Empyema thoracis is an accumulation of pus in the pleural cavity that can develop as a complication of pneumonia. It involves three stages: exudative, fibropurulent, and organization. Clinical features include fever, cough, and chest pain. Diagnosis involves pleural fluid analysis and imaging like chest X-ray or CT scan. Treatment may include antibiotics, chest tube drainage, intrapleural fibrinolytics, and surgery like VATS. Early recognition and treatment can prevent disease progression and reduce length of hospital stay. While VATS has benefits, fibrinolytics and tube drainage are effective for select cases.

1. Empyema Thoracis

2. Empyema Thoracis
• Empyema thoracis is defined as an accumulation of pus
within the pleural cavity
• parapneumonic effusion and empyema is approximately
3.3 cases per 100,000 children
• 1 in every 150 children hospitalized with pneumonia will
develop an empyema(more in india)

4. • Hippocrates
• “if pus that flows after opening was mixed with blood, muddy
and foul smelling : death was likely
• and the pus was “pale and white” the patient would survive
• Pare described evacuation of infected blood from the pleural
cavity
• Wyman performed the first therapeutic pleural aspiration
• Playfair modified the technique of thoracocentesis to closed
tube drainage in 1875
• Fowler reported the first decortication in 1893
History

5. Etiology
• acute bacterial lobar pneumonia
• chicken pox and measles children
• chronic pulmonary diseases,
• long-term steroid therapy, organ transplantation
• immune suppression,
• recurrent aspiration
• secondary infection of a traumatic hemothorax contusion
• intrathoracic esophagus anastomotic dehiscence or rupture
following dilatation of an esophageal stricture

6. Pathogenesis
• rapidity with which pus accumulates
• virulence of the organisms,
• resistance offered by the host
• antibiotics and appropriate drainage procedures
• rupture of an amebic liver
• hydatid cysts rupture - - with secondary infection
• 10% of tuberculous effusions --secondary bacterial infection

7. Stage I exudative phase
Intense inflammation
increased capillary permeability
proteinaceous exudate, parapneumonic effusion
Chemical mediators
coagulation cascade and complement system
Suppurative products

8. Stage II: fibropurulent phase
coagulation cascade is activated and fibrinolysis suppressed
fibrin deposition
pyogenic membrane
fibrin strands septate the empyema cavity and loculations

9. Stage III: Organization Phase
fibrous tissue gradually replaces fibrin
deposit layers of fibrous tissue (rinds)
encases the collapsed lung and prevents it from re-expanding
consolidated lung acts as a source of chronic infection
fibrous sheet , blood supply from surrounding tissues

10. Clinical Features
• cough, breathlessness,
• High grade fever, malaise
• loss of appetite
• decreased chest expansion,
• stony dullness to percussion,
• reduced or absent breath sounds,
• Scoliosis
• Mediastinal shift --tracheal deviation

11. Diagnosis
• Acute Phase Reactants
• Biochemistry,
• Blood, pleural fluid, sputum, Hematology
• Pleural Aspiration
empyema sympathetic effusion
glucose concentration
< 2.2 mMol/L
glucose concentration
> 2.2 mMol/L.
pH <7.2 pH > 7.2
LDH > 1,000 I/dL
protein > 2.5 g/dL
specific gravity> 1.018

12. Radiology
• First radiological investigation is a plain chest X-ray
Chest X-ray showing a fluid level in the
pleural collection

13. Ultrasound showing loculations and septa with the pleural effusion

14. split-pleura sign in the setting of
right lower lobe (RLL) consolidation
and atelectasis.
enhancing pleural membrane (arrow)
defines the empyema extending into
the chest wall
CT scanning is the imaging study of choice
typical empyema is lenticular
 atypical pleural effusions along the mediastinum,
 thickened pleurae,
 loculations in the fissures, septa,
Loss of lung volume

15. Adv vs Dis
• CT scanning detects more parenchymal abnormalities than
chest radiography.
• the additional information does not alter management
• is unable to predict clinical outcome
• exposure of children to unnecessary radiation and costs.
• parenchymal lung abnormalities such as endobronchial
obstruction or a lung abscess, as well as helping with
mediastinal pathology

17. Early Primary VATS
Surgical Management
• The goal of surgery is to achieve full expansion
of the lung and resolution of the empyema.
• Early surgical intervention in childhood
empyema reduces morbidity.
• Treatment failure should be recognized early
to avoid disease progression.

18. Intercostal Chest Tube Insertion
and Management

19. Instruments

20. Intercostal Chest Tube Insertion and Management
• Informed consent
• General anesthesia
• Skin antiseptic solution, e.g. povidone iodine (Betadine)
• Sterile gloves and gown
• Sterile drapes, Closed drainage system
• Plain bupivacaine 0.25% (maximum dose of 2 mg/kg (0.8 ml/kg)
• Empyema 16–24 F
• Fibrinolytic agents suggests that small-bore catheters 12–14 F
may be sufficient
• Seldinger introduction kits(Small-bore chest drains)
• “purse-string” sutures
(painful and produce a cosmetically unacceptable scar)

21. • Guide wire with dilators for Seldinger technique
• Chest tube: 10–12 FG appropriate for most children
• Connecting tubing
• Sterile universal containers and anaerobic blood culture
bottle for pleural fluid
• Steristrips and large transparent adhesive dressings

22. Safety Triangle

27. • Clinical picture: hospital admission
• Diagnostic imaging : CT scans should not be performed routinely
• Diagnostic analysis of pleural fluid: Blood, sputum, Tuberculosis and malignancy
• Referral to tertiary centre
• Conservative management (antibiotics, simple drainage not for large effusion)
• Repeated thoracentesis: no role
• Antibiotics
• Chest drains
• Intrapleural fibrinolytics
• Surgery
• Other management
• Follow up

28. • Chest drains should be inserted by adequately trained
personnel to reduce the risk of complications.
• A suitable assistant and trained nurse must be available.
• Routine measurement of the platelet count and clotting
studies are only recommended in patients with known risk
factors.
• Where possible, any coagulopathy or platelet defect should
be corrected before chest drain insertion.
• Ultrasound should be used to guide thoracocentesis or drain
placement.
• intravenous sedation should only be given by those trained in
the use of conscious sedation, airway management and
resuscitation of children, using full monitoring equipment

29. • there is no evidence that large bore chest drains confer any
advantage,
• small drains (including pigtail catheters) should be used
whenever possible (stages)
• Neither substantial force nor a trocar should ever be
used to insert a drain
• A chest radiograph should be performed after insertion of a
chest drain.
• All chest tubes should be connected to a
• Unidirectional flow drainage system

30. • A bubbling chest drain should never be clamped.
• A clamped drain should be immediately unclamped
and medical advice sought if a patient complains of
breathlessness or chest pain
• The drain should be clamped for 1 hour once 10 ml/ kg is
initially removed
• Flushed carefully with normal saline (10 ml)
• amount of fluid draining, the child’s temperature
and general well being,
• chest radiographic (removal)

31. • Older children can be asked to perform a Valsalva’s maneuver
while the drain is removed.
• In younger children the drain should be removed as rapidly
as possible during expiration
• Antipyretics should be given.
• Analgesia is important to keep the child comfortable,
particularly in the presence of a chest drain.
• Early mobilisation and exercise is recommended.
• Secondary scoliosis noted on the chest radiograph is common
but transient; no specific treatment is required but resolution
must be confirmed

32. Cochrane database by Coote (2002)
it was suggested that primary video-assisted thoracoscopic
surgical (VATS) drainage had a significantly higher success rate
with shorter duration of hospital stay compared with patients
managed with chest tube drainage with streptokinase

33. Our findings suggest there is no statistically significant difference in mortality
between primary surgical and non-surgical management of pleural empyema for all
age groups. Video-assisted thoracoscopic surgery may reduce length of hospital
stay compared to thoracostomy drainage alone.
There was insufficient evidence to assess the
impact of fibrinolytic therapy.
We included eight trials with a total of 391 participants. Six trials focused on
children and two on adults. The trials compared chest tube drainage (non-
surgical), with or without fibrinolysis, to either VATS or thoracotomy (surgical).
2017

34. The treatment of ET is complex. Failure to adequately evacuate
the pleural space and/or persistent signs of infection should
prompt surgical intervention.
Surgical therapy is preferred for advanced stages of ET.
Delaying definitive surgical treatment is largely responsible for
prolonging hospital course.
[Am J Med Sci 2003;326(1):9–14.]

35. Clin Pulm Med 2002;9(2):97–104
Currently there are no data available that indicate the exact time a patient
with pleural disease should undergo decortication.
Although late-stage empyema characterized by a constrictive peel
often requires decortication,
management of patients with multiloculated fibrinopurulent effusion is
controversial

36. Results
One hundred fifteen patients had 159 interventions over the study period.
Fifty-four children were successfully treated with intercostal drainage (ICD) and
urokinase fibrinolysis alone. There were 19 primary video assisted
thoracoscopic surgeries (VATS) and 12 VATS after initial intercostal
drains. Thirty-three children required a thoracotomy, a reduction of 26%
from the previous era (p = 0.009). The median length of stay was 9 days (range 2–
54).
Conclusion
a proportion requires further surgical intervention,
increased utilisation of fibrinolysis and VATS occurred with a corresponding
decrease in the need for thoracotomy.
Patients needing thoracotomy all had severe disease on
ultrasound, but ultrasound did not reliably predict failure of
fibrinolytic therapy.

38. VATS for PPE and TE may shorten the duration of
hospital stay. However, UK administration may be used
for selective patients because it is considered to yield
outcomes similar to VATS
Age was the only statistically different parameter between both groups
(P=0.025); with the mean age of the VATS and UK groups being 64 and 76
years, respectively. There was no significant difference in the duration of
drainage or success rate between the UK or VATS groups. Although no
statistically significant differences (P=0.20) were observed, duration of hospital
stay was longer in the UK group (21 and 28 day for VATS and UK, respectively).
ADULT

39. Tuberculosis-Empyema
• Pediatric Medicine has discussed

40. Take home message
• Early recognition of symptoms,
• Initiation of Antibiotics and judicious use,
• Chest physiotherapy,
• Intercostal drainage,
• Early referral to Pediatric Surgery,
• VATS is still considered gold standard in ideal
cases.
• Avoid unnecessary Radiation (Xray/CT)