EMPYEMA

Empyema thoracicEmpyema thoracic

Dr Rajesh KumarMD (PGI), DM (Neonatology) PGI,

Chandigarh, IndiaRani Children Hospital, Ranchi

There are no universally accepted guidelines for There are no universally accepted guidelines for management of empyema thoracicmanagement of empyema thoracic

DefinitionDefinition

presence of pus or microorganism in the presence of pus or microorganism in the pleural fluid. Microorganisms may be seen on pleural fluid. Microorganisms may be seen on smear examination or on culture.smear examination or on culture.

In the absence of microorganism,In the absence of microorganism,– The pH of pleural fluid is less than 7.0The pH of pleural fluid is less than 7.0– Lactic dehydrogenase (LDH) is more than 1000 Lactic dehydrogenase (LDH) is more than 1000

IU/LIU/L– glucose is less than 40 mg/dlglucose is less than 40 mg/dl– lactate is more than 5 mol/L or 45 mg/mllactate is more than 5 mol/L or 45 mg/ml

OrganismsOrganisms Staphylococcus aureus, Streptococcus pneumoniae Staphylococcus aureus, Streptococcus pneumoniae

and and Streptococcus pyogenesStreptococcus pyogenes Pneumococcal pneumonia presents with effusion in Pneumococcal pneumonia presents with effusion in

40% patients, empyema occurs only in 5%40% patients, empyema occurs only in 5% Anaerobes and enterobacter are common in mixed Anaerobes and enterobacter are common in mixed

infections. Anaerobes are more common after 6 infections. Anaerobes are more common after 6 years of age. For anaerobes, aspiration pneumonia is years of age. For anaerobes, aspiration pneumonia is the most common cause followed by lung abscess, the most common cause followed by lung abscess, sub diaphrag-matic abscess and spreading infection sub diaphrag-matic abscess and spreading infection from adjacent sites, from adjacent sites, e.g.e.g. periodontal, retropharyn- periodontal, retropharyn-geal, peritonsillar and neck abscesses. geal, peritonsillar and neck abscesses.

TuberculousTuberculous

230 children, 32 % pleural fluid culture 230 children, 32 % pleural fluid culture positive, 11% additional blood culure positive, 11% additional blood culure positivepositive

60 % S Aureus ( 78 % MRSA)60 % S Aureus ( 78 % MRSA) First PRSP in 1995, First MRSA 1998First PRSP in 1995, First MRSA 1998 Early (<48 hours) VATS decreased the Early (<48 hours) VATS decreased the

hospital stayhospital stay

Stages of EmpyemaStages of Empyema

Exudative stage (1-3 days )Exudative stage (1-3 days )

Fibrino purulent stage (4 to 14 days)Fibrino purulent stage (4 to 14 days)

Organizing stage (after 14 days)Organizing stage (after 14 days)

Exudative stage (1-3 days)Exudative stage (1-3 days) Immediate response with outpouring of the Immediate response with outpouring of the

fluid. fluid. Low cellular content Low cellular content It is simple parapneumonic effusion with It is simple parapneumonic effusion with

normal pH and glucose levels. normal pH and glucose levels. – pH more than 7.30pH more than 7.30– glucose more than 60 mg/dlglucose more than 60 mg/dl– pleural fluid/serum glucose ratio more than 0.5pleural fluid/serum glucose ratio more than 0.5– LDH less than 1000 IU/L LDH less than 1000 IU/L – Gram stain and culture is negative for micro-Gram stain and culture is negative for micro-

organism. organism.

Fibrino purulent stage (4 to 14 days)Fibrino purulent stage (4 to 14 days)

Large number of poly-morphonuclear leukocytes and Large number of poly-morphonuclear leukocytes and fibrin accumulatesfibrin accumulates

Fluid pH and glucose level fall while LDH rises. Fluid pH and glucose level fall while LDH rises. Acumulation of neutro-phils and fibrin, effusion Acumulation of neutro-phils and fibrin, effusion

becomes purulent and viscous leading to becomes purulent and viscous leading to development of empyema.development of empyema.

There is progressive tendency towards loculations There is progressive tendency towards loculations and formation of a limiting membranes.and formation of a limiting membranes.

Pleural fluid analysisPleural fluid analysis– Purulent fluid or pH less than 7.10, glucose less than 40 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 mg/dl and LDH more than 1000 IU/L. Gram stain and culture reports show microorganism. reports show microorganism.

Organizing stage (after 14 days)Organizing stage (after 14 days)

Fibro-blasts grow into exudates on both the Fibro-blasts grow into exudates on both the visceral and parietal pleural surfacesvisceral and parietal pleural surfaces

Development of an inelastic membrane "the Development of an inelastic membrane "the peel". peel".

Thickened pleural peel may prevent the entry of Thickened pleural peel may prevent the entry of anti-microbial drugs in the pleural space and in anti-microbial drugs in the pleural space and in some cases can lead to drug resistance. some cases can lead to drug resistance.

Most common in Most common in S. aureus S. aureus infection. infection. Thickened pleural peel can restrict lung Thickened pleural peel can restrict lung

movement and it is commonly termed as trapped movement and it is commonly termed as trapped lunglung

CXRCXR

Large pleural effusion can be diagnosed Large pleural effusion can be diagnosed in posteroanterior viewin posteroanterior view

Lateral decubitus view with affected Lateral decubitus view with affected side inferior facilitates recognition of side inferior facilitates recognition of smaller volumes of fluid. smaller volumes of fluid.

XX-ray in different positions helps to -ray in different positions helps to recognize the extent of parenchymal recognize the extent of parenchymal infection and may reveal loculated fluidinfection and may reveal loculated fluid

USGUSG Very useful tool for diagnosis, guidance of thoraco-Very useful tool for diagnosis, guidance of thoraco-

centesis, or pleural catheter placement. centesis, or pleural catheter placement. Sonography can distinugish solid from liquid pleural Sonography can distinugish solid from liquid pleural

abnormalities with 92% accuracy compared to 68% abnormalities with 92% accuracy compared to 68% accuracy with chest accuracy with chest XX-ray. When both are combined, -ray. When both are combined, accuracy rises to 98%accuracy rises to 98%

USG shows limiting membranes suggesting the USG shows limiting membranes suggesting the presence of loculated collections even when they are presence of loculated collections even when they are invisible by CT scan.invisible by CT scan.

Thoracocentesis and Pleural Fluid Analysis Thoracocentesis and Pleural Fluid Analysis

If effusion is free flowing and greater than one If effusion is free flowing and greater than one centimeter from inside of the chest wall to the centimeter from inside of the chest wall to the pleural fluid line on the lateral decubitus view, pleural fluid line on the lateral decubitus view, immediate diagnostic thoracocentesis should immediate diagnostic thoracocentesis should be done. be done.

If loculated, thoracocentesis should be done If loculated, thoracocentesis should be done under ultrasound guidance. The site for under ultrasound guidance. The site for thoracocentesis is 1 cm below upper level of thoracocentesis is 1 cm below upper level of dullnessdullness

Thoracocentesis and Pleural Fluid AnalysisThoracocentesis and Pleural Fluid Analysis

Two third of the cases of anaerobic infection have malodorous Two third of the cases of anaerobic infection have malodorous empyemaempyema

Protein level and specific gravity is rarely helpful in differentiating Protein level and specific gravity is rarely helpful in differentiating stages of empyemastages of empyema

In some cases with frank pus, organisms are neither seen on In some cases with frank pus, organisms are neither seen on Gram stain nor grown in culture. Such cases must raise a Gram stain nor grown in culture. Such cases must raise a suspicion of chylous effusionsuspicion of chylous effusion

cell fragments will sediment where a chylous effusion will remain cell fragments will sediment where a chylous effusion will remain opaque after centrifugationopaque after centrifugation

Tuberculous empyema can be confirmed by stains for acid fast Tuberculous empyema can be confirmed by stains for acid fast bacilli in fewer than 25% cases but pleural biopsy and culture can bacilli in fewer than 25% cases but pleural biopsy and culture can diagnose more than 90% casesdiagnose more than 90% cases

ADA more than 70 U/L supports the diagnosis of tuberculous ADA more than 70 U/L supports the diagnosis of tuberculous pleural empyemapleural empyema

PCRPCR

Goal of treatmentGoal of treatment

1.1. Control of infectionControl of infection2.2. Drainage of pusDrainage of pus3.3. Expansion of lungsExpansion of lungs

Treatment OptionsTreatment Options

Non-OperativeNon-Operative– AntibioticsAntibiotics– ThoracocentesisThoracocentesis– ICTDICTD– FibrinolysisFibrinolysis

OperativeOperative– VATSVATS– ThoracotomyThoracotomy

Primary non-operative Primary non-operative Salvage operative Salvage operative

Primary operativePrimary operative

Emperical antibioticsEmperical antibiotics

Anti Staph antibiotic + Cephalosporin Anti Staph antibiotic + Cephalosporin ++ AminoglycosideAminoglycoside

Suspectedanaerobic infection Suspectedanaerobic infection Clindamycin should be addedClindamycin should be added

AntibioticsAntibiotics Paren-teral therapy should be continued for Paren-teral therapy should be continued for

48-72 hours after abatement of fever and 48-72 hours after abatement of fever and then oral therapy can be used to complete then oral therapy can be used to complete the course. the course.

Antibiotic should be continued until patient is Antibiotic should be continued until patient is afebrile, WBC count is normal, radiograph afebrile, WBC count is normal, radiograph show consider-able clearingshow consider-able clearing

Duration of therapyDuration of therapy– H. influnezae, S. pneumonia: 10-14 daysH. influnezae, S. pneumonia: 10-14 days– Staph aureus: 3-4 weeksStaph aureus: 3-4 weeks

Empyema drainageEmpyema drainage Indications for drainageIndications for drainage

– Frank pus, smear positive fluid, loculated fluidFrank pus, smear positive fluid, loculated fluid– pH less than 7.10, glucose less than 40 mg/dl and LDH more than pH less than 7.10, glucose less than 40 mg/dl and LDH more than

1000 IU/L1000 IU/L Repeated thoracocentesis is rarely successful; Small-bore Repeated thoracocentesis is rarely successful; Small-bore

percutaneous catheters can be used if the fluid is thinpercutaneous catheters can be used if the fluid is thin CT or USG guided drainage if empyema collection is small. CT or USG guided drainage if empyema collection is small. Chest tube drainage is advised for drainage of tuberculous Chest tube drainage is advised for drainage of tuberculous

empyema. empyema. Chest tube must be kept inside till drainage is less than 30-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(50 ml per day and cavity size is less than 50 ml in size(

Predicting Factors for Outcome of Tube Predicting Factors for Outcome of Tube Thoracostomy in Complicated Thoracostomy in Complicated

Parapneumonic Effusion or Empyema : Chest Parapneumonic Effusion or Empyema : Chest 19991999

loculation of pleural effusion and pleural fluid loculation of pleural effusion and pleural fluid WBC count 6,400/µL were independent WBC count 6,400/µL were independent predicting factors for poor outcome of tube predicting factors for poor outcome of tube thoracostomythoracostomy

Surgical intervention should be considered early Surgical intervention should be considered early after failure of first chest tube drainage in good after failure of first chest tube drainage in good surgical candidates with loculated empyema or surgical candidates with loculated empyema or pleural fluid with WBC count 6,400/µL to pleural fluid with WBC count 6,400/µL to minimize the mortality and morbidityminimize the mortality and morbidity

Thrombolytic TherapyThrombolytic Therapy Useful in multiloculated empyema.It hydrolyse fibrin leading to Useful in multiloculated empyema.It hydrolyse fibrin leading to

hydrolysis of fibrin coagulumhydrolysis of fibrin coagulum Multiloculation of empyema defined on the basis of USG/CTMultiloculation of empyema defined on the basis of USG/CT SK 2,50,000 unit or UK 1,00,000 unit in 100 ml normal saline SK 2,50,000 unit or UK 1,00,000 unit in 100 ml normal saline

was instilled through chest tube and tube was clamped for 3 was instilled through chest tube and tube was clamped for 3 hours. hours.

Number of instillation in SK and UK were 6 ± 2.16 and 5.92 ± Number of instillation in SK and UK were 6 ± 2.16 and 5.92 ± 2.05, two patients out of 25 patients failed to respond 2.05, two patients out of 25 patients failed to respond completely. completely.

Transient increase of body temperature was noted in 28% Transient increase of body temperature was noted in 28% cases of SK while no complication was noted with UK. cases of SK while no complication was noted with UK.

UK as little as 50,000 unit per instillation was found to be UK as little as 50,000 unit per instillation was found to be successful in 95% cases in one series. successful in 95% cases in one series.

Surgical modalitiesSurgical modalities Videoassisted Thoracoscopic Surgery (VATS):Videoassisted Thoracoscopic Surgery (VATS): It is It is

quite effective in lysis of adhesions in multiloculated quite effective in lysis of adhesions in multiloculated effusions and removal of fibrinous material from effusions and removal of fibrinous material from pleural cavity. VATS is often not as useful in pleural cavity. VATS is often not as useful in organizing stage. organizing stage.

Thoracoscopic Debridement and Irrigation: Thoracoscopic Debridement and Irrigation: It is quite It is quite effective in cases with multiloculated empyema. effective in cases with multiloculated empyema. Success rate is as high as 69% to 89% Success rate is as high as 69% to 89%

Decortication: Decortication: helpful in organizing stage with thick helpful in organizing stage with thick pleural peel, pleural peel,

Bronchopleural fistulaBronchopleural fistula ICTDICTD Decortication and fistula closure: after 2-3 Decortication and fistula closure: after 2-3

weeks of ICTDweeks of ICTD Gradual tube withdrawalGradual tube withdrawal Thoracoplasty or resectional surgeryThoracoplasty or resectional surgery Response depends onResponse depends on

– Size of fistula, Size of fistula, – state of underlying lung and contralateral lung, state of underlying lung and contralateral lung, – presence or absence of systemic illness, presence or absence of systemic illness, – nutritional rehabilitationnutritional rehabilitation

Response to therapyResponse to therapy S. pneumoniaeS. pneumoniae and and H. influenzaeH. influenzae infection children can remain infection children can remain

febrile for 7 or more days after adequate antibiotic therapy has febrile for 7 or more days after adequate antibiotic therapy has been instituted while children having been instituted while children having S. aureusS. aureus infection can infection can remain febrile for 10-14 days despite appropriate managementremain febrile for 10-14 days despite appropriate management

Scoring system for empyema thoracis Scoring system for empyema thoracis and help in management: IJJP 2005and help in management: IJJP 2005

SSE > 4 a is predictors of SSE > 4 a is predictors of surgical intervention for surgical intervention for fibrinopurulent empyema fibrinopurulent empyema in the present study. Early in the present study. Early elective VATS may be elective VATS may be adopted not later than 7 adopted not later than 7 days after failure of days after failure of appropriate antibiotic appropriate antibiotic therapy and adequate therapy and adequate drainage of empyema to drainage of empyema to decrease the length of stay decrease the length of stay and minimize morbidity.and minimize morbidity.

PrognosisPrognosis

In most of the cases, pulmonary In most of the cases, pulmonary function is found to be normalfunction is found to be normal

Few cases show complications such as Few cases show complications such as scoliosis, mild pleural thickening and scoliosis, mild pleural thickening and mild restrictive defectmild restrictive defect

Younger children fared less well Younger children fared less well