Empyema Guidelines
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Guidelines in management of Empyema

Guidelines in management of Empyema

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Empyema Guidelines Presentation Transcript

  • 1. EMPYEMA GUIDELINES Dr.PREETHAM KUMAR REDDY CONSULTANT PEDIATRICIAN & INTENSIVIST RAINBOW CHILDREN’S HOSPITAL
  • 2. Empyema
    • Pus and fluid from infected tissue in the pleural cavity.
    • Also called empyema thoracis, or empyema of the chest.
    • Empyema has a number of causes but is most frequently a complication of pneumonia.
  • 3. Thoracic Empyema
  • 4. Thoracic Empyema-- Stage 1
    • Exudative effusion.
    • Increased permeability of the inflammatory and swollen pleural surface.
    • Corresponds to the uncomplicated parapneumonic effusion.
    • Sterile, fibrin and PMN may present.
  • 5. Uncomplicated Effusion
    • Nonpurulent.
    • -ve Gram’s stain -ve culture.
    • Free flowing
    • pH 7.3
    • normal glucose level
    • LDH <1000 IU/L.
    • Most resolve with appropriate antibiotics treatment and resolution of the pulmonary infection.
    • Progress from stage 1 to 2 may occur quickly, often within 24–48 h .
  • 6. Thoracic Empyema-- Stage 2
    • Fibropurulent / true empyema / complicated pleural effusion.
    • Initial-- fluid is clear :
    • WBC > 500 cell/μL
    • Protein> 2.5 g/dL
    • pH< 7.2,
    • LDH< 1000 IU/L, fibrin deposits.
    • Angioblastic and fibroblastic proliferation, heavy fibrin deposition on both pleura, particularly the parietal pleura.
  • 7.
    • Later–
    • fluid purulent
    • WBC 15000,
    • ph <7.0,
    • glucose < 50 mg/dL
    • LDH > 1000 IU/L.
  • 8. Thoracic Empyema-- Stage 3
    • 1 week after infection-- collagen organization, entrapment of the underlying lung.
    • 3-4 week-- mature, turns into a peel.
    • peel prevents entry of anti-microbial drugs in the pleural space and contributes to drug resistance.
    • Thickened pleural peel restricts lung movement and leads to trapped lung and f ibrothorax
  • 9. Etiology
    • Pneumococcal infection remains the most common isolated cause in developed countries, with Staphylococcus aureus the predominant pathogen in the developing world.
    • Jaffe et al. Pediatr Pulmonol. 2005; 40:148-156 .
  • 10. US prevalence
    • After prevnar (1999-2000 vs 2001-2002)
    • 1) Patients admitted with empyema (per 10 000 admissions) decreased from 23 to 12.6
    • 2) Prevalence of S pneumoniae has decreased from 66% to 27%
    • 3) S aureus has become the most common pathogen isolated (18% vs 60%), with 78% of those being methicillin resistant.
    • Schultz et al.Pediatrics. 2004 Jun;113(6):1735-40
  • 11. 265 children with empyema admitted to the PGIMER, 1989–98
    • Culture positivity had decreased significantly (48% v 75%) over the years.
    • Staphylococcus aureus commonest (77%) aetiological agent;
    • S treptococcus pneumoniae cases seen during the winter and spring season.
    • Gram negative rods grew in 11%.
    • Community acquired MRSA in 3 patients
    • Baranwal et al .Arch Dis Child. 2003 November; 88(11): 1009–1014 .
  • 12. Diagnostic Evaluation
    • Radiographic Studies
    • PA and decubitus x-ray
    • First step in diagnosis
    • Fluid layer is seen on dependent side
  • 13. USG
    • Very useful tool for diagnosis, guidance of thoraco-centesis, or pleural catheter placement.
    • Sonography can distinguish solid from liquid pleural abnormalities with 92% accuracy compared to 68% accuracy with chest X -ray. When both are combined, accuracy rises to 98%
    • USG shows limiting membranes suggesting the presence of loculated collections even when they are invisible by CT scan.
  • 14. CT scan
    • Chest CT Scan
    • Defines effusion
    • consolidation
    • abscess
    • necrosis
    • adhesions
    • Guides interventions
  • 15. Is CT Scan necessary
    • Unnecessary for most cases of pediatric empyema
    • Has a role in complicated cases
    • Initial failure to aspirate pleural fluid
    • failing medical management and
    • particularly in immunocompromised children where a CT scan could reveal other serious clinical problems.
  • 16. Goal of treatment
    • Control of infection
    • Drainage of pus
    • Expansion of lungs
  • 17. Stage 1/exudative stage
    • Free-flowing serous effusion pH>7.20, Sugar >60 mg/dL, LDH >3 times the upper limit of normal
    • Management with
    • Antibiotics
    • Drainage if effusion is significant
    • Give consideration to early active treatment as conservative treatment results in prolonged duration of illness and hospital stay.
  • 18. Empirical antibiotics
    • Anti Staph antibiotic + Cephalosporin + Aminoglycoside
    • Suspected anaerobic infection Clindamycin should be added
  • 19. Antibiotics
    • Parenteral therapy to be continued for 48-72 hours after abatement of fever and then oral therapy can be used to complete the course.
    • Antibiotic to be continued until
    • patient is afebrile,
    • WBC count is normal,
    • radiograph shows considerable clearing
    • Duration of oral therapy is 1- 4 weeks.
  • 20. Drainage Options
    • Simple thoracocentesis
    • Necessary for analyzing pleural fluid & to direct antibiotic therapy
    • Chest tube placement
    • Indicated for all large transudative effusions & the early exudative phase of parapneumonic pneumonias
    • Repeated thoracocentesis is rarely successful
  • 21. Empyema drainage
    • CT or USG guided drainage if empyema collection is small
    • Chest tube must be kept inside till drainage is less than 30-50 ml per day and cavity size is less than 50 ml in size
    • The addition of fibrinolytic therapy may improve drainage during the fibrinopurulent stage
  • 22. Who what where
    • Chest drains should be inserted by adequately trained personnel to reduce the risk of complications.
    • Small bore percutaneous drains should be inserted at the optimum site suggested by chest ultrasound
    • The drain should be removed once there is clinical resolution or drainage is < 50 ml.
  • 23. Safe triangle for insertion of chest drains
  • 24. Stage 2/fibronopurulent stage
    • Uncomplicated<7.20, Sugar <60 mg/dL, LDH >3 times the upper limit of normal
    • Antibiotics
    • Chest tube
    • Drainage
    • Consider fibrinolytics
  • 25.
    • Complicated
    • pH <7.00,Sugar <60 mg/dL, LDH>3 times the upper limit
    • Antibiotics
    • Chest tube drainage, consider
    • fibrinolytics or
    • VATS
  • 26. Fibrinolytics
    • There is no evidence that any of the three fibrinolytics are more effective than the others, only urokinase studied in a RCT in children so is recommended.
    • tPA is used in US
    • Thompson et al Thorax 2002; 57 :343-347;
  • 27. Stage 3/organizing stage Fibrinous peel, lung entrapment
    • Antibiotics
    • VATS
    • if unsuccessful decortication
    • Ampofo et al. Pediatr Infect Dis J. 2007 May ; 26(5): 445–446 .
  • 28. Indications for Surgical Treatment
    • Gates et al (2004) in a retrospective review found that 80% of children with empyema did not require surgical intervention
    • Lack of clinical & radiological response to medical treatment
    • Complex empyema with significant lung pathology
  • 29. Systematic Review of Optimal Treatment (Gates et al, 2004)
    • 44 studies describing treatment of empyema in 1369 infants & children (retrospective reviews)
    • 4 treatment strategies: chest tube drainage, chest tube + fibrinolytics,
    • open thoracotomy + decortication &
    • VATS
    • LOS was the only statistically significant difference between 4 strategies
    • VATS LOS = 10.5 days vs. CT 16.4 days or fibrinolytic 18.9 days
  • 30. Thank You