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Empyema

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    Empyema Empyema Presentation Transcript

    • DR.HARESH SHAH.CONSULTANT PULMONOLOGIST BARODA
    • EMPYEMAGREAT VARIATIONWORLDWIDE INMANAGEMENT OFPATIENT WITHPLEURALINFECTION
    • 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
    • EMPYEMAETIOLOGY1) CAP AND HOSPITAL ACQUIRED PNEUMONIA2) IATROGENIC PNEUMONIA3) PRIMARY EMPYEMA
    • 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
    • BTS and ACCP criteria ACCP: • Positive culture • pH<7.2 • Glucose <60mg/dL • Effusion>half of the hemithorax Porcel et al, Respir Med 2006
    • BOTH GUIDELINES ARE SAME PRACTICALLY Porcel et al, Respir Med 2006
    • 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).
    • EMPYEMA - TYPE OF PLEURAL FLUID IN INFECTIONA) SIMPLE PARAPNEUMONIC EFFUSIONB) COMPLICATED PARAPNUMOPNICC) EMPYEMA
    • 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
    • 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.
    • EMPYEMA - TYPE OF PLEURAL FLUID IN INFECTIONC) EMPYEMA  FRANK PUS IN PLEURAL CAVITY  +/- gram stain/CULTURE  NO ADDITIONAL BIOCHEMICAL TEST NEEDED  CHEST TUBE DRAINAGE
    • Wait et al, Chest 1997 Cheng et al, Chest 2005
    • Maskell et al, NEJM 2005
    • 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
    • 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
    • EMPYEMA BACTERIOLOGY Anaerobic: Not uncommon Aspiration pneumonia / poor dental hygiene Insidious onset 14% culture +ve alone 12-36% mix
    • WHICH PATIENT NEEDS DIAGNOSTIC TAPPING?All patient withpleural effusion inassociation withsepsis orpneumonic illnessneeds diagnosticsampling.
    • 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
    • PRIMARY TREATMENT OPTIONS Antibiotics alone; Recurrent thoracocentesis Insertion of chest drain alone or in combination with fibrinolytics VATS. Open decortication
    • INDICATION FOR CHEST TUBE DRAINAGE2) Patient with frank purulent, turbid/cloudy pleural fluid.3) Presence of organism by gm stain or culture.
    • INDICATION FOR CHEST TUBE DRAINAGE2) Pleural fluid pH less than 7.2 should be carried out in all nonpurulent – possibly infected patient.
    • OTHER INDICATIONS FOR CHEST TUBE DRAINAGE1)Loculated pleural fluid collection2) Massive non purulent pleural effusion with >40% of hemithorax.
    • 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
    • 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.
    • 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
    • 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
    • EMPYEMA - ANTIBIOTICS CAP : ORALAmoxicillin + clavulinic acidMetronidazole or Clindamycin
    • 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
    • Local antibiotics Usually Rifampin or Colimycin Still debated Do not replace systemic treatment
    • 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
    • EMPYEMA - INTRAPLEURAL FIBRINOLYTIC AGENTMay not improve Patient mortality Frequency of surgery Residual lung function
    • EMPYEMA - INTRAPLEURAL FIBRINOLYTIC AGENTIt shows better drainage and breaking of septas with improved radiological criteria.
    • EMPYEMA - INTRAPLEURAL FIBRINOLYTIC AGENTSide effects :Immunological reactionsFeverLocal pleural painHaemorrageOccasionally ARDS
    • EMPYEMA - INTRAPLEURAL FIBRINOLYTIC AGENTSide effects? Systemic antibody responseNext need of fibrinolytic agent should be UK or TPA
    •  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
    •  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
    • E C N SE VE ER EF D F O E MTI Cochrane analysis 2007
    • AY ST AL IT SP O H F O N IO ATRUD Cochrane analysis 2007
    • D U R AT IO N O F C H ES T TU BE IN SI T UCochrane analysis 2007
    • Y ER G R SU R FO DEEN Cochrane analysis 2007
    • O VE R AL L TR EA TM EN T FA IL U R ECochrane analysis 2007
    • E GALL PARAMETERS N AI IMPROVED WITH R D FIBRINOLYTIC ID AGENTS UFL Cochrane analysis 2007
    • EMPYEMA -BRONCHOSCOPY* Only be preferred with high index of suspicion of endobronchial obstruction* Before surgery
    • EMPYEMA - REFERRALFOR SURGICALINTERVENTIONFailure of chest tube drainage, antibiotic and fibrinolytic agent
    • EMPYEMA
    • Wait et al, Chest 1997 Cheng et al, Chest 2005
    • Maskell et al, NEJM 2005