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Pleural Empyema Management

Pleural Empyema Management. Benoit Guery Maladies Infectieuses Philippe Ramon Service d’endoscopie Respiratoire CHRU Lille. Empyema formation. Exudative stage fibrinous material forms on both pleural surfaces. As more fibrin is deposited Fibrinopurulent stage may last several weeks

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Pleural Empyema Management

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  1. Pleural EmpyemaManagement Benoit Guery Maladies Infectieuses Philippe Ramon Service d’endoscopie Respiratoire CHRU Lille

  2. Empyema formation • Exudative stage • fibrinous material forms on both pleural surfaces. • As more fibrin is deposited • Fibrinopurulent stage • may last several weeks • pleural surfaces may be joined by fibrinous septae which cause the fluid to become loculated • Organisational stage • Proliferation of fibroblasts on the pleural surfaces, which form an inelastic covering preventing adequate lung expansion (fibrothorax).

  3. Goals of the treatment • Treat the infection • Drain the purulent effusion adequately and completely • Re-expand the lung to fill the pleural space • Eliminate complications and avoid chronicity

  4. The infection

  5. Bacteriological data • Pleural Ponction : • Exsudate • Direct analysis, Gram stain • Aerobic and anaerobic cultures (Bactec) • If possible before antibiotic treatment • Results • Mono or polymicrobial ( 4-30%) • Variations between series • Variations between underlying conditions

  6. Wait et al, Chest 1997 Cheng et al, Chest 2005

  7. Maskell et al, NEJM 2005

  8. Bacteriological data. • Streptococcus pneumoniae: 15-20% • Increased resistance • Staphylococcus:15-30% • Streptococcus spp • Gram Negative: 20-50% • Klebsiella, Enterobacter, Pseudomonas, Hemophilus, E.Coli • Anaerobes: • Fusobacterium, Bacteroides fragilis

  9. Microbiological diagnosis techniques 3 methods - Standard culture - PCA: Pneumococcal capsular antigen - 16S rDNA PCR confirmed by pneumolysin PCR Le Monnier et al, Clin Inf Dis 2006

  10. Microbiological diagnosis techniques Latex antigen detection Se: 90% Sp: 95% Le Monnier et al, Clin Inf Dis 2006

  11. Antibiotic treatment • As soon as the bacteriologic sample are recovered • Pneumonia • Amoxicillin, 3GC or 3GC +/- Metronidazole • Amox-clavulanic acid • Dosage of the molecule • Nosocomial • Tazobactam or Imipenem • +/- Aminoglycoside or Quinolone • Not Pneumococcus directed molecules • Adapted to the laboratory results

  12. Adequate drainage Available techniques

  13. Primary treatment options • Antibiotics alone; • Recurrent thoracocentesis • Insertion of chest drain alone or in combination with fibrinolytics • VATS. • Open decortication

  14. Thoracocenthesis • Big caliber needle • Mostly diagnosis technique • Therapeutically used if the liquid remains fluid • Theoretically allows pleural lavage

  15. Chest Tube • As soon as the liquid is thick • Localization • free: axillary • loculated: Chest imaging using ultrasonography and/or computed tomography • Size: 20 à 24 • Bedside

  16. Pleural Lavage • Isotonic saline • +/- Noxyflex (noxytioline) • Modalités • 3 way stopcock • Directly through the CT: 250 to 500 ml • Cautiously if suspicion of broncho-pleural fistula • Timing: • Immediately after CT placement+++ • Once a day until the liquid is clear

  17. NOXYFLEX (noxytioline) • Local disinfectant (formaldéhyde) • 2,5 g diluted in a least 100ml isotonic saline • Maximum: 5g/day • Incompatible with iodine polyvidone,chlorhexidin, chlorine solution, lactic acid

  18. Fibrinolytics • Urokinase: 100 000 or 300 000 IU conditioning • Streptokinase: 250000 IU conditioning • 250.000 IU in 10-20 ml isotonic saline • Don’t evacuate before 24 to 48 heures • Constantly associated with fever (38-39°C) • Then evacuate • Pleural lavage • clamp 4h ( Chest 1996)

  19. Video-assisted thoracic surgery • Collection<10 cm: unusual • Visual control of the CT position • 5 mm introducer, 4 mm optical • Collection>10 cm • 10 mm introducer • Two or three ports are made in the chest • One port is utilised for the camera and the others for grasping instruments • Free fluid is evacuated and loculations drained under thoracoscopic visualisation. • Fibrinous adhesions are separated and the pleural debris removed from the pleural lining using endoscopic grasping forceps or by extensive irrigation and suction. • Following the procedure, one or two chest drains are then placed in the portholes.

  20. Local antibiotics • Usually Rifampin or Colimycin • Still debated • Do not replace systemic treatment

  21. Physiotherapy • Key to a correct evolution • After CT removal • Often and for a long time….. • Decrease surgery • Decrease long term pain and functionnal limitations

  22. Therapeutic choices

  23. Guidelines to predict which patients with non-purulent parapneumonic effusions warrant chest tube drainage • 240 patients with PPE • 85 uncomplicated PPE • 67 complicated PPE • 88 empyema Porcel et al, Respir Med 2006

  24. BTS: non purulent PPE is complicated if any of the following pH<7.2 LDH> 1000 IU/L Glucose <40mg/dL Positive culture ACCP: Positive culture pH<7.2 Glucose <60mg/dL Effusion>half of the hemithorax BTS and ACCP criteria Porcel et al, Respir Med 2006

  25. Porcel et al, Respir Med 2006

  26. Compare Chest Tube + Streptokinase (n=9) vs VATS (n=11) B score on the Cochrane analysis with methodological concerns: Small number Patient selection Unclear allocation and outcome assessor blinding But: VATS is superior to CT for large loculated pleural empyemas Duration CT LOS Wait et al, Chest 1997 Cochrane 2005

  27. Prospective study between 1997 and 2004 2 groups I: video-assisted thoracoscopy (chest tube, fibrin debrided) II: chest tube without VAT Surgical decortication Group I: 17.1% Group II: 37.1% LOS Group I: 8.3 days Group II: 12.8 days Bilgin et al, ANZ J Surg 2006

  28. Hypothesis: Urokinase is effective through the lysis and not the volume effect Randomized double blind study UK (15 patients) for 3 days, 100 000 IU in 100 ml NS Control (16 patients), 100 ml NS for 3 days Complete drainage UK: 13/15 (86%) NS: 4/16 (25%) Bouros et al, AJRCCM 1999

  29. Cochrane analysis 2007

  30. Cochrane analysis 2007

  31. Cochrane analysis 2007

  32. Cochrane analysis 2007

  33. Cochrane analysis 2007

  34. Cochrane analysis 2007

  35. Prospective study from 2001 to 2004 • Cause: bacterial pneumonia • 2 groups: • A: CT (70) • B: CT + SK (57) Multivariate analysis: the use of fibrinolysis is the only independent factor associated with a favorable outcome Misthos et al, Eur J Car Thor Surg 2005

  36. 452 patients with pleural infection Sk 250 000 IU twice daily for 3 days Placebo No difference in mortality, rate of surgery, radiographic outcomes, LOS Serious adverse events more common with Sk (chest pain, allergy, fever) Maskell et al, NEJM 2005

  37. Meta-analysis with 5 properly randomized trials comparing fibrinolytic agents to placebo • 575 patients Tokuda et al, Chest 2006

  38. Only one study analyzed… no differences observed on the parameters Cochrane analysis 2007

  39. Fibrinolytics vs VATS • 60 children matched • No difference • LOS after intervention • Failure rate • Radiologic outcome at 6 month • Treatment cost with UK ($6 914)< VATS ($10 146) Sonnappa et al, AJRCCM 2006

  40. Case report 1 • 50 yo • Left Pneumococcus empyema • Admitted on the 4th day • D2 streptase instillation • D3 VATS+2 CT • CT removal on D8 • Discharged on D12

  41. Case report 2 • 76 yo • March 96: Pneumonia • April 96 : Left lung effusion • No fever, CRP 29, fibrinogen 7g/l • Exsudate, LDH 7200, glucose 0,24g/l cytology PMN, negative direct examination

  42. VATS (25/4/96): • loculated • Removed debris and liquid (600ml) • Posterior CT n°24 • Pleural lavage (Noxyflex) • CT removal on 2/5/96

  43. Indications Thoracocentesis Clear liquid Not clear or purulent effusion pH>7.20 pH<7.20 Not loculated Loculated No intervention Reccurent thoracocentesis Drainage Pleural lavage Drainage Pleural lavage Fibrinolytics Failure VATS Surgery Hamm et al, ERJ 1997

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