Empyema

8,126 views

Published on

0 Comments
23 Likes
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total views
8,126
On SlideShare
0
From Embeds
0
Number of Embeds
8
Actions
Shares
0
Downloads
0
Comments
0
Likes
23
Embeds 0
No embeds

No notes for slide

Empyema

  1. 1. DR.HARESH SHAH.CONSULTANT PULMONOLOGIST BARODA
  2. 2. EMPYEMAGREAT VARIATIONWORLDWIDE INMANAGEMENT OFPATIENT WITHPLEURALINFECTION
  3. 3. EMPYEMA GRAVITY OF PROBLEM UK : 50,000 PNEUMONIA CASES / YR 57% DEVELOP PLEURAL FLUID 40% GO FOR SURGERY DUE TO FAILED ICD 20% OVERALL DEATH OCCURES EMPYEMAS USA : 60,000CASES OF PLEURAL INFECTION/YR
  4. 4. EMPYEMAETIOLOGY1) CAP AND HOSPITAL ACQUIRED PNEUMONIA2) IATROGENIC PNEUMONIA3) PRIMARY EMPYEMA
  5. 5. BTS and ACCP criteria BTS: non purulent PPE is complicated if any of the following • pH<7.2 • LDH> 1000 IU/L • Glucose <40mg/dL • Positive culture Porcel et al, Respir Med 2006
  6. 6. BTS and ACCP criteria ACCP: • Positive culture • pH<7.2 • Glucose <60mg/dL • Effusion>half of the hemithorax Porcel et al, Respir Med 2006
  7. 7. BOTH GUIDELINES ARE SAME PRACTICALLY Porcel et al, Respir Med 2006
  8. 8. 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).
  9. 9. EMPYEMA - TYPE OF PLEURAL FLUID IN INFECTIONA) SIMPLE PARAPNEUMONIC EFFUSIONB) COMPLICATED PARAPNUMOPNICC) EMPYEMA
  10. 10. EMPYEMA - TYPE OF PLEURAL FLUID IN INFECTION (A) SIMPLE PARAPNEUMONIC EFFUSION  CLEAR, pH>7.2, LDH<1000  SUGAR >40. NO ORGANISMS  Resolves with antibiotics alone
  11. 11. EMPYEMA - TYPE OF PLEURAL FLUID IN INFECTIONB) COMPLICATEDPARAPNEUMONIC  CLEAR OR TURBID  pH<7.2,  LDH >1000  GLUCOSE >40  +/- gr stain/culture  Chest tube drainage is needed.
  12. 12. EMPYEMA - TYPE OF PLEURAL FLUID IN INFECTIONC) EMPYEMA  FRANK PUS IN PLEURAL CAVITY  +/- gram stain/CULTURE  NO ADDITIONAL BIOCHEMICAL TEST NEEDED  CHEST TUBE DRAINAGE
  13. 13. Wait et al, Chest 1997 Cheng et al, Chest 2005
  14. 14. Maskell et al, NEJM 2005
  15. 15. 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
  16. 16. EMPYEMA BACTERIOLOGY1. Aerobic:  Gram +ve : S. milleri, S. pneumo Staph aureus (post op, nosocomial, trauma, Immunocompromised host)  Gram –ve : E. colli, Pseuomonas spp, H.influenza, Klebsiella spp
  17. 17. EMPYEMA BACTERIOLOGY Anaerobic: Not uncommon Aspiration pneumonia / poor dental hygiene Insidious onset 14% culture +ve alone 12-36% mix
  18. 18. WHICH PATIENT NEEDS DIAGNOSTIC TAPPING?All patient withpleural effusion inassociation withsepsis orpneumonic illnessneeds diagnosticsampling.
  19. 19. WHICH PATIENT NEEDS DIAGNOSTIC TAPPING?d/d between simple v/s complicated parapneumonic effusion is difficult clinically.Age, symptoms : pain or temp or degree of infiltrates on x-ray chest does not differentiate
  20. 20. PRIMARY TREATMENT OPTIONS Antibiotics alone; Recurrent thoracocentesis Insertion of chest drain alone or in combination with fibrinolytics VATS. Open decortication
  21. 21. INDICATION FOR CHEST TUBE DRAINAGE2) Patient with frank purulent, turbid/cloudy pleural fluid.3) Presence of organism by gm stain or culture.
  22. 22. INDICATION FOR CHEST TUBE DRAINAGE2) Pleural fluid pH less than 7.2 should be carried out in all nonpurulent – possibly infected patient.
  23. 23. OTHER INDICATIONS FOR CHEST TUBE DRAINAGE1)Loculated pleural fluid collection2) Massive non purulent pleural effusion with >40% of hemithorax.
  24. 24. Which patients with non-purulent parapneumonic effusions warrant chest tube drainage?  240 patients with PPE – 85 uncomplicated PPE – 67 complicated PPE – 88 empyema NO PREDICTION CAN BE MADE FROM SYMPTOMS OR ON CLINICAL GROUNDS Porcel et al, Respir Med 2006
  25. 25. EMPYEMA - pH measurement Pl fluid should be collected in heparinised syringe collected anerobically and analysed in blood gas analyser Clear fluid suspicious of infection/ turbid fluid should be subjected Frank pus should not be subjected pH meter or pH litmus paper should not be used.
  26. 26. EMPYEMA - Antibiotics All patient should receive antibiotic As far as possible should be guided by culture report Whenever culture is –ve it should cover cap and anaerobes. Hospital acq pneumo needs broad spectrum antibiotic
  27. 27. EMPYEMA - ANTIBIOTICS : CAP : INTRAVENEOUSCefotaxime 1.5 iv tdsMetronidazole 500mg iv tdsBenzyl penicillin 1.2gm iv qdsCiprofloxacin 400mg iv bdMeropenam 1gm iv tdsMetronidazole 500mg iv tds
  28. 28. EMPYEMA - ANTIBIOTICS CAP : ORALAmoxicillin + clavulinic acidMetronidazole or Clindamycin
  29. 29. ANTIBIOTICS : HOSPITAL ACQUIRED CULTURE NEGATIVE INFECTIONS Piperacillin + tazobactam 4.5gm qds iv Ceftazidime 2gm tds iv Meropenem 1gm tds iv +/- metronidazole 400mg orally or 500mg iv tds
  30. 30. Local antibiotics Usually Rifampin or Colimycin Still debated Do not replace systemic treatment
  31. 31. EMPYEMA - INTRAPLEURAL FIBRINOLYTIC AGENTSK : 2.5 lack u bd for 3daysUK : 1 lack u od for 3 daysTo be kept in pleural space for 2-4 hrs
  32. 32. EMPYEMA - INTRAPLEURAL FIBRINOLYTIC AGENTMay not improve Patient mortality Frequency of surgery Residual lung function
  33. 33. EMPYEMA - INTRAPLEURAL FIBRINOLYTIC AGENTIt shows better drainage and breaking of septas with improved radiological criteria.
  34. 34. EMPYEMA - INTRAPLEURAL FIBRINOLYTIC AGENTSide effects :Immunological reactionsFeverLocal pleural painHaemorrageOccasionally ARDS
  35. 35. EMPYEMA - INTRAPLEURAL FIBRINOLYTIC AGENTSide effects? Systemic antibody responseNext need of fibrinolytic agent should be UK or TPA
  36. 36.  Prospective study from 2001 to 2004 Cause: bacterial pneumonia 2 groups:  A: CT (70)  B: CT + SK (57) Misthos et al, Eur J Car Thor Surg 2005
  37. 37.  452 patients with pleural infection  Sk 250 000 IU twice daily for 3 days  Placebo Controverses No difference in mortality, rate of surgery, created radiographic outcomes, LOS Serious adverse events more common with Sk (chest pain, allergy, fever) Maskell et al, NEJM 2005
  38. 38. E C N SE VE ER EF D F O E MTI Cochrane analysis 2007
  39. 39. AY ST AL IT SP O H F O N IO ATRUD Cochrane analysis 2007
  40. 40. D U R AT IO N O F C H ES T TU BE IN SI T UCochrane analysis 2007
  41. 41. Y ER G R SU R FO DEEN Cochrane analysis 2007
  42. 42. O VE R AL L TR EA TM EN T FA IL U R ECochrane analysis 2007
  43. 43. E GALL PARAMETERS N AI IMPROVED WITH R D FIBRINOLYTIC ID AGENTS UFL Cochrane analysis 2007
  44. 44. EMPYEMA -BRONCHOSCOPY* Only be preferred with high index of suspicion of endobronchial obstruction* Before surgery
  45. 45. EMPYEMA - REFERRALFOR SURGICALINTERVENTIONFailure of chest tube drainage, antibiotic and fibrinolytic agent
  46. 46. EMPYEMA
  47. 47. Wait et al, Chest 1997 Cheng et al, Chest 2005
  48. 48. Maskell et al, NEJM 2005

×