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Updates in Parapneumonic Effusion and Empyema
Updates in Parapneumonic
Effusion and Empyema
Gamal Rabie Agmy, MD,FCCP
Professor of Chest Diseases, Assiut university
Pneumonias – Classification
• Community AcquiredCAP
• Health Care AssociatedHCAP
• Hospital AcquiredHAP
• ICU AcquiredICUAP
• Ventilator AcquiredVAP
Nosocomial
Pneumonias
*HCAP: diagnosis made < 48h after
admission with any of the following risk
factors:
(1)hospitalized in an acute care hospital for >
48h within 90d of the diagnosis;
(2) resided in a nursing home or long-term
care facility;
(3) received recent IV antibiotic therapy,
chemotherapy, or wound care within the 30d
preceding the current diagnosis; and
(4) attended a hospital or hemodialysis
clinic
HCAP
"Pleurisy" (syn. pleuritis) is best defined
as an inflammatory process of the pleura,
which can be caused either by a variety of
infectious microorganisms or by other
inflammatory mechanisms. It is usually
associated with localized chest pain that
is synchronous with the respiratory cycle
and is often manifested as a pleural rub
on auscultation..
Definitions
It may induce an exudative pleural
effusion. The pain and the rub sometimes
subside when an effusion develops.
A "parapneumonic effusion" is an
accumulation of exudative pleural fluid
associated with an ipsilateral pulmonary
infection.
Definitions
"Uncomplicated parapneumonic
effusions" are not infected and do not
usually need tube thoracostomy.
"Complicated parapneumonic
effusions" are usually associated with the
pleural invasion of the infectious agent and
require tube thoracostomy and sometimes
decortication for their resolution.
Definitions
"An effusion is called an "empyema"
when the concentration of leucocytes
becomes macroscopically evident as a
thick and turbid fluid (pus). In more than
50% of cases, it is of parapneumonic
origin. Other common causes include
surgical procedures (mainly thoracic
surgery), traumas and oesophageal
perforation
Definitions
The pleuritis sicca stage
The inflammatory process of the
pulmonary parenchyma extends to the
visceral pleura, causing a local pleuritic
reaction. This leads to a pleural rub and
the characteristic pleuritic chest pain,
which originates from the sensitive
innervation of the adjacent parietal pleura.
Pathophysiology
The pleuritis sicca stage
A significant number of patients with
pneumonia report pleuritic chest pain
without developing a pleural effusion ,
suggesting that the involvement of the
pleura may be limited to this stage in many
cases of pneumonia..
Pathophysiology
The exudative stage
The ongoing inflammatory process leads
to a mediator induced increased
permeability of local tissue and of regional
capillaries. The subsequent accumulation
of fluid in the pleural space is probably the
combined result of the influx of pulmonary
interstitial fluid and of a local microvascular
exudate.
Pathophysiology
The exudative stage
The fluid is usually clear and sterile,
cytological specimens show a
predominance of neutrophils, the pH is
normal and the lactate dehydrogenate
(LDH) activity is <1,000 international units
(IU).
Pathophysiology
The fibropurulent stage
This stage may develop quickly (within
hours) in patients who are not receiving
antibiotics, or who are treated with
ineffective antibiotics. It is characterized
by the deposition of fibrin clots and fibrin
membranes ("sails") in the pleural space,
which lead to loculations with increasing
numbers of isolated collections of fluid.
Pathophysiology
The fibropurulent stage
It is usually accompanied by (and caused by)
bacterial invasion from the pulmonary
parenchyma. The fluid is often turbid or frank
pus. Cytology shows neutrophils and often
degenerated cells, and Gram stains and
bacterial cultures are usually positive. The
metabolic and cytolytical activity in these
effusions is high, as reflected by low pH values
(<7.2), and high LDH activities (often >1,000
IU).
Pathophysiology
The organizational stage
This final stage is characterized by the
invasion of fibroblasts, leading to the
transformation of interpleural fibrin
membranes into a web of thick and
nonelastic pleural peels. Functionally, gas
exchange is often severely impaired on the
side of the organizing empyema ("trapped
lung").
Pathophysiology
The organizational stage
The further course may vary from
spontaneous healing with persistent
defects of lung function to chronic forms of
empyema with high risks for further
complications, such as bronchopleural
fistula, lung abscess, or "empyema
necessitatis" (spontaneous perforation
through the chest wall).
Pathophysiology
The clinical presentation of patients with
pneumonia, whether or not they have
parapneumonic effusions, is similar. there
were no significant differences between
these two groups of patients regarding
white blood cell count (WBC) and the
occurrence of pleuritic chest pain.
Clinical aspects and differential diagnosis
Patients with pneumonia due to infection
with aerobic bacteria usually suffer from an
acute febrile illness, whilst patients with
anaerobic infections tend to present with a
more subacute or chronic condition, with a
longer duration of symptoms and frequent
weight loss
Clinical aspects and differential diagnosis
Anaerobic pleuropulmonary infections
often follow aspiration of oral or gastric
contents. These patients usually have poor
oral hygiene (foetor ex ore!) with anaerobic
colonization of the oropharynx, and often
suffer from conditions that predispose to
aspiration, such as seizure disorders,
syncopes of other origin, or alcoholism.
The latter has been found to be a relevant
associated disorder in as many as 29% to
40% of cases.
Clinical aspects and differential diagnosis
The finding of a purulent effusion without
pneumonia may be explained as a
postpneumonic empyema, in which the
pulmonary infiltrates have already
resolved. However, pleural empyemas are
not necessarily caused by pneumonia.
Clinical aspects and differential diagnosis
The majority of nonpneumonic empyemas
are of iatrogenic origin, most commonly as
a complication of a pneumonectomy or
other thoracic surgical procedures.
Thoracic surgery is responsible for about
20% of all thoracic empyemas Around
5% occur following a thoracic trauma and
5% following an oesophageal perforation
(often iatrogenic).
Clinical aspects and differential diagnosis
The majority of nonpneumonic empyemas
are of iatrogenic origin, most commonly as
a complication of a pneumonectomy or
other thoracic surgical procedures.
Thoracic surgery is responsible for about
20% of all thoracic empyemas Around
5% occur following a thoracic trauma and
5% following an oesophageal perforation
(often iatrogenic).
Clinical aspects and differential diagnosis
Fever, pulmonary infiltrates, and a pleural
effusion are not invariably due to
pneumonia or to a complication of some
surgical procedure. A very important
differential diagnosis, which should always
be considered, is pulmonary infarction.
Clinical aspects and differential diagnosis
Pulmonary embolism is a common disorder
and paraembolic effusions occur in 25–
50% of cases . The effusions may become
infected and will then require treatment
identical to complicated parapneumonic
effusions.
Clinical aspects and differential diagnosis
Other disorders which should be
considered include tuberculosis ,lupus
erythematosus and other autoimmune
disorders , acute pancreatitis and other
diseases of the gastrointestinal (GI) tract [,
and drug-induced pleuropulmonary
disease . The turbid or milky aspect of
empyemas may sometimes lead to the
misconception of a chylothorax or
pseudochylothorax .
Clinical aspects and differential diagnosis
Other disorders which should be
considered include tuberculosis ,lupus
erythematosus and other autoimmune
disorders , acute pancreatitis and other
diseases of the gastrointestinal (GI) tract [,
and drug-induced pleuropulmonary
disease . The turbid or milky aspect of
empyemas may sometimes lead to the
misconception of a chylothorax or
pseudochylothorax .
Clinical aspects and differential diagnosis
Laboratory Studies
No specific laboratory studies of the serum suggest the
presence of a parapneumonic effusion or empyema.
However, the possibility of a parapneumonic effusion
and empyema should be a consideration for every patient
with pneumonia.
The presence of pleural fluid may be suggested based on
physical examination findings; however, small pleural
effusions may not be detected during the physical
examination. In this case, any significant effusion can be
visualized using 2-view (ie, posteroanterior, lateral) chest
radiography.
Laboratory Studies
Sputum should be submitted for culture, especially if purulent.
The infecting organism may be suggested based on Gram stain
results. Mixed florae are often seen in anaerobic infections..
As with any infection, leukocytosis may be present (>12,000/µL)
; however, it should decrease with adequate antibiotic therapy.
Persistent fever and leukocytosis despite adequate antibiotic
therapy may signal a persistent focus of infection, such as a
complicated parapneumonic effusion or empyema.
Diagnosing a complicated parapneumonic effusion and/or
empyema is crucial for optimal management because a delay in
drainage of the pleural fluid substantially increases morbidity.
Imaging Studies
Chest radiography:
Lateral chest radiography usually demonstrates the presence of a significant
amount of pleural fluid, as shown in the image below.
Left lateral chest radiograph shows a large,
left pleural effusion.
Updates in Parapneumonic Effusion and Empyema
Updates in Parapneumonic Effusion and Empyema
Updates in Parapneumonic Effusion and Empyema
Updates in Parapneumonic Effusion and Empyema
Updates in Parapneumonic Effusion and Empyema
Updates in Parapneumonic Effusion and Empyema
Imaging Studies
Chest radiography:
If either of the diaphragms is not visible throughout its entire length, the
posterior costophrenic angles are blunted, or a lateral meniscus is visible,
then bilateral decubitus chest radiographs should be obtained.
Free pleural fluid is seen as a dense linear shadow layering between the
chest wall and the lung parenchyma.
Unchanging pleural-based linear densities, pleural-based mass-liked
densities, or collections with obtuse angles suggest the presence of
loculated fluid, especially if the differences in the fluid or the appearance
between upright and lateral views are minimal.
If the pleural fluid distance measures more than 10 mm from the chest wall,
sufficient free-flowing fluid is present to perform a diagnostic thoracentesis.
Imaging Studies
Ultrasonography:
Ultrasonography can be used to localize fluid for a
thoracentesis. Fluid appears dark or black on ultrasound
images, and most bedside ultrasonography devices
permit measurement of the depth of location from the
chest wall.
Complex fluid (purulent or viscous) may have more
density or shadows within in the pleural fluid collection.
Sometimes, fibrinous strands can be seen floating in the
pleural fluid.
Other structures such as the diaphragm or lung
parenchyma can provide landmarks to assist in needle
placement for thoracentesis.
Imaging Studies
Ultrasonography:
Loculated pleural effusions may be difficult to localize
during physical examination, but they can usually be
identified with ultrasonography.
Ultrasonography can effectively distinguish loculated
pleural fluid from an infiltrate. The latter may have air
bronchograms visible, but the distinction may be difficult
if a dense consolidation is present.
If a loculated pleural effusion is suspected, an
ultrasonographic examination is recommended for
diagnosis and marking the area for thoracentesis.
Anechoic effusion
Complex nonseptated effusion
Complex septated effusion with movable
septa
Complex septated
effusion with
Fixed septa
Echogenic effusion
Imaging Studies
CT scanning of the thorax:|
CT scanning of the chest with contrast, as shown in the image below, enhances
the pleural surface and assists in delineating the pleural fluid loculations.
CT scan of thorax shows loculated pleural
effusion on left and contrast enhancement
of visceral pleura, indicating the etiology is
likely an empyema.
Imaging Studies
CT scanning of the thorax:|
Chest CT scan with intravenous
contrast in a patient with mixed
Streptococcus milleri and anaerobic
empyema following aspiration
pneumonia, showing a thickened
contrast-enhanced pleural rind,
high-density pleural effusion,
loculation, and septation.
Thoracentesis yielded foul-smelling
pus.
Imaging Studies
CT scanning of the thorax:|
Pleural enhancement can be seen in patients with active inflammation
and severe pleuropulmonary infections, which provides another sign of
the possibility of a complicated pleural effusion or empyema.
CT scanning of the chest may also help detect airway or parenchymal
abnormalities such as endobronchial obstruction or the presence
of lung abscesses.
Figure26.24
Simple parapneumonic effusion. The left pleural effusion is…
Parapneumoniceffusions
Updates in Parapneumonic Effusion and Empyema
Updates in Parapneumonic Effusion and Empyema
Procedures
Thoracentesis is recommended when the suspected
parapneumonic pleural effusion is greater than or equal
to 10 mm thick on a lateral decubitus chest radiograph
Pleural fluid appearance may vary from a clear yellow
liquid to an opaque turbid fluid to grossly purulent thick,
viscous, foul-smelling pus. Foul-smelling fluid indicates
an anaerobic infection.
Pleural fluid studies
Blood cell count (WBC count) and differential: Results
generally are not diagnostic, but most transudates are
associated with a WBC counts of less than 1000 cells/µL
and empyemas are exudates, with WBC counts generally
greater than 50,000 cells/µL.
Pleural fluid total protein, LDH, and glucose
(corresponding serum protein and LDH): Exudates are
defined by pleural/serum total protein ratio of greater than
0.5 and a pleural/serum LDH ratio of greater than 0.6 or a
pleural fluid LDH value greater than two thirds the upper
limit of normal. One criterion is sufficient to classify fluid
as an exudate.
Pleural fluid studies
Pleural fluid pH (iced blood gas syringe): Values of less
than 7.20 are suggestive of a complicated pleural effusion.
Other laboratories suggestive of complicated pleural
effusion or empyema: These include (1) an LDH value of
greater than 1000 U/L, (2) a pH of less than 7.00, and (3) a
glucose level of less than 40 mg/dL.
Microbiology (Gram stain, bacterial culture): Acid-fast
bacilli and fungal infections may cause pleural effusions or
empyema, but these organisms are more difficult to culture
from pleural fluid.
Histologic Findings
Multiple granulocytes are typically identified on
histologic examination. Necrotic debris may be present.
Bacteria are seen in the pleural fluid in severe infections.
Staging
The following classification and treatment scheme has
been used to characterize parapneumonic effusions and
empyema.
Category 1 (parapneumonic effusion):
Minimal free-flowing fluid, smaller than 10 mm on decubitus films
Culture, Gram stain, and pH unknown
No thoracentesis needed; treatment with antibiotics alone
Category 2 (uncomplicated parapneumonic effusion):
Larger than 10 mm fluid and less than half the hemithorax on
decubitus films
Gram stain and culture negative
pH higher than 7.20
Treatment with antibiotics alone
Staging
Category 3 (complicated parapneumonic effusion):
Large free-flowing effusion, more than half the hemithorax
pH lower than 7.20, LDH level greater than 1000 U/L and glucose
level greater than 40 mg/dL
Gram stain or culture positive
Treatment with tube thoracostomy and antibiotics
Multiloculated effusions may require multiple tubes
Thrombolytics may help resolution
Staging
Category 4 (empyema):
Large free-flowing effusion, greater than equal to half the hemithorax
Loculated effusion or effusion with thickened pleura
Gross pus on aspiration
Treatment with tube thoracostomy
Thrombolytics may help resolution
May require decortication
Medical Care
The initial treatment of a patient with pneumonia and
pleural effusion involves two major decisions. The first
decision involves selection of an appropriate antibiotic
that will cover likely pathogens.
The second decision involves the need for drainage of
pleural fluid and is be guided by the American College of
Chest Physicians (ACCP) guideline recommendations for
the medical and surgical treatment of parapneumonic
effusions.
Medical Care
The initial antibiotic selection is usually based on whether the
pneumonia is community or hospital acquired and on the
severity of the patient's illness.
For a patient with community-acquired pneumonia, the
recommended agents are second- or third-generation
cephalosporins in addition to a macrolide.
For patients hospitalized with severe community-acquired
pneumonia, initiate treatment with a macrolide plus a third-
generation cephalosporin with antipseudomonal activity. Enteric
Gram-negative bacilli frequently cause pneumonia acquired in
institutions (eg, hospitals, nursing homes). Therefore, initial
antibiotic coverage should include an antibiotic effective against
pseudomonads. If aspiration is evident or suspected, oral
anaerobic micro-organism should also be covered.
Medical Care
Infectious Diseases Society of America (IDSA)/American
Thoracic Society (ATS) consensus guidelines on the
management of community-acquired pneumonia, hospital-
acquired pneumonia, ventilator-associated pneumonia, and
healthcare-associated pneumonia in adults are published
elsewhere.[9, 10] Also seePneumonia, Bacterial.
Effusions with pleural fluid layering less than 10 mm on
decubitus chest radiographs almost always resolve with
appropriate systemic antibiotics. Patients with pleural effusions
that have a pleural fluid layering greater than 10 mm on lateral
decubitus radiographs should have a diagnostic thoracentesis
unless there is a contra-indication to the procedure. If the
diagnostic thoracentesis yields thick pus, the patient has an
empyema thoracis and definitive pleural drainage is absolutely
required. If the pleural fluid is not thick pus, then results of
pleural fluid Gram stain or culture, pleural fluid pH and glucose
Medical Care
Effusions with pleural fluid layering less than 10 mm on
decubitus chest radiographs almost always resolve with
appropriate systemic antibiotics.
Patients with pleural effusions that have a pleural fluid layering
greater than 10 mm on lateral decubitus radiographs should
have a diagnostic thoracentesis unless there is a contra-
indication to the procedure. If the diagnostic thoracentesis yields
thick pus, the patient has an empyema thoracis and definitive
pleural drainage is absolutely required.
If the pleural fluid is not thick pus, then results of pleural fluid
Gram stain or culture, pleural fluid pH and glucose levels, and
the presence or absence of pleural fluid loculations should guide
the course of action as recommended in the guidelines.
Medical Care
In summary, the recommendations are as follows:
In all patients with acute bacterial pneumonia, the presence of a
parapneumonic pleural effusion should be considered (level C
evidence).
In patients with parapneumonic pleural effusions, the estimated risk
for poor outcome, using the panel-recommended approach based on
pleural space anatomy, pleural fluid bacteriology, and pleural fluid
chemistry, should be the basis for determining whether the
parapneumonic pleural effusions should be drained (level D
evidence).
Poor outcomes could result from any or all of the following: prolonged
hospitalization, prolonged evidence of systemic toxicity, increased
morbidity from any drainage procedure, increased risk for residual
ventilatory impairment, increased risk for local spread of the inflammatory
reaction, and increased mortality.
Surgical Care
Thoracoscopy:
Thoracoscopy is an alternate therapy for multiloculated empyema
thoracis. In patients with multiloculated parapneumonic pleural
effusions, the loculations in the pleural space can be disrupted with
a thoracoscope, and the pleural space can be drained completely. If
extensive adhesions are present or thick pleural peel entraps the
lung, the procedure may be converted to open thoracostomy and
decortication.
Surgical Care
Luh et al published their experience in the treatment of
complicated parapneumonic pleural effusions and empyema
thoracis by VATS in 234 patients (108 women, 126 men).
More than 85% (200 patients) received preoperative
diagnostic or therapeutic thoracentesis, tube thoracostomy, or
fibrinolytics. Of 234 patients, 202 patients (86.3%) achieved
satisfactory results with VATS. Only 40 patients required open
decortication or repeat procedures. VATS is safe and effective
for treatment; earlier intervention with VATS can produce
better clinical results
Surgical Care
Hope et al reviewed outcomes of surgical treatment for
parapneumonic empyema thoracis. The use of VATS was
compared with thoracotomy. Morbidity and mortality rates
were similar among all groups. The conversion rate to open
thoracotomy was 21%. Based on a shorter postoperative
length of stay with similar morbidity and mortality in patients
operated on within 11 days of admission, early aggressive
surgery treatment for complicated parapneumonic effusions or
empyema thoracis is recommended.
Surgical Care
Retrospective evaluation of 2 different surgical procedures
(decortication vs debridement) and approaches (VATS vs
thoracotomy) were analyzed by Casali and colleagues. VATS
debridement had a lower postoperative hospital stay and
shorter duration of chest drainage and greater improvement in a
subjective dyspnea score. The long-term spirometric evaluation
was normal in 58 patients (56%). Age older than 70 years old
was the only variable associated with poor long-term results
(forced expiratory volume in 1 second [FEV1] < 60% and/or
dyspnea Medical Research Council grade ≥2) at multivariate
analysis. VATS is associated with less postoperative mortality
and shorter postoperative hospital stay.
Surgical Care
Rib resection and open drainage of pleural space:
Open drainage of the pleural space may be used when closed-
tube drainage of the pleural infection is inadequate and the
patient does not respond to intrapleural thrombolytic agents.
This procedure is recommended only when the patient is too ill
to tolerate decortication. The resection of one to three ribs
overlying the lower part of the empyema thoracis cavity is
performed, a large-bore chest tube is inserted into the
empyema thoracis cavity, and the tube is drained into a
colostomy bag.
Surgical Care
Decortication:
In decortication, all the fibrous tissue is removed from
the visceral pleural peel, and all pus is evacuated from
the pleural space. Decortication is a major thoracic
operation requiring full thoracotomy; therefore,
decortication is not tolerated by critically ill patients.
Decortication is the procedure of choice for patients in
whom pleural sepsis is not controlled by closed-tube
thoracostomy, intrapleural thrombolytic agents, and,
possibly, thoracoscopy. Mortality rates as high as 10%
have been described with this procedure.
Surgical Care
Decortication:
Decortication should not be performed solely to
remove the thickened pleural peel; the thickened
pleural peel usually resolves over several months. If
the pleura remains thickened with symptom-limiting
reduction in pulmonary function after approximately 6
months, decortication can be considered.
Surgical Care
Postpneumonectomy empyema thoracis:
an uncommon but life-threatening complication, is
often associated with a bronchopleural fistula.
Treatment of bronchopleural fistula depends on
several factors, including the extent of dehiscence,
degree of pleural contamination, and general condition
of the patient. Early diagnosis and aggressive
therapeutic strategies for controlling infection, closing
the fistula, and sterilizing the closed pleural space are
mandatory. Repeated debridement, VATS, endoscopic
application of tissue glue, and stenting may be
additional management strategies..
Updates in Parapneumonic Effusion and Empyema

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Updates in Parapneumonic Effusion and Empyema

  • 2. Updates in Parapneumonic Effusion and Empyema Gamal Rabie Agmy, MD,FCCP Professor of Chest Diseases, Assiut university
  • 3. Pneumonias – Classification • Community AcquiredCAP • Health Care AssociatedHCAP • Hospital AcquiredHAP • ICU AcquiredICUAP • Ventilator AcquiredVAP Nosocomial Pneumonias
  • 4. *HCAP: diagnosis made < 48h after admission with any of the following risk factors: (1)hospitalized in an acute care hospital for > 48h within 90d of the diagnosis; (2) resided in a nursing home or long-term care facility; (3) received recent IV antibiotic therapy, chemotherapy, or wound care within the 30d preceding the current diagnosis; and (4) attended a hospital or hemodialysis clinic HCAP
  • 5. "Pleurisy" (syn. pleuritis) is best defined as an inflammatory process of the pleura, which can be caused either by a variety of infectious microorganisms or by other inflammatory mechanisms. It is usually associated with localized chest pain that is synchronous with the respiratory cycle and is often manifested as a pleural rub on auscultation.. Definitions
  • 6. It may induce an exudative pleural effusion. The pain and the rub sometimes subside when an effusion develops. A "parapneumonic effusion" is an accumulation of exudative pleural fluid associated with an ipsilateral pulmonary infection. Definitions
  • 7. "Uncomplicated parapneumonic effusions" are not infected and do not usually need tube thoracostomy. "Complicated parapneumonic effusions" are usually associated with the pleural invasion of the infectious agent and require tube thoracostomy and sometimes decortication for their resolution. Definitions
  • 8. "An effusion is called an "empyema" when the concentration of leucocytes becomes macroscopically evident as a thick and turbid fluid (pus). In more than 50% of cases, it is of parapneumonic origin. Other common causes include surgical procedures (mainly thoracic surgery), traumas and oesophageal perforation Definitions
  • 9. The pleuritis sicca stage The inflammatory process of the pulmonary parenchyma extends to the visceral pleura, causing a local pleuritic reaction. This leads to a pleural rub and the characteristic pleuritic chest pain, which originates from the sensitive innervation of the adjacent parietal pleura. Pathophysiology
  • 10. The pleuritis sicca stage A significant number of patients with pneumonia report pleuritic chest pain without developing a pleural effusion , suggesting that the involvement of the pleura may be limited to this stage in many cases of pneumonia.. Pathophysiology
  • 11. The exudative stage The ongoing inflammatory process leads to a mediator induced increased permeability of local tissue and of regional capillaries. The subsequent accumulation of fluid in the pleural space is probably the combined result of the influx of pulmonary interstitial fluid and of a local microvascular exudate. Pathophysiology
  • 12. The exudative stage The fluid is usually clear and sterile, cytological specimens show a predominance of neutrophils, the pH is normal and the lactate dehydrogenate (LDH) activity is <1,000 international units (IU). Pathophysiology
  • 13. The fibropurulent stage This stage may develop quickly (within hours) in patients who are not receiving antibiotics, or who are treated with ineffective antibiotics. It is characterized by the deposition of fibrin clots and fibrin membranes ("sails") in the pleural space, which lead to loculations with increasing numbers of isolated collections of fluid. Pathophysiology
  • 14. The fibropurulent stage It is usually accompanied by (and caused by) bacterial invasion from the pulmonary parenchyma. The fluid is often turbid or frank pus. Cytology shows neutrophils and often degenerated cells, and Gram stains and bacterial cultures are usually positive. The metabolic and cytolytical activity in these effusions is high, as reflected by low pH values (<7.2), and high LDH activities (often >1,000 IU). Pathophysiology
  • 15. The organizational stage This final stage is characterized by the invasion of fibroblasts, leading to the transformation of interpleural fibrin membranes into a web of thick and nonelastic pleural peels. Functionally, gas exchange is often severely impaired on the side of the organizing empyema ("trapped lung"). Pathophysiology
  • 16. The organizational stage The further course may vary from spontaneous healing with persistent defects of lung function to chronic forms of empyema with high risks for further complications, such as bronchopleural fistula, lung abscess, or "empyema necessitatis" (spontaneous perforation through the chest wall). Pathophysiology
  • 17. The clinical presentation of patients with pneumonia, whether or not they have parapneumonic effusions, is similar. there were no significant differences between these two groups of patients regarding white blood cell count (WBC) and the occurrence of pleuritic chest pain. Clinical aspects and differential diagnosis
  • 18. Patients with pneumonia due to infection with aerobic bacteria usually suffer from an acute febrile illness, whilst patients with anaerobic infections tend to present with a more subacute or chronic condition, with a longer duration of symptoms and frequent weight loss Clinical aspects and differential diagnosis
  • 19. Anaerobic pleuropulmonary infections often follow aspiration of oral or gastric contents. These patients usually have poor oral hygiene (foetor ex ore!) with anaerobic colonization of the oropharynx, and often suffer from conditions that predispose to aspiration, such as seizure disorders, syncopes of other origin, or alcoholism. The latter has been found to be a relevant associated disorder in as many as 29% to 40% of cases. Clinical aspects and differential diagnosis
  • 20. The finding of a purulent effusion without pneumonia may be explained as a postpneumonic empyema, in which the pulmonary infiltrates have already resolved. However, pleural empyemas are not necessarily caused by pneumonia. Clinical aspects and differential diagnosis
  • 21. The majority of nonpneumonic empyemas are of iatrogenic origin, most commonly as a complication of a pneumonectomy or other thoracic surgical procedures. Thoracic surgery is responsible for about 20% of all thoracic empyemas Around 5% occur following a thoracic trauma and 5% following an oesophageal perforation (often iatrogenic). Clinical aspects and differential diagnosis
  • 22. The majority of nonpneumonic empyemas are of iatrogenic origin, most commonly as a complication of a pneumonectomy or other thoracic surgical procedures. Thoracic surgery is responsible for about 20% of all thoracic empyemas Around 5% occur following a thoracic trauma and 5% following an oesophageal perforation (often iatrogenic). Clinical aspects and differential diagnosis
  • 23. Fever, pulmonary infiltrates, and a pleural effusion are not invariably due to pneumonia or to a complication of some surgical procedure. A very important differential diagnosis, which should always be considered, is pulmonary infarction. Clinical aspects and differential diagnosis
  • 24. Pulmonary embolism is a common disorder and paraembolic effusions occur in 25– 50% of cases . The effusions may become infected and will then require treatment identical to complicated parapneumonic effusions. Clinical aspects and differential diagnosis
  • 25. Other disorders which should be considered include tuberculosis ,lupus erythematosus and other autoimmune disorders , acute pancreatitis and other diseases of the gastrointestinal (GI) tract [, and drug-induced pleuropulmonary disease . The turbid or milky aspect of empyemas may sometimes lead to the misconception of a chylothorax or pseudochylothorax . Clinical aspects and differential diagnosis
  • 26. Other disorders which should be considered include tuberculosis ,lupus erythematosus and other autoimmune disorders , acute pancreatitis and other diseases of the gastrointestinal (GI) tract [, and drug-induced pleuropulmonary disease . The turbid or milky aspect of empyemas may sometimes lead to the misconception of a chylothorax or pseudochylothorax . Clinical aspects and differential diagnosis
  • 27. Laboratory Studies No specific laboratory studies of the serum suggest the presence of a parapneumonic effusion or empyema. However, the possibility of a parapneumonic effusion and empyema should be a consideration for every patient with pneumonia. The presence of pleural fluid may be suggested based on physical examination findings; however, small pleural effusions may not be detected during the physical examination. In this case, any significant effusion can be visualized using 2-view (ie, posteroanterior, lateral) chest radiography.
  • 28. Laboratory Studies Sputum should be submitted for culture, especially if purulent. The infecting organism may be suggested based on Gram stain results. Mixed florae are often seen in anaerobic infections.. As with any infection, leukocytosis may be present (>12,000/µL) ; however, it should decrease with adequate antibiotic therapy. Persistent fever and leukocytosis despite adequate antibiotic therapy may signal a persistent focus of infection, such as a complicated parapneumonic effusion or empyema. Diagnosing a complicated parapneumonic effusion and/or empyema is crucial for optimal management because a delay in drainage of the pleural fluid substantially increases morbidity.
  • 29. Imaging Studies Chest radiography: Lateral chest radiography usually demonstrates the presence of a significant amount of pleural fluid, as shown in the image below. Left lateral chest radiograph shows a large, left pleural effusion.
  • 36. Imaging Studies Chest radiography: If either of the diaphragms is not visible throughout its entire length, the posterior costophrenic angles are blunted, or a lateral meniscus is visible, then bilateral decubitus chest radiographs should be obtained. Free pleural fluid is seen as a dense linear shadow layering between the chest wall and the lung parenchyma. Unchanging pleural-based linear densities, pleural-based mass-liked densities, or collections with obtuse angles suggest the presence of loculated fluid, especially if the differences in the fluid or the appearance between upright and lateral views are minimal. If the pleural fluid distance measures more than 10 mm from the chest wall, sufficient free-flowing fluid is present to perform a diagnostic thoracentesis.
  • 37. Imaging Studies Ultrasonography: Ultrasonography can be used to localize fluid for a thoracentesis. Fluid appears dark or black on ultrasound images, and most bedside ultrasonography devices permit measurement of the depth of location from the chest wall. Complex fluid (purulent or viscous) may have more density or shadows within in the pleural fluid collection. Sometimes, fibrinous strands can be seen floating in the pleural fluid. Other structures such as the diaphragm or lung parenchyma can provide landmarks to assist in needle placement for thoracentesis.
  • 38. Imaging Studies Ultrasonography: Loculated pleural effusions may be difficult to localize during physical examination, but they can usually be identified with ultrasonography. Ultrasonography can effectively distinguish loculated pleural fluid from an infiltrate. The latter may have air bronchograms visible, but the distinction may be difficult if a dense consolidation is present. If a loculated pleural effusion is suspected, an ultrasonographic examination is recommended for diagnosis and marking the area for thoracentesis.
  • 40. Complex nonseptated effusion Complex septated effusion with movable septa Complex septated effusion with Fixed septa
  • 42. Imaging Studies CT scanning of the thorax:| CT scanning of the chest with contrast, as shown in the image below, enhances the pleural surface and assists in delineating the pleural fluid loculations. CT scan of thorax shows loculated pleural effusion on left and contrast enhancement of visceral pleura, indicating the etiology is likely an empyema.
  • 43. Imaging Studies CT scanning of the thorax:| Chest CT scan with intravenous contrast in a patient with mixed Streptococcus milleri and anaerobic empyema following aspiration pneumonia, showing a thickened contrast-enhanced pleural rind, high-density pleural effusion, loculation, and septation. Thoracentesis yielded foul-smelling pus.
  • 44. Imaging Studies CT scanning of the thorax:| Pleural enhancement can be seen in patients with active inflammation and severe pleuropulmonary infections, which provides another sign of the possibility of a complicated pleural effusion or empyema. CT scanning of the chest may also help detect airway or parenchymal abnormalities such as endobronchial obstruction or the presence of lung abscesses.
  • 45. Figure26.24 Simple parapneumonic effusion. The left pleural effusion is… Parapneumoniceffusions
  • 48. Procedures Thoracentesis is recommended when the suspected parapneumonic pleural effusion is greater than or equal to 10 mm thick on a lateral decubitus chest radiograph Pleural fluid appearance may vary from a clear yellow liquid to an opaque turbid fluid to grossly purulent thick, viscous, foul-smelling pus. Foul-smelling fluid indicates an anaerobic infection.
  • 49. Pleural fluid studies Blood cell count (WBC count) and differential: Results generally are not diagnostic, but most transudates are associated with a WBC counts of less than 1000 cells/µL and empyemas are exudates, with WBC counts generally greater than 50,000 cells/µL. Pleural fluid total protein, LDH, and glucose (corresponding serum protein and LDH): Exudates are defined by pleural/serum total protein ratio of greater than 0.5 and a pleural/serum LDH ratio of greater than 0.6 or a pleural fluid LDH value greater than two thirds the upper limit of normal. One criterion is sufficient to classify fluid as an exudate.
  • 50. Pleural fluid studies Pleural fluid pH (iced blood gas syringe): Values of less than 7.20 are suggestive of a complicated pleural effusion. Other laboratories suggestive of complicated pleural effusion or empyema: These include (1) an LDH value of greater than 1000 U/L, (2) a pH of less than 7.00, and (3) a glucose level of less than 40 mg/dL. Microbiology (Gram stain, bacterial culture): Acid-fast bacilli and fungal infections may cause pleural effusions or empyema, but these organisms are more difficult to culture from pleural fluid.
  • 51. Histologic Findings Multiple granulocytes are typically identified on histologic examination. Necrotic debris may be present. Bacteria are seen in the pleural fluid in severe infections.
  • 52. Staging The following classification and treatment scheme has been used to characterize parapneumonic effusions and empyema. Category 1 (parapneumonic effusion): Minimal free-flowing fluid, smaller than 10 mm on decubitus films Culture, Gram stain, and pH unknown No thoracentesis needed; treatment with antibiotics alone Category 2 (uncomplicated parapneumonic effusion): Larger than 10 mm fluid and less than half the hemithorax on decubitus films Gram stain and culture negative pH higher than 7.20 Treatment with antibiotics alone
  • 53. Staging Category 3 (complicated parapneumonic effusion): Large free-flowing effusion, more than half the hemithorax pH lower than 7.20, LDH level greater than 1000 U/L and glucose level greater than 40 mg/dL Gram stain or culture positive Treatment with tube thoracostomy and antibiotics Multiloculated effusions may require multiple tubes Thrombolytics may help resolution
  • 54. Staging Category 4 (empyema): Large free-flowing effusion, greater than equal to half the hemithorax Loculated effusion or effusion with thickened pleura Gross pus on aspiration Treatment with tube thoracostomy Thrombolytics may help resolution May require decortication
  • 55. Medical Care The initial treatment of a patient with pneumonia and pleural effusion involves two major decisions. The first decision involves selection of an appropriate antibiotic that will cover likely pathogens. The second decision involves the need for drainage of pleural fluid and is be guided by the American College of Chest Physicians (ACCP) guideline recommendations for the medical and surgical treatment of parapneumonic effusions.
  • 56. Medical Care The initial antibiotic selection is usually based on whether the pneumonia is community or hospital acquired and on the severity of the patient's illness. For a patient with community-acquired pneumonia, the recommended agents are second- or third-generation cephalosporins in addition to a macrolide. For patients hospitalized with severe community-acquired pneumonia, initiate treatment with a macrolide plus a third- generation cephalosporin with antipseudomonal activity. Enteric Gram-negative bacilli frequently cause pneumonia acquired in institutions (eg, hospitals, nursing homes). Therefore, initial antibiotic coverage should include an antibiotic effective against pseudomonads. If aspiration is evident or suspected, oral anaerobic micro-organism should also be covered.
  • 57. Medical Care Infectious Diseases Society of America (IDSA)/American Thoracic Society (ATS) consensus guidelines on the management of community-acquired pneumonia, hospital- acquired pneumonia, ventilator-associated pneumonia, and healthcare-associated pneumonia in adults are published elsewhere.[9, 10] Also seePneumonia, Bacterial. Effusions with pleural fluid layering less than 10 mm on decubitus chest radiographs almost always resolve with appropriate systemic antibiotics. Patients with pleural effusions that have a pleural fluid layering greater than 10 mm on lateral decubitus radiographs should have a diagnostic thoracentesis unless there is a contra-indication to the procedure. If the diagnostic thoracentesis yields thick pus, the patient has an empyema thoracis and definitive pleural drainage is absolutely required. If the pleural fluid is not thick pus, then results of pleural fluid Gram stain or culture, pleural fluid pH and glucose
  • 58. Medical Care Effusions with pleural fluid layering less than 10 mm on decubitus chest radiographs almost always resolve with appropriate systemic antibiotics. Patients with pleural effusions that have a pleural fluid layering greater than 10 mm on lateral decubitus radiographs should have a diagnostic thoracentesis unless there is a contra- indication to the procedure. If the diagnostic thoracentesis yields thick pus, the patient has an empyema thoracis and definitive pleural drainage is absolutely required. If the pleural fluid is not thick pus, then results of pleural fluid Gram stain or culture, pleural fluid pH and glucose levels, and the presence or absence of pleural fluid loculations should guide the course of action as recommended in the guidelines.
  • 59. Medical Care In summary, the recommendations are as follows: In all patients with acute bacterial pneumonia, the presence of a parapneumonic pleural effusion should be considered (level C evidence). In patients with parapneumonic pleural effusions, the estimated risk for poor outcome, using the panel-recommended approach based on pleural space anatomy, pleural fluid bacteriology, and pleural fluid chemistry, should be the basis for determining whether the parapneumonic pleural effusions should be drained (level D evidence). Poor outcomes could result from any or all of the following: prolonged hospitalization, prolonged evidence of systemic toxicity, increased morbidity from any drainage procedure, increased risk for residual ventilatory impairment, increased risk for local spread of the inflammatory reaction, and increased mortality.
  • 60. Surgical Care Thoracoscopy: Thoracoscopy is an alternate therapy for multiloculated empyema thoracis. In patients with multiloculated parapneumonic pleural effusions, the loculations in the pleural space can be disrupted with a thoracoscope, and the pleural space can be drained completely. If extensive adhesions are present or thick pleural peel entraps the lung, the procedure may be converted to open thoracostomy and decortication.
  • 61. Surgical Care Luh et al published their experience in the treatment of complicated parapneumonic pleural effusions and empyema thoracis by VATS in 234 patients (108 women, 126 men). More than 85% (200 patients) received preoperative diagnostic or therapeutic thoracentesis, tube thoracostomy, or fibrinolytics. Of 234 patients, 202 patients (86.3%) achieved satisfactory results with VATS. Only 40 patients required open decortication or repeat procedures. VATS is safe and effective for treatment; earlier intervention with VATS can produce better clinical results
  • 62. Surgical Care Hope et al reviewed outcomes of surgical treatment for parapneumonic empyema thoracis. The use of VATS was compared with thoracotomy. Morbidity and mortality rates were similar among all groups. The conversion rate to open thoracotomy was 21%. Based on a shorter postoperative length of stay with similar morbidity and mortality in patients operated on within 11 days of admission, early aggressive surgery treatment for complicated parapneumonic effusions or empyema thoracis is recommended.
  • 63. Surgical Care Retrospective evaluation of 2 different surgical procedures (decortication vs debridement) and approaches (VATS vs thoracotomy) were analyzed by Casali and colleagues. VATS debridement had a lower postoperative hospital stay and shorter duration of chest drainage and greater improvement in a subjective dyspnea score. The long-term spirometric evaluation was normal in 58 patients (56%). Age older than 70 years old was the only variable associated with poor long-term results (forced expiratory volume in 1 second [FEV1] < 60% and/or dyspnea Medical Research Council grade ≥2) at multivariate analysis. VATS is associated with less postoperative mortality and shorter postoperative hospital stay.
  • 64. Surgical Care Rib resection and open drainage of pleural space: Open drainage of the pleural space may be used when closed- tube drainage of the pleural infection is inadequate and the patient does not respond to intrapleural thrombolytic agents. This procedure is recommended only when the patient is too ill to tolerate decortication. The resection of one to three ribs overlying the lower part of the empyema thoracis cavity is performed, a large-bore chest tube is inserted into the empyema thoracis cavity, and the tube is drained into a colostomy bag.
  • 65. Surgical Care Decortication: In decortication, all the fibrous tissue is removed from the visceral pleural peel, and all pus is evacuated from the pleural space. Decortication is a major thoracic operation requiring full thoracotomy; therefore, decortication is not tolerated by critically ill patients. Decortication is the procedure of choice for patients in whom pleural sepsis is not controlled by closed-tube thoracostomy, intrapleural thrombolytic agents, and, possibly, thoracoscopy. Mortality rates as high as 10% have been described with this procedure.
  • 66. Surgical Care Decortication: Decortication should not be performed solely to remove the thickened pleural peel; the thickened pleural peel usually resolves over several months. If the pleura remains thickened with symptom-limiting reduction in pulmonary function after approximately 6 months, decortication can be considered.
  • 67. Surgical Care Postpneumonectomy empyema thoracis: an uncommon but life-threatening complication, is often associated with a bronchopleural fistula. Treatment of bronchopleural fistula depends on several factors, including the extent of dehiscence, degree of pleural contamination, and general condition of the patient. Early diagnosis and aggressive therapeutic strategies for controlling infection, closing the fistula, and sterilizing the closed pleural space are mandatory. Repeated debridement, VATS, endoscopic application of tissue glue, and stenting may be additional management strategies..