(1):8-27
references.pmid: 9431328
references.citation: Cancer. 2011 May 1;117(9):1957-65
references.pmid: 21509773
references.citation: N Engl J Med. 2015 Jul 30;373(5):415-27
references.pmid: 26172429
references.citation: Ann Emerg Med. 2015 Nov;66(5):511-20
references.pmid: 25725592
references.citation: Chest. 2011 Jul;140(1):156-163
references.pmid: 21163875
references.citation: Biometrics. 1977 Mar;33(1):159-74
references.pmid: 843571
references.citation: Clin Ther. 1998 Jul-Aug;20(4):820-37
references.pmid: 9737840
references.citation: Thorax. 2010 Jan;65(1):91
references.pmid: 20029043
references.citation: Respirology. 2015 Jul;20(5):813-8
references.pmid: 25998684
references.citation: Thorax. 2009 Jul;64(7):592-7
references.pmid: 19131449
references.citation: Clin Orthop Relat Res. 2014 Sep;472(9):2878-86
references.pmid: 24867450
references.citation: Arch Intern Med. 1996 Oct 28;156(19):2206-12
references.pmid: 8885819
references.citation: Am J Med. 2006 Oct;119(10):877-83
references.pmid: 17000220