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Empyema Guidelines
Empyema Guidelines
Empyema Guidelines
Empyema Guidelines
Empyema Guidelines
Empyema Guidelines
Empyema Guidelines
Empyema Guidelines
Empyema Guidelines
Empyema Guidelines
Empyema Guidelines
Empyema Guidelines
Empyema Guidelines
Empyema Guidelines
Empyema Guidelines
Empyema Guidelines
Empyema Guidelines
Empyema Guidelines
Empyema Guidelines
Empyema Guidelines
Empyema Guidelines
Empyema Guidelines
Empyema Guidelines
Empyema Guidelines
Empyema Guidelines
Empyema Guidelines
Empyema Guidelines
Empyema Guidelines
Empyema Guidelines
Empyema Guidelines
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Empyema Guidelines

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Guidelines in management of Empyema

Guidelines in management of Empyema

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  • 1. EMPYEMA GUIDELINES Dr.PREETHAM KUMAR REDDY CONSULTANT PEDIATRICIAN & INTENSIVIST RAINBOW CHILDREN’S HOSPITAL
  • 2. Empyema <ul><li>Pus and fluid from infected tissue in the pleural cavity. </li></ul><ul><li>Also called empyema thoracis, or empyema of the chest. </li></ul><ul><li>Empyema has a number of causes but is most frequently a complication of pneumonia. </li></ul>
  • 3. Thoracic Empyema
  • 4. Thoracic Empyema-- Stage 1 <ul><li>Exudative effusion. </li></ul><ul><li>Increased permeability of the inflammatory and swollen pleural surface. </li></ul><ul><li>Corresponds to the uncomplicated parapneumonic effusion. </li></ul><ul><li>Sterile, fibrin and PMN may present. </li></ul>
  • 5. Uncomplicated Effusion <ul><li>Nonpurulent. </li></ul><ul><li>-ve Gram’s stain -ve culture. </li></ul><ul><li>Free flowing </li></ul><ul><li>pH 7.3 </li></ul><ul><li>normal glucose level </li></ul><ul><li>LDH <1000 IU/L. </li></ul><ul><li>Most resolve with appropriate antibiotics treatment and resolution of the pulmonary infection. </li></ul><ul><li>Progress from stage 1 to 2 may occur quickly, often within 24–48 h . </li></ul>
  • 6. Thoracic Empyema-- Stage 2 <ul><li>Fibropurulent / true empyema / complicated pleural effusion. </li></ul><ul><li>Initial-- fluid is clear : </li></ul><ul><li> WBC > 500 cell/μL </li></ul><ul><li> Protein> 2.5 g/dL </li></ul><ul><li> pH< 7.2, </li></ul><ul><li> LDH< 1000 IU/L, fibrin deposits. </li></ul><ul><li>Angioblastic and fibroblastic proliferation, heavy fibrin deposition on both pleura, particularly the parietal pleura. </li></ul>
  • 7. <ul><li>Later– </li></ul><ul><li>fluid purulent </li></ul><ul><li>WBC 15000, </li></ul><ul><li>ph <7.0, </li></ul><ul><li>glucose < 50 mg/dL </li></ul><ul><li>LDH > 1000 IU/L. </li></ul>
  • 8. Thoracic Empyema-- Stage 3 <ul><li>1 week after infection-- collagen organization, entrapment of the underlying lung. </li></ul><ul><li>3-4 week-- mature, turns into a peel. </li></ul><ul><li>peel prevents entry of anti-microbial drugs in the pleural space and contributes to drug resistance. </li></ul><ul><li>Thickened pleural peel restricts lung movement and leads to trapped lung and f ibrothorax </li></ul>
  • 9. Etiology <ul><li>Pneumococcal infection remains the most common isolated cause in developed countries, with Staphylococcus aureus the predominant pathogen in the developing world. </li></ul><ul><li>Jaffe et al. Pediatr Pulmonol. 2005; 40:148-156 . </li></ul>
  • 10. US prevalence <ul><li>After prevnar (1999-2000 vs 2001-2002) </li></ul><ul><li>1) Patients admitted with empyema (per 10 000 admissions) decreased from 23 to 12.6 </li></ul><ul><li>2) Prevalence of S pneumoniae has decreased from 66% to 27% </li></ul><ul><li>3) S aureus has become the most common pathogen isolated (18% vs 60%), with 78% of those being methicillin resistant. </li></ul><ul><li>Schultz et al.Pediatrics. 2004 Jun;113(6):1735-40 </li></ul>
  • 11. 265 children with empyema admitted to the PGIMER, 1989–98 <ul><li>Culture positivity had decreased significantly (48% v 75%) over the years. </li></ul><ul><li>Staphylococcus aureus commonest (77%) aetiological agent; </li></ul><ul><li>S treptococcus pneumoniae cases seen during the winter and spring season. </li></ul><ul><li>Gram negative rods grew in 11%. </li></ul><ul><li>Community acquired MRSA in 3 patients </li></ul><ul><li>Baranwal et al .Arch Dis Child. 2003 November; 88(11): 1009–1014 . </li></ul>
  • 12. Diagnostic Evaluation <ul><li>Radiographic Studies </li></ul><ul><li>PA and decubitus x-ray </li></ul><ul><li>First step in diagnosis </li></ul><ul><li>Fluid layer is seen on dependent side </li></ul>
  • 13. USG <ul><li>Very useful tool for diagnosis, guidance of thoraco-centesis, or pleural catheter placement. </li></ul><ul><li>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% </li></ul><ul><li>USG shows limiting membranes suggesting the presence of loculated collections even when they are invisible by CT scan. </li></ul>
  • 14. CT scan <ul><li>Chest CT Scan </li></ul><ul><li>Defines effusion </li></ul><ul><li>consolidation </li></ul><ul><li>abscess </li></ul><ul><li>necrosis </li></ul><ul><li>adhesions </li></ul><ul><li>Guides interventions </li></ul>
  • 15. Is CT Scan necessary <ul><li>Unnecessary for most cases of pediatric empyema </li></ul><ul><li>Has a role in complicated cases </li></ul><ul><li>Initial failure to aspirate pleural fluid </li></ul><ul><li>failing medical management and </li></ul><ul><li>particularly in immunocompromised children where a CT scan could reveal other serious clinical problems. </li></ul>
  • 16. Goal of treatment <ul><li>Control of infection </li></ul><ul><li>Drainage of pus </li></ul><ul><li>Expansion of lungs </li></ul>
  • 17. Stage 1/exudative stage <ul><li>Free-flowing serous effusion pH>7.20, Sugar >60 mg/dL, LDH >3 times the upper limit of normal </li></ul><ul><li>Management with </li></ul><ul><li>Antibiotics </li></ul><ul><li>Drainage if effusion is significant </li></ul><ul><li>Give consideration to early active treatment as conservative treatment results in prolonged duration of illness and hospital stay. </li></ul>
  • 18. Empirical antibiotics <ul><li>Anti Staph antibiotic + Cephalosporin + Aminoglycoside </li></ul><ul><li>Suspected anaerobic infection Clindamycin should be added </li></ul>
  • 19. Antibiotics <ul><li>Parenteral therapy to be continued for 48-72 hours after abatement of fever and then oral therapy can be used to complete the course. </li></ul><ul><li>Antibiotic to be continued until </li></ul><ul><li>patient is afebrile, </li></ul><ul><li>WBC count is normal, </li></ul><ul><li>radiograph shows considerable clearing </li></ul><ul><li>Duration of oral therapy is 1- 4 weeks. </li></ul>
  • 20. Drainage Options <ul><li>Simple thoracocentesis </li></ul><ul><li> Necessary for analyzing pleural fluid & to direct antibiotic therapy </li></ul><ul><li>Chest tube placement </li></ul><ul><li>Indicated for all large transudative effusions & the early exudative phase of parapneumonic pneumonias </li></ul><ul><li>Repeated thoracocentesis is rarely successful </li></ul>
  • 21. Empyema drainage <ul><li>CT or USG guided drainage if empyema collection is small </li></ul><ul><li>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 </li></ul><ul><li>The addition of fibrinolytic therapy may improve drainage during the fibrinopurulent stage </li></ul>
  • 22. Who what where <ul><li>Chest drains should be inserted by adequately trained personnel to reduce the risk of complications. </li></ul><ul><li>Small bore percutaneous drains should be inserted at the optimum site suggested by chest ultrasound </li></ul><ul><li>The drain should be removed once there is clinical resolution or drainage is < 50 ml. </li></ul>
  • 23. Safe triangle for insertion of chest drains
  • 24. Stage 2/fibronopurulent stage <ul><li>Uncomplicated<7.20, Sugar <60 mg/dL, LDH >3 times the upper limit of normal </li></ul><ul><li>Antibiotics </li></ul><ul><li>Chest tube </li></ul><ul><li>Drainage </li></ul><ul><li>Consider fibrinolytics </li></ul>
  • 25. <ul><li>Complicated </li></ul><ul><li>pH <7.00,Sugar <60 mg/dL, LDH>3 times the upper limit </li></ul><ul><li>Antibiotics </li></ul><ul><li>Chest tube drainage, consider </li></ul><ul><li>fibrinolytics or </li></ul><ul><li>VATS </li></ul>
  • 26. Fibrinolytics <ul><li>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. </li></ul><ul><li>tPA is used in US </li></ul><ul><li>Thompson et al Thorax 2002; 57 :343-347; </li></ul>
  • 27. Stage 3/organizing stage Fibrinous peel, lung entrapment <ul><li>Antibiotics </li></ul><ul><li>VATS </li></ul><ul><li>if unsuccessful decortication </li></ul><ul><li>Ampofo et al. Pediatr Infect Dis J. 2007 May ; 26(5): 445–446 . </li></ul>
  • 28. Indications for Surgical Treatment <ul><li>Gates et al (2004) in a retrospective review found that 80% of children with empyema did not require surgical intervention </li></ul><ul><li>Lack of clinical & radiological response to medical treatment </li></ul><ul><li>Complex empyema with significant lung pathology </li></ul>
  • 29. Systematic Review of Optimal Treatment (Gates et al, 2004) <ul><li>44 studies describing treatment of empyema in 1369 infants & children (retrospective reviews) </li></ul><ul><li>4 treatment strategies: chest tube drainage, chest tube + fibrinolytics, </li></ul><ul><li>open thoracotomy + decortication & </li></ul><ul><li>VATS </li></ul><ul><li>LOS was the only statistically significant difference between 4 strategies </li></ul><ul><li>VATS LOS = 10.5 days vs. CT 16.4 days or fibrinolytic 18.9 days </li></ul>
  • 30. Thank You

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