Empyema Guidelines


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Guidelines in management of Empyema

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Empyema Guidelines

  2. 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. 3. Thoracic Empyema
  4. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 18. Empirical antibiotics <ul><li>Anti Staph antibiotic + Cephalosporin + Aminoglycoside </li></ul><ul><li>Suspected anaerobic infection Clindamycin should be added </li></ul>
  19. 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. 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. 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. 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. 23. Safe triangle for insertion of chest drains
  24. 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. 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. 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. 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. 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. 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. 30. Thank You