Management of Parapneumonic Effusion and Empyema

1. Management of Parapneumonic
Effusion and Empyema
Dr Dileep MD
Asst. Professor
Pulmonary Medicine
MIMS

2. • Definitions
• Pathogenesis
• Bacteriology
• Clinical presentation
• Diagnosis
• Management

3. DEFINITIONS
• Parapneumonic effusion:
Any pleural effusion associated with bacterial
pneumonia, lung abscess or bronchiectasis
• Empyema:
Pus in the pleural space
- Light’s

4. PATHOGENESIS
• Etiology of pleural infection:
• Primary:
Hematogenous spread of organisms
From URTI or gingiva(or) due to Myc.tb
• Secondary:
Pneumonia, lung abscess
Bronchiectasis
Thoracic surgery
Diagnostic procedure inv pleural space
Trauma
Esophageal rupture
Trans diaphragmatic spread

5. FIBROblasts grow into the pleural space from both the visceral and parietal pleura.thick pleural peel that restricts the
chest mechanics
Organising phase TGF-B1,fibrogenic cytokine
Ongoing phagocytosis,cell lysis,pleural space becomes increasingly infected ,locualations may develop,disturbance in
the equilibrium b/w clotting and fibrinolysis,activation of coagulaton cascade and inhibition of fibrinolysis.
Fibrinopurulent stage TNF-ALFA,PAI,tPA
Increased pulmonary interstitial fluid traversing the pleura to enter the pleural space,increased vascular permeability
sec to pro inflammatory cytokines
Exudative stage IL-8,TNF-ALFA

6. BACTERIOLOGY

7. LIGHT’S CLASSIFICATION

8. classification
Class 1
Non significant pl.ef
Small
<10mm on decubitus x-ray
No thoracentesis
Class 2
Typical parapn. pl.ef.
>10mm thick
pH>7.2,gl>40mg/dl
LDH<3times,gr.st&cul -ve
Antibiotics alone
Class 3
Borderline complicated
pl.ef
7.0<Ph<7.2
Gl>40,LDH>3x,gr.st&cul-ve
Antibiotics +serial
thoracentesis
Class 4
Simple complicated pl.ef.
pH<7.0,gl<40
Gr.st,cul+ve,
Not loculated
Tube thoracostomy+
Antibiotics
Class 5
Complex complicated pl.ef.
pH<7.0,gl<40
Gr.st,cul+ve,multiloculated
Tube thoracostomy+
fibrinolytics
Class 6
Simple empyema
Frank pus ,single locule Tube thoracostomy+/-
decortication
Class 7
Complex empyema
Frank pus ,multiple locules Tube thoracostomy+/-
Fibrinolytics;often
thoracoscopy or decort

9. DIAGNOSIS
• Clinical
• Imaging
 Chest X-ray
 Ultrasound
 CT Scanning
 MRI
• Pleural fluid aspiration

10. CLINICAL PRESENTATION
• Immunoncompetent patient with aerobic infection:
Acutely ill(similar to pneumonia)pleuritic chest pain, fever spikes and
failure to improve on apparently adequate antibiotic therapy
• Elderly individual, immunocompromised with anaerobic infection:
More indolent course, weight loss, cough, unexplained fever

11. • Initial Imaging- Chest X-ray:
• A pleural effusion -obvious on the chest x-ray and the
coexistence of pulmonary infiltrates,parapneumonic collection
• Lateral chest x-rays may confirm pleural fluid not suspected on
the chest x-ray PA view
• Lateral decubitus chest X-ray
• Volume Required:
– Decubitus: 20ml
– Lateral: 50ml
– PA: 175ml
– Supine: 175ml

12. Lateral decubitus Lateral

13. Ultrasound:
• Confirm Presence
• Estimate Size
• Identify Septa
• Other Pathology
• Guide Drainage
• All echogenic effusions were caused by exudates and
homogeneous echogenic effusions-
Empyema or haemorrhage

14. U/S pleural space: marked septations
throughout fluid collection

15. • Multiple thin llinear
septations

16. CT scanning:
• Confirm Presence
• Estimate Size
• Identify Septa
• Other Pathology
• Guide Drainage

17. • CT scanning can help to differentiate empyema from lung
abscess
• Empyemas - lenticular and compress lung parenchyma
• Lung abscesses - indistinct boundary between lung parenchyma
and collection
• Collections in the interlobar spaces, paramediastinal pleura,
small paravertebral collections can be visualised
• Management decisions about drainage, drain insertion and
subsequent tube positioning and need for surgical intervention

19. • Empyema -‘Split pleura’ sign caused by enhancement of both parietal
and visceral pleural surfaces
• Pleural thickening is seen in 86-100% of empyemas and 56% of
exudative parapneumonic effusions
• Pleural thickness on CECT scans is greater in frankly purulent
effusions

21. • MRI
• MRI is not routinely indicated and offers no advantage
over CT scanning for pleural infection
• Considered in specific situations - allergy to contrast
agents or young/ pregnant patients to minimise ionising
radiation exposure
• MRI -helps to define chest wall involvement with the
infection (eg, empyema necessitans or tuberculous
empyema).

22. • Pleural Fluid Aspiration:
• Diagnostic pleural fluid sampling is recommended in pleural effusion
>10 mm depth
• Small effusions (ie, <10 mm thickness) will usually resolve with
antibiotics alone
• Pleural fluid pH should be assessed in all non-purulent effusions
(<7.2 is indication for ICD)
• If pH is not available glucose should be measured, glucose level <60
mg/dl, can be used as an alternative to indicate a need for chest drain
• Gram staining and microbiological culture analysis should be
routinely requested on all initial samples

23. • Imaging guidance should be used -minimises risks of organ
perforation and improves recovery rate of pleural fluid
• Pleural fluid cytology and acid/alcohol fast bacilli analysis for
mycobacteria should be performed if clinically indicated

24. MANAGEMENT
• Indications for pleural fluid drainage in pleural
infection
• Chest tube drainage
• Antibiotics
• Intrapleural fibrinolytics
• Surgery
• Thoracoscopy

25. Indications for pleural fluid drainage in
pleural infection
• Patients with frank pus on sampling should receive ICD
• Presence of organisms on GS and/or culture from a non-
purulent pleural fluid indicates pleural infection and should
receive ICD
• Pleural fluid pH <7.2 in patients with suspected pleural infection
indicates a need for ICD
• Pleural fluid glucose < 60 mg/dl
• Patients with a loculated pleural collection should receive ICD

26. Chest tube drainage
• A small-bore catheter 10-14 F will be adequate for most cases of
pleural infection. However, there is no consensus on size of
optimal chest tube for drainage
• Chest tube insertion should be performed under imaging
guidance wherever possible
• Chest tube insertion should be performed in line with the BTS
pleural procedures guidelines and National Patient Safety
Agency recommendations

27. Timing of chest drain removal in pleural infection
• After radiological confirmation of successful pleural drainage-
 Reduction in the size of the pleural collection on the chest x-
ray or thoracic ultrasound
 objective evidence of sepsis resolution -improvement in
temperature and clinical condition and decreasing
inflammatory markers (eg, CRP)
• In patient observation for 24 h after drain removal is usual, a
longer period of rehabilitation may be necessary for some
patients

28. Antibiotics
• All patients should receive antibiotics targeted to treat bacterial
profile of modern pleural infection and based on local antibiotic
policies and resistance patterns
• Antibiotics to cover anaerobic infection be used in all cases
with either clindamycin or metronidazole
• Macrolide antibiotics are not indicated unless there is evidence
for ‘atypical’ pathogens
• Where possible, antibiotic choice should be guided by bacterial
culture results and advice from a microbiologist

29. • Antibiotic penetration into pleural space in descending order
Metronidazole > Penicillin > Clindamycin> Vancomycin >
Ceftriaxone > Gentamycin
• Penicillin allergic- can be treated by clindamycin alone or in
combination with ciprofloxacin or a cephalosporin
• When bacterial cultures are negative, antibiotics should cover
both common community-acquired bacterial pathogens and
anaerobic organisms
• Empirical antibiotic treatment for hospital-acquired empyema
should include treatment for MRSA ,Gram negative and
anaerobic bacteria

30. • IV antibiotics should be changed to oral therapy once there is
clinical and objective evidence of improvement in sepsis
• Prolonged courses of antibiotics may be necessary and can
often be administered as an outpatient after discharge
• At least 4 to 6 weeks of therapy is required, and a longer course
may be necessary unless there is prompt resolution of fever and
leukocytosis

31. Intrapleural fibrinolytics
• There is no indication for routine use of intrapleural fibrinolytics
in patients for pleural infection
• It is not associated with reduced mortality, frequency of surgery,
length of hospital stay or long-term radiological & lung function
outc.
(MIST-1 trial)
• Occasionally be indicated for physical decompression of
multiloculated pleural fluid collections that are responsible for
dyspnoea or respiratory failure

32. • Doses of fibrinolytics used in studies have varied but include
Streptokinase 250 000 IU daily or 250 000 IU 12-hourly or
urokinase 100 000 IU daily retained for 2-4 h in the pleural
space
• Combination therapy with fibrinolytics and fluid viscosity and
biofilm-disrupting agents such as streptodornase and
deoxyribonuclease (DNase) may be beneficial
• MIST-2 trial - Results from trial suggests that a combination of
intrapleural tPA and DNase may provide superior drainage to a
fibrinolytic alone

33. Persistent sepsis and pleural collection
• Patients with persistent sepsis and a residual pleural collection
should undergo further radiological imaging
• Should be discussed with a thoracic surgeon to consider all
surgical options
• The diagnosis should be reviewed and a further chest x-ray and
CT scan or thoracic ultrasound performed
• CECT accurately identifies chest tube position, anatomy of
effusion, pleural thickening, endobronchial obstruction and
mediastinal pathology

34. • Bronchoscopy should only be performed in patients where there is
high index of suspicion of bronchial obstruction
• The choice of antibiotic should be reviewed and prolonged course
administered where appropriate
• Patients should receive surgical treatment if they have persisting
sepsis with a persistent pleural collection, despite ICD and antibiotics
• Failure of sepsis to resolve within 5-7 days is suggested as an
appropriate period following which a surgical opinion be sought

35. • Surgical Options:
• VATS is used as 1st line therapy , open thoracic drainage or
thoracotomy and decortication remain alternatives
• In patients unable to tolerate GA, placement of additional image-
guided small-bore catheter, a larger bore ICD or intrapleural
fibrinolytic could be considered after discussion with surgeon
• Less radical surgical interventions - rib resection and placement of a
large-bore drain may be considered in frail patients under epidural an
• For some patients, palliative treatment and active symptom control
measures will be appropriate

36. Thoracoscopy
• Thoracoscopy can be used in management of early empyema,
mainly to achieve early and complete drainage
• In cases with multiple loculations, it is possible to open these
spaces to remove the fibrinopurulent membranes by forceps
and to create a single cavity that can then be successfully
drained and irrigated
• If performed for this indication, thoracoscopy should be carried
out early in the course of empyema, before the adhesions
become too fibrous and adherent to perform pleuroscopy

37. • It is particularly advisable for frail patients at high
surgical risk
• Thus, if indication for ICD is present and if facilities are
available, thoracoscopy can be performed at the time
of ICD insertion
• Large prospective randomised comparator trials are
needed to elucidate role of local thoracoscopy

38. Parapneumonic Effusion/Empyema
Purulent/turbid
/Cloudy
ICD
Gram Stain +ve
Culture +ve
PH<7.2
> 10mm thick
Glucose >40 mg/dl,
pH > 7.2
Gram 's stain &
culture negative
Antibiotics Alone
Loculated
ICD
Ongoing sepsis and
persistent pleural
collection
ICD
Ongoing sepsis and persistent pleural
collection
Review of the Diagnosis –CECT thorax
-ICD position, anatomy, pleural thickening,
endobronchial obstruction and mediastinal path.
Failure of sepsis to resolve within 5-7 days
Surgical Intervention

39. REFERENCES
• BTS Guidelines for the management of Pleural
Infections
• Murray and Nadal’ Text Book of respiratory Medicine
• Pleural Diseases 6th Edition Richard W.Light
• Upto date
• C Ravaglia et al. Respiration 84 (3), 219-224. 2012 Jul
24.

40. Thank You