The management of empyema the practical

vs. ideal approach

R. MasekelaUniversity 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

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.

• 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

On ExaminationOn 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

30/5/07

ICD inserted

19/5 22/5 30/5

Hb 11.9 11.0 9.8

MCV 69.9 71.9 .30

Platelets 961 729 844

WCC 27.88 16.70 16.77

Neutrophils 10.23

Lymphocytes 4.53

Monocytes 2.01

Na 145 140 140

K 4.7 3.2 4.8

CL 108 105 105

CO2 14 20 16

Urea 9.1 1.5 <1.0

Creatinine 83 23 30

Anion Gap 28 18 24

CRP 221.5 72.8 144.4

ESR 69

NGA - AFB -ve -ve

Pleural pus specimen - 31/05/07

Cultured Staph. Aureus

R - Penicillin/ampicillin

R - Erythromycin

R - Clindamycin

S - Cloxacillin

1/06/07

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”

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.

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

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

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

Other minor criteria Cholesterol > 45mg/dl

Protein content > 3.0 g/dl

pH <7.2

Glucose < 50% serum

Parapneumonic pleural effusions 3 groups or stages based on pathogenesis:

Uncomplicated parapneumonic effusion

Complicated parapneumonic effusion

Thoracic empyema.

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.

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

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

Complications Dissect into lung parenchyma→

bronchopleural fistulas and pyopneumothorax

Dissection through chest wall (empyema necessitatis) RARE

Dissection into abdominal cavity

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

Organisms Tuberculosis

Rare cause but common PPE

Fungi

Viral

Atypical organism Mycoplasma

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.

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.

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

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

Ultrasound Size of effusion

Differentiate consolidation from empyema

Unreliable predictor of disease severity

CT scan Anatomical

Parenchymal lesions Endobronchial lesions Mediastinal lesions Lung abscess

Management

IV antibiotics and intercostal drainage

Fibrinolytics

Video -Assisted Thoracoscopic Surgery (VATS)

Open thoracotomy and decortication

Management Supportive

Bed rest Analgesia Oxygen Fluids

Identify the cause Malnutrition TB HIV

Antibiotic therapy

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

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)

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

VATS Can be done as primary procedure

Experienced surgeon necessary

Benefits lower mortality Re-intervention Reduced length of hospital stay Reduced hospital costs

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

Thoracotomy Treatment of choice if no experience or

success with VATS

Early and accurate diagnosis and therapy

Attempt “mini” vs. full procedure

Mortality reduced

Ideal approach

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

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

Prognosis Favourable in patients started on

appropriate antibiotic

Early chest tube drainage is beneficial.

Decortication or open drainage has decreased mortality and morbidity.

Prognosis Mortality 6-12%

Complications Bronchopleural fistula Tension pneumatocoele Fibrothorax

4/06/07

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