1. ROLE OF MEDICAL THORACOSCOPY
IN TREATMENT OF
PARAPNEUMONIC EFFUSIONS
Dr. Mohamed Mostafa Kamel
MBBCh,MSc, MD
Professor of Pulmonology
Kasr El Aini Faculty of Medicine
Cairo University
mmkhope@hotmail.com

3. Identification: pleural fluid aspiration
All patients with a pleural effusion in association
with sepsis or a pneumonic illness require
diagnostic pleural fluid sampling. (C)
• If a pleural effusion is identified on the chest x-ray
of a patient with possible pleural infection, it is
impossible clinically to differentiate the presence
of a complicated parapneumonic effusion
requiring chest tube drainage from a simple
effusion that may resolve with antibiotics alone.

4.  Imaging guidance should be used since this minimises risks
of organ perforation and improves the recovery rate of
pleural fluid. Sampling using thoracic ultrasound is simple,
safer and will reduce patient discomfort.
 Sampling can be performed by sterile procedure using a
needle and syringe with local anaesthetic if necessary.
 Small effusions (ie, <10 mm thickness) will usually resolve
with antibiotics alone.
 The presence of frank pus is diagnostic of an empyema.
National Patient Safety Agency (NPSA). Rapid Response Report: Risks of chest drain insertion (Reference NPSA/2008/RRR03).
2008:1e10. (4).
Diacon AH, Brutsche MH, Soler M. Accuracy of pleural puncture sites: a prospective comparison of clinical examination with
ultrasound. Chest 2003;123:436e41. (2+).
Jones PW, Moyers JP, Rogers JT, et al. Ultrasound-guided thoracentesis: is it a safer method? Chest 2003;123:418e23.

5. Pleural fluid pH should be assessed in all non-
purulent effusions when pleural infection is
suspected. (B)
If pleural fluid pH measurement is not
available, pleural fluid glucose assessment
should be performed where pleural infection
is possible. (B)

6. • A patient with pleural infection requiring drainage will
develop a pleural fluid acidosis associated with a rising LDH
level and a falling glucose level.
• A pleural fluid pH of <7.2 is also the single most powerful
indicator to predict a need for chest tube drainage, and
that pleural fluid LDH (>1000 IU/l) and glucose (<3.4
mmol/l) did not improve diagnostic accuracy.
• Where pleural fluid pH measurement is not available
glucose and LDH should be measured, a pleural fluid
glucose level <3.4 mmol/l may be used as an alternative
marker to indicate a need for chest drain insertion.

7. • Pleural fluid cytokine and/or inflammatory
mediator levels (IL-8, TNFa, vascular
endothelial growth factor or CRP) may be
useful to differentiate complicated
parapneumonic effusions from other
exudative collections.

8. Indications for pleural fluid drainage
in pleural infection
Patients with frankly purulent or turbid/cloudy
pleural fluid on sampling should receive prompt
pleural space chest tube drainage. (B)
The presence of organisms identified by Gram
stain and/or culture from a non-purulent pleural
fluid sample indicates that pleural infection is
established and should lead to prompt chest
tube drainage. (B)

9.  Pleural fluid pH <7.2 in patients with suspected pleural
infection indicates a need for chest tube drainage. (B)
 Parapneumonic effusions that do not fulfill any of these
criteria for chest tube drainage could be treated with
antibiotics alone provided clinical progress is good. (B)
 Poor clinical progress during treatment with antibiotics
alone should lead to prompt patient review, repeat
pleural fluid sampling and probably chest tube
drainage.(B)

10. Patients with a loculated pleural collection
should receive early chest tube drainage. (C)
 Large non-purulent effusions could be
drained by aspiration and/or chest tube if
required for symptomatic benefit. (C)

11. 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 the size of the optimal chest tube for
drainage. (C)
 If a small-bore flexible catheter is used, regular
flushing is recommended to avoid catheter blockage.
(C)
 Chest tube insertion should be performed under
imaging guidance wherever possible. (D)

12. • In the absence of clear septation on
ultrasonography, simple pleural drainage
could be the standard treatment, whereas
patients with clear septation are felt by many
to require a form of thoracoscopy as a first-
line treatment.
Davies HE, Davies RJ, Davies CW: Management of pleural infection in adults: British Thoracic Society Pleural Disease Guideline
2010. Thorax 2010; 65:ii41–ii53.

14. • Empyema can be subdivided into 3 stages:
1. Exudative or acute (characterized by an effusion that is free
moving in the pleural cavity),
2. Fibro-purulent (in which a reduced endocavitary fibrinolysis
causes fibrin deposition on the pleural surfaces with a cloudy and
viscous fluid and a tendency toward loculation and the formation
of limiting membranes), and
3. Organizing or chronic (characterized by fibrous thickening of the
visceral pleura, a sort of ‘peel’ which traps the lung).
Ferguson AD, Prescott RJ, Selkon JB, Watson D, Swinburn CR: The clinical course and management of thoracic
empyema. QJM

15. AIM OF WORK
• To report experience and analyze the efficacy
and safety of medical thoracoscopy in
patients with multiloculated and organized
empyema stratified early by chest
ultrasonography.

16. Material and Methods
• Retrospective study reviewing all files of 41
patients referred for empyema and treated
with medical thoracoscopy at the
Pulmonology Department of a referral
hospital for respiratory diseases (Forli Italy)
from July 2005 to February 2011.

17. • All patients underwent chest radiography and also chest CT scan
and ultrasonography to localize pleural fluid collection and to
assess the echogenicity of the effusion and diaphragmatic motility.
• Thoracentesis was performed at our department in all patients
and empyema was defined as frank pus on thoracocentesis (turbid
malodorous liquid) with or without positive Gram stain smear
and bacteriologic culture findings or pH < 7.2 with signs of infection.
• Multiloculated empyema was defined as ultrasonographic
presence of multiple empyema loculations with presence of
intrapleural septae, and Organized empyema was characterized by
fibrous thickening of the pleura

18. • Medical thoracoscopy was carried out in the
lateral decubitus position under local
anesthesia with 2% lidocaine and moderate
sedation.
• A 7.5- and/or 10-mm trocar was inserted
under ultrasonographic guidance in the
appropriate intercostal space

19. thorocoscopy

21. • With the closed biopsy forceps, step by step,
fibrinous septae were perforated, the pleural
space was irrigated with saline, and fluid and
fibrinopurulent material were aspirated and
removed from the pleural cavity.
• At the end of the procedure, a drain (20–32 F)
was inserted and connected to underwater seal
suction with a negative pressure suction of 20 cm
H20.

22. • All patients received IV antibiotics for at least
1 week after the procedure; in 23 patients,
100,000 U of urokinase diluted in 100 ml of
normal saline solution was administered into
the pleural space once daily for 3–5 days and,
after rinsing with the saline solution, the drain
was clamped for 2 hours.

23. Antibiotics
All patients should receive antibiotics
targeted to treat the bacterial profile of
modern pleural infection and based on local
antibiotic policies and resistance patterns. (B)
Antibiotics to cover anaerobic infection
should be used in all patients except those
with culture proven pneumococcal infection.
(B)

24. Macrolide antibiotics are not indicated unless
there is objective evidence for or a high
clinical index of suspicion of ‘atypical’
pathogens. (B)
Where possible, antibiotic choice should be
guided by bacterial culture results and advice
from a microbiologist.(B)

25. Penicillins, penicillins combined with b-
lactamase inhibitors, metronidazole and
cephalosporins penetrate the pleural space
well. Aminoglycosides should be avoided. (B)
Empirical antibiotic treatment for hospital-
acquired empyema should include treatment
for MRSA and anaerobic bacteria. (B)

26.  Intravenous antibiotics should be changed to oral
therapy once there is clinical and objective evidence
of improvement in sepsis. (D)
 Intrapleural antibiotics are not recommended. (D)
 Prolonged courses of antibiotics may be necessary
and can often be administered as an outpatient after
discharge. (D)

27. Intrapleural fibrinolytics
 There is no indication for the routine use of intrapleural
fibrinolytics in patients for pleural infection. (A)
 On occasions, such treatment may be indicated for the
physical decompression of multiloculated (and so tube
drainage resistant) pleural fluid collections that are
responsible for dyspnoea or respiratory failure if
discussion with a thoracic surgeon identifies that either
surgery is not immediately possible due to additional
patient co-morbidity, the feasibility of transfer to a
surgical unit or other clinical or logistical reasons.

28. • Urokinase is non-antigenic but may still cause
acute reactions with fever and cardiac
arrhythmia.
• 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 2to 4 h in the
pleural space.
Bouros D, Schiza S, Patsourakis G, et al. Intrapleural streptokinase versus urokinase in the treatment of complicated parapneumonic effusions: a prospective,
double-blind study. Am J Respir Crit Care Med 1997;155:291e5. (1+).
Bouros D, Schiza S, Tzanakis N, et al. Intrapleural urokinase versus normal salinein the treatment of complicated parapneumonic effusions and empyema.
A randomized, double-blind study. Am J Respir Crit Care Med 1999;159:37e42. (1+).
Cameron R, Davies HR. Intra-pleural fibrinolytic therapy versus conservative management in the treatment of parapneumonic effusions and empyema. Cochrane
Database Syst Rev 2004:CD002312. (1++).
Davies RJ, Traill ZC, Gleeson FV. Randomised controlled trial of intrapleural streptokinase in community acquired pleural infection. Thorax 1997;52:416e21.

30. • Treatment success was defined as :
 Radiologic confirmation of successful pleural drainage (i.e.
reduction of the size of the pleural fluid on the chest X-ray
and a thoracic ultrasound of less than one third of the
hemithorax in complete resolution or greater than one
third in partial resolution), with no need for further
treatment (subsequent chest tube insertions or surgical
interventions) and
 Objective evidence of sepsis resolution (improvement in
temperature and clinical condition and decreasing
inflammatory laboratory markers).

31. Results
• Patients were examined with radiologic
techniques (ultrasound, X-ray, and CT scan);
empyema was considered multiloculated in
24 patients (58.5%), organizing in 8 patients
(19.5%), and free-flowing in 9 patients (22%).

34. • Free-flowing and multiloculated pleural
empyema stratified by chest ultrasonography
could be treated safely and successfully by
medical thoracoscopy, while organizing
empyema can be resistant to drainage with
medical thoracoscopy, requiring, video-
assisted thoracic surgery or open surgical
decortication.

35. • Other studies, however, do not consider medical
thoracoscopy as an alternative to surgical intervention
in the presence of loculations.
• Medical thoracoscopy is a much less invasive video-
assisted thoracoscopy, it is performed under local
anesthesia and moderate sedation.
• Medical thoracoscopy can achieve opening of multiple
loculations and aspiration of the purulent liquid and
removal of the fibrinous adhesions, and it can provide
local treatment with fibrinolytics
19 Cafiero F: Jacobaeus operation during parapneumothoracic empyema. Minerva Med.
20 Kern L, Robert J, Brutsche M: Managemen t of parapneumonic effusion and empyema:
medical thoracoscopy and surgical approach.Respiration 2011; 82: 193–196.
21 Waller DA: Thoracoscopy in management of postpneumonic pleural infections. Curr Opin Pulm Med 2008; 4: 323–326.

36. • The advantages of medical thoracoscopy
compared with VATS include a lower cost and
better tolerance by frail patients who may not
tolerate general anesthesia with tracheal
intubation.
• Some limitations to this technique can be related
to the fact that, in contrast to surgical VATS, it is
usually performed via a single port so the lung is
not fully collapsed during the intervention and it
can be more time consuming.

38. Timing of chest drain removal in
pleural infection
• Removal of the chest drain is appropriate after
radiological confirmation of successful
pleural drainage ; that is, reduction in the size
of the pleural collection on the chest x-ray or
thoracic ultrasound and objective evidence of
sepsis resolution ; that is, improvement in
temperature and clinical condition and
decreasing inflammatory markers (eg, CRP).

39. Persistent sepsis and pleural
collection ????

41. Patients with persistent sepsis and a residual
pleural collection should undergo further
radiological imaging. (C)
Patients with persistent sepsis and a residual
pleural collection should be discussed with a
thoracic surgeon to consider all possible
surgical options available. (D)

42. THANK YOU