Aetiopathogenesis and management of empyema thoracis

1. AETIOPATHOGENESIS AND
MANAGEMENT OF EMPYEMA
THORACIS

2. INTRODUCTION
 Empyema is the presence of gross pus in
the pleural cavity; it consists of an effusion
containing polymorphonuclear leukocytes
and fibrin.
 The Greek philosopher, Aristotle,
recognized empyema and described the
drainage of pus with incision and a metal
tube as early as 300 BC.

3.  Hippocarates in 600 B.C. defined Empyema
Thoracis as a collection of pus in the pleural
cavity and advocated open drainage as its
treatment. Since then the management of
this condition has posed a challenge to
physicians and surgeons alike.

4. The inflammatory process in a preformed
anatomical space defined by the visceral
and parietal pleura
DEFINITION
Pleural empyema
Thoracis empyema
or

5.  Staphylococcus aureus,Streptococcus pneumoniae
and Streptococcus pyogenes
 Pneumococcal pneumonia presents with effusion
in 40% patients, empyema occurs only in 5% -
10%.
 Anaerobes and enterobacter are common in mixed
infections. Anaerobes are more common after 6
years of age. For anaerobes, aspiration pneumonia
is the most common cause followed by lung
abscess, sub diaphragmatic abscess and spreading
infection from adjacent sites, e.g. periodontal,
retropharyngeal, peritonsillar and neck abscesses.

6. Development of empyema from para
pneumonic effusion
Compartmentalization of
pleural fluid in empyema

7. LUNG INFECTIONS
 Atypical pneumonia ; Mycoplasma
Pneumoniae
 Viruses: respiratory syncytial virus,
parainfluenza virus, adenovirus (in
military rectruits) and infulenza A and B
 Chronic Lung infections : by
M.Tuberculosis and atypical
mycobacteria, Nocardia and actinomyces
spp.

8. LUNG INFECTIONS
 In Neutropenic or immunocompromised
patients CMV, Pneumocystis carinii,
aspergillosis and candidiasis are
common
 In Children Staph Aureus is the
commonest organism.

9. Pathogenesis of pleural effusion
 Elevated capillary hydrostatic pressure -
cardiac failure.
 Reduced capillary oncotic pressure –
hypoalbuminemia
 Enhanced capillary permeability –
inflammation.
 Obstructed lymphatics – tumor etc.
 Movement of fluid from extrathoracic
site – pancreatitis.

10. Development of empyema from
para pneumonic effusion
Stage of excessive accumulation of effusion
>drainage via lymphatics (uncomplicated
parapneumonic effusion)
Low LDH /N. glucose /PH>7.3 / sterile
(low wbc + neg c/s) / minimal
sedimentation
the infectious agent invades
the pleural space ( empyema)---high
LDH/ low glucose /P.H <7.3/ high wbc /
positive c/s /increased
volume/sedimentation
Fibrin deposition—organised effusion

11. Cause of post-traumatic
empyema
 Iatrogenic infection during Tube thoracostomy
 Direct infection from penetrating injury
 Secondary infection from associated intra-
abdominal injuries with diaphragmatic disruption
or haematogenous or lymphatic spread to pleural
space
 Secondary infection of undrained haemothorax
 Parapneumonic empyema resulting from post
traumatic pneumonia ,contusion or ARDS

12. Development of Empyema
 Exudative stage (1-3 days )
 Fibrino purulent stage (4 to 14 days)
 Organizing stage (after 14 days)

13. PLEURAL EMPYEMA PHASES

14. Exudative stage (1-3 days)
 Immediate response with outpouring of the fluid.
 Low cellular content
 It is simple parapneumonic effusion with normal
pH and glucose levels.
 pH more than 7.30
 glucose more than 60 mg/dl
 pleural fluid/serum protien ratio more than 0.5
 LDH less than 1000 IU/L
 Gram stain and culture is negative for micro-
organism.

16. Fibrino purulent stage
(4 to 14 days)
 Large number of polymorphonuclear leukocytes and
fibrin accumulates
 Fluid pH and glucose level fall while LDH rises.
 Accumulation of neutrophils and fibrin, effusion
becomes purulent and viscous leading to development
of empyema.
 There is progressive tendency towards loculations and
formation of limiting membranes.
 Pleural fluid analysis
 Purulent fluid or pH less than 7.10, glucose less
than 40 mg/dl and LDH more than 1000 IU/L.
Gram stain and culture reports show
microorganism

17.  Fibro-blasts grow into exudates on both the
visceral and parietal pleural surfaces
 Development of an inelastic membrane "the peel".
 Thickened pleural peel may prevent the entry of
anti-microbial drugs in the pleural space and in
some cases can lead to drug resistance.
 Most common in S. aureus infection.
 Thickened pleural peel can restrict lung
movement and it is commonly termed as trapped
lung

18. Risk factors
 Risk factors for empyema thoracis include age
(children and elderly persons), debilitation,
pneumonia requiring hospitalization, and
comorbid diseases, such
as bronchiectasis, rheumatoid arthritis,
alcoholism, diabetes, and gastroesophageal Reflux
disease
 COAD is associated with decreased risk for
empyema thoracis

19.  Symptoms are often the same as those associated with
pneumonia. They include:
 Fever
 Cough
 Shortness of breath
 Chest pain
 Night sweats
 Dehydration
 Unintended weight loss
 General discomfort or uneasiness
 In more progressive cases, the patient might develop very
bad breath, or cough up bloody or offensive sputum with a
strong fetid odor.

20. DIAGNOSIS : EMPYEMA THORACIC
characteristic clinical presentation
 features of hydrothorax
 in physical examination
 chest X-ray
 pleural ultrasonography
 computed tomography
 diagnostic thoracocentesis
( macroscopic features of liquid, positive bacterial cultures, glucose
 concentration< 40 mg/dl, pH<7,0, LDH > 1000 U/L)
 flexible bronchoscopy (useful in a case of bronchial fistula)
 needle pleural biopsy
 diagnostic videothoracoscopy
 diagnostic thoracotomy

22.  sputum culture
 pleural fluid culture
 blood culture in some situations
 molecular techniques such as pleural
fluid PCR or streptococcal antigen.

23.  To obtain Bronchoalveolar lavage for
diagnosis
 To see Endobronchial obstruction by
tumour, broncholith or foreign bodies

24.  PA and lateral decubitus
 PA at least 400ml fluid vs. 50ml
lateral decubitus
 Assess for loculations

26. Ultrasound
 Classification
 Stage 1: anechoic fluid
 Stage 2: loculations
 Stage 3: solid peel
 Guide placement of intercostal drain
 Size of effusion
 Differentiate consolidation from empyema
 Unreliable predictor of disease severity

27.  Anatomical
 Parenchymal lesions
 Endobronchial lesions
 Mediastinal lesions
 Lung abscess

28. EMPYEMA THORACIC

29.  If effusion is free flowing and greater than one
centimeter from inside of the chest wall to the
pleural fluid line on the lateral decubitus view,
immediate diagnostic thoracocentesis should
be done.
 If loculated, thoracocentesis should be done
under ultrasound guidance. The site for
thoracocentesis is 1 cm below upper level of
dullness

30.  Two third of the cases of anaerobic infection
have malodorous empyema
 Protein level and specific gravity is rarely
helpful in differentiating stages of empyema
 In some cases with frank pus, organisms are
neither seen on Gram stain nor grown in
culture. Such cases must raise a suspicion of
chylous effusion

31.  Cell fragments will sediment where a chylous
effusion will remain opaque after
centrifugation
 Tuberculous empyema can be confirmed by
stains for acid fast bacilli in fewer than 25%
cases but pleural biopsy and culture can
diagnose more than 90% cases
 ADA more than 60 U/L supports the diagnosis
of tuberculous pleural empyema
 PCR

32.  Control of infection
 Drainage of pus
 Expansion of lungs
Aim of the Management/Treatment

33.  Non-Operative
 Antibiotics
 Thoracocentesis
 ICWSD
 Fibrinolysis
 Operative
 VATS
 Thoracotomy &
decortication
 Rib Resection &
drainage
 Thoracoplasty
 Open window
thoracostomy
 Eloesser Flap
Procedure

34.  Antibiotics may be administered
empirically/according to the CS of
pleural fluid.
 Anti Staph antibiotic +Cephalosporin
+ Aminoglycoside
 Suspected anaerobic infection
Clindamycin should be added

35.  Parenteral therapy should be continued for 48-72
hours after abatement of fever and then oral
therapy can be used to complete the course.
 Antibiotic should be continued until patient is
afebrile, WBC count is normal, radiograph show
consider-able clearing
 Duration of therapy
 H. influnezae, S. pneumonia: 10-14 days
 Staph aureus: 3-4 weeks

36.  Indications for drainage
 Frank pus, smear positive fluid, loculated
fluid
 pH less than 7.10, glucose less than 40
mg/dl and LDH more than 1000 IU/L
 Repeated thoracocentesis is rarely
successful; Small-bore percutaneous
catheters can be used if the fluid is thin

37.  CT or USG guided drainage if empyema
collection is small.
 Chest tube drainage is advised for
drainage of tuberculous empyema.
 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

38.  loculation of pleural effusion and pleural fluid
WBC count 6,400/µL were independent
predicting factors for poor outcome of tube
thoracostomy
 Surgical intervention should be considered early
after failure of first chest tube drainage in good
surgical candidates with loculated empyema or
pleural fluid with WBC count 6,400/µL to
minimize the mortality and morbidity

39.  Useful in multiloculated empyema.It degrades
fibrin ,blood clots and pleural loculi in pleural
space leading to hydrolysis of fibrin coagulum
 Streptokinase: 25 ,000U in 20-50ml saline once
daily for 3 days: 66% Efficacy.
 Urokinase: 100,000 u in 100ml saline for 3
consecutive days . 90-92% Efficacious.

40.  But FDA has withdrawn Urokinase from
clinical use owing to the reasons of quality
control issues.
 tPA 10mg/kg in 10-30ml saline X 3 consecutive
days
 Transient increase of body temperature was
noted in 28% cases of SK while no complication
was noted with UK.

41.  Can be done as primary procedure
 Experienced surgeon necessary
 Thoracoscopic Debridement and Irrigation: It
is quite effective in cases with multiloculated
empyema. Success rate is as high as 69% to
89%
 Most effective if performed within 48-72 hrs of
Fibrinolytic therapy

42.  Benefits
 lower mortality
 Re-intervention
 Reduced length of hospital stay
 Reduced hospital costs
Disadvantage : Not effective in 3rd stage of Empyema
as it leads to parenchymal lung injury and bleeding.

43.  This is a effective procedure for chronic
empyema with thick cortex
 Indicated when the lung is adherent to the
parietal pleura and will not collapse when a
limited thoracotomy into the abscess alone is
performed.
 Intrapulmonary pus can also be drained in the
same manner

44.  Treatment of choice if no experience or
success with VATS
 Indicated in Organised stage of empyema
with pleural thickening
 Early and accurate diagnosis and therapy
 Mortality reduced
 Haemorhage, prolonged air leak and residual
Empyema are some complications of
Decortication

45. Thoracoplasty
Thoracostomy/ Eloesser flap
procedure: A more permanent
skin lined drainge into the chest.

46.  Dissect into lung parenchyma→bronchopleural
fistulas and pyopneumothorax
 Dissection through chest wall (empyema
necessitatis)
 Dissection into abdominal cavity
 Skeletal deformity: scoliosis
 Fibrothorax

47. Empyema and associated
complications
Empyema nessitancs manifests as a chest wall swelling (cystic)
secondary to extravastation of empyema due to parenchymal
pressure , erosion of ribs or icm Icd insertion into empyema
space mostly drains both collections

49.  Early diagnosis
 CXR include lateral decubitus
 Early antibiotics
 Early chest drainage
 Loculations
 Early referral
 Thoracotomy if no improvement with ICD
placement and correct antibiotics

50.  Favourable in patients started on appropriate
antibiotic
 Early chest tube drainage is beneficial.
 Decortication or open drainage has decreased
mortality and morbidity.
 Mortality 6-12%

52.  In case no expansion is achieved post icd insertion various factors
may be responsible Icd site air leakage : icd refixing with
pursestring
 Large bpf with empyema (collapse lung) : modified eleosser flap (
time given to patient for sepsis recovery, weight gain , ATT course
completion, mediastinal shift to affected side reducing need for
major rib resection) ---definitive space reducing thoracoplasty.
 Post empyema pleural thickening restricting lung expansion:
decortication---open or video assisted
 Vats contraindicated in gross pleural thickening ,calcifications
 Destroyed lung post empyema ---- thoracoplasty
 Pneumonectomy has no role in management of empyema due to
extensive mediastenal fibrosis , high incidence of post resection bpf
,post pnuemonectomy empyema.

54. Etiological classification:
 specific (tuberculosis)
 non-specific – non-specific bacterial infection
 Mixed
 mycotic
Pathogenetic classification:
 synpneumonic – empyema coexists with another lung
inflammation
 metapneumonic – it develops when a primary inflammation
has already regressed

55. Size criterion:
 non-localized empyemas – the whole pleural cavity is involved
 localized (encapsulated) empyemas - ( unilocular or multilocular)
Duration and pathologic criterion :
 acute empyema
 chronic empyema
Iatrogenic empyemas:
 empyemas with preserved
pulmonary parenchyma
 empyemas after lung resection
(pneumonectomy)
- with bronchial fistula
- without bronchial fistula

57. VATS decortication and irrigation pleural space

59. THORACOPLASTY

60. THORACOPLASTY

61. DECORTICATION

62. DECORTICATION

63. MYOPLASTY in treatment of bronchial fistula post pneumonectomy

64. Muscle Flap Interposition

65. Post lung resection empyema
Methods of tretment: - Muscle flap closure
- Limited thoracoplasty
- Open window thoracostomy
Post lobectomy(0,01%-2,0%), post pneumonectomy (2%-16%),
residual space and air leak

66. The Clagett procedure open-window
thoracostomy in patient with pleural
empyema and bronchial
postpneumonectomy fistula (own
meterial)