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The management of empyema the practical vs. ideal approach

The management of empyema the practical vs. ideal approach. R. Masekela University of Pretoria . Case presentation. Patient A.K 11 month old baby boy Main Complaint : Coughing - two weeks non productive Fever - two weeks Vomiting - after coughing

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The management of empyema the practical vs. ideal approach

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  1. The management of empyema the practical vs. ideal approach R. Masekela University of Pretoria

  2. Case presentation

  3. Patient A.K 11 month old baby boy Main Complaint : Coughing - two weeks non productive Fever - two weeks Vomiting - after coughing Diarrhoea - one week, brown and loose no blood noted in stool 3 weeks before admission to primary care hospital was seen with a cough and fever and treated with Amoxycillin and Paracetamol. Did not improve after a week and was taken back.

  4. Diagnosis with bronchopneumonia and a pleural effusion Ampicillin and Amikacin for 6 days • Vancomycin for 2 days • PMH : No previous admissions, healthy • Family history : no atopy, no asthma • No TB contacts

  5. On Examination Mass 10kg, 100% expected Length 78cm, 100% expected Vitals : RR 60, Pulse 110, Temp 37.5, BP 90/40 Sats 90% 5% dehydrated Chest: Grunting, Nasal flaring, subcostal recessions, bilateral scattered crepitations, decreased air entry right lower lobe and stony dullness right base

  6. 30/5/07

  7. ICD inserted

  8. Pleural pus specimen - 31/05/07 Cultured Staph. Aureus R - Penicillin/ampicillin R - Erythromycin R - Clindamycin S - Cloxacillin

  9. 1/06/07

  10. HISTORY • 460 BC • Em=within • Pyema=accumulation of pus • Hippocratic physicians recommended treating empyema with open drainage • “those diseases that medicines do not cure are cured by the knife”

  11. HISTORY cont’d • 1876- Hewitt described a method of closed drainage of the chest in which a rubber tube was placed into the empyema cavity and drained via the water seal drainage • Early 20th century introduction of surgical therapies for empyema • thoracoplasty, decortication.

  12. Empyema • Empyema: presence of pus in the pleural space • Boys affected more than girls • First world 0.6-3% bacterial pneumonias Megan et al Curr Opinion Pediatr 2007 • HIV positive 8% of South African children Zar et al. Acta Paediatrica 2001

  13. Normal pleural fluid • Pleural space potential space 10-24µm • 0.1-0.2 ml/kg pleural fluid • Starlings forces: filtration and reabsorption • pH 7.6

  14. Light’s criteria • Pleural fluid protein: serum protein > O.5 • Pleural fluid : serum LDH >0.6 • Pleural fluid LDH > 2/3 upper limit of serum LDH Light R. Chest 1995;108:299-301

  15. Other minor criteria • Cholesterol > 45mg/dl • Protein content > 3.0 g/dl • pH <7.2 • Glucose < 50% serum

  16. Parapneumonic pleural effusions • 3 groups or stages based on pathogenesis: • Uncomplicated parapneumonic effusion • Complicated parapneumonic effusion • Thoracic empyema.

  17. Exudative stage • Sterile pleural fluid accumulates in pleural space. • Pleural fluid originates in lung interstitial spaces and in capillaries of visceral pleura due to increased permeability. • Pleural fluid ↓ WBC ↓ LDH level, glucose and pH levels are normal • Effusions resolve with antibiotic therapy.

  18. Fibropurulent stage • Bacterial invasion of the pleural space occurs → accumulation of neutrophils, bacteria and cellular debris • Deposition of fibrin loculations • Pleural fluid pH <7.2 , glucose levels ↓, LDH level >1000IU/l

  19. Organizational stage • Fibroblasts grow into the exudates from both the visceral and parietal pleural surfaces • They produce an inelastic membrane called pleural peel. • Thick pleural fluid

  20. Complications • Dissect into lung parenchyma→ bronchopleural fistulas and pyopneumothorax • Dissection through chest wall (empyema necessitatis) RARE • Dissection into abdominal cavity

  21. Organisms • Strep. pneumonia • HIV infection 41X risk of invasive disease and more resistance Mahdi et al PIDJ 2000 • Incidence increasing in developing world • S. aureus • Increasing incidence CA-MRSA in HIV-infected children 50% in Natal blood culture positive. McNally et al. Lancet 2007 • 67 of 100 empyema. Goel et al. J Tropical Peadiatr 1999 • H. influenza type b • Gram negatives • Pseudomonas • Klebsiella • E.coli

  22. Organisms • Tuberculosis • Rare cause but common PPE • Fungi • Viral • Atypical organism • Mycoplasma

  23. Clinical manifestations • Aerobic bacterial pneumonia • An acute febrile illness with chest pain, sputum production, and leukocytosis. • A complicated parapneumonic effusion with presence of a fever lasting more than 48 hours after initiation of antibiotic therapy.

  24. Clinical manifestation • Anaerobic bacterial infection • Usually presents with subacute illness. • symptoms persisting for more than 7 days. •  60% of patients have weight loss. • Poor oral hygiene • Factors predisposing to recurrent aspiration.

  25. Chest x-rays • PA and lateral decubitus • Adult studies sensitivity 67% and specificity 70% Heffner JE. Clinics Chest Med 1999;20:607-622 • PA at least 400ml fluid vs. 50ml lateral decubitus • Assess for loculations

  26. Ultrasound • Classification • Stage 1: anechoic fluid • Stage 2: loculations • Stage 3: solid peel • Guide placement of intercostal drain Hogan MJ, Cooley BD. Paediatric Resp Reviews 2008;9:77-84

  27. Ultrasound • Size of effusion • Differentiate consolidation from empyema • Unreliable predictor of disease severity

  28. CT scan • Anatomical • Parenchymal lesions • Endobronchial lesions • Mediastinal lesions • Lung abscess

  29. Management • IV antibiotics and intercostal drainage • Fibrinolytics • Video -Assisted Thoracoscopic Surgery (VATS) • Open thoracotomy and decortication

  30. Management • Supportive • Bed rest • Analgesia • Oxygen • Fluids • Identify the cause • Malnutrition • TB • HIV

  31. Antibiotic therapy Zampoli M, Zar H. SAJCH 2007;1(3):121-8

  32. Fibrinolytics • Degrade fibrin, blood clots and pleural loculi in pleural space • Streptokinase: 15 000U/kg in 20-50ml saline once daily for 3 days (vial 750 000U R1400, 1 million units R2700) • Urokinase: 40 000u in 40ml saline (> 1 year) or 10 000 in 10 ml BD for 3 days(< 1 year) • tPA 0.1mg/kg in 10-30ml saline dwell time 1 hour (50mg vial R3100)

  33. Fibrinolytic therapy versus conservative managements: Cochrane review • Seven studies 761 participants • No significant difference in risk of death (RR 1.08;95% CI 0.69-1.68) • Reduction in risk of treatment failure (RR 0.63;95% CI 0.46-0.85) • Fibrinolytics confer significant benefit and reduce requirement for surgical intervention (in early studies published) Cameron R, Davies HR. Cochrane review April 23 2008 Issue 2

  34. VATS • Can be done as primary procedure • Experienced surgeon necessary • Benefits • lower mortality • Re-intervention • Reduced length of hospital stay • Reduced hospital costs

  35. Aziz et al Surgical infections 2008;9(3):317-23

  36. Thoracotomy • Treatment of choice if no experience or success with VATS • Early and accurate diagnosis and therapy • Attempt “mini” vs. full procedure • Mortality reduced

  37. Ideal approach Fuller MK, Helmrath MA. Curr Opinion Pediatrics 2007;19:328-332

  38. Practical • Early diagnosis • CXR include lateral decubitus • Early antibiotics • Early chest drainage • Loculations • Early referral • Thoracotomy if no improvement with ICD placement and correct antibiotics

  39. Prognosis • Favourable in patients started on appropriate antibiotic • Early chest tube drainage is beneficial. • Decortication or open drainage has decreased mortality and morbidity.

  40. Prognosis • Mortality 6-12% • Complications • Bronchopleural fistula • Tension pneumatocoele • Fibrothorax

  41. 4/06/07

  42. Acknowledgements • Prof R Green • Dr O Kitchin • Dr S Risenga • Dr Moodley • ICU staff

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