The management of empyema
the practical vs. ideal approach
R. Masekela
University of Pretoria
Case presentation
Patient A.K
11 month old baby boy
Main Complaint :
Coughing - two weeks non productive
Fever - two weeks
Vomiting - after coughing
Diarrhoea - one week, brown and loose no blood noted in stool
3 weeks before admission to primary care hospital was seen with a
cough and fever and treated with Amoxycillin and Paracetamol. Did
not improve after a week and was taken back.
• Diagnosis with bronchopneumonia and a pleural effusion
Ampicillin and Amikacin for 6 days
Vancomycin for 2 days
• PMH : No previous admissions, healthy
• Family history : no atopy, no asthma
•No TB contacts
On Examination
Mass 10kg, 100% expected
Length 78cm, 100% expected
Vitals : RR 60, Pulse 110, Temp 37.5, BP 90/40 Sats 90%
5% dehydrated
Chest: Grunting, Nasal flaring, subcostal recessions,
bilateral scattered crepitations, decreased air entry right lower
lobe and stony dullness right base
30/5/07
ICD inserted
19/5
22/5
30/5
Hb
11.9
11.0
9.8
MCV
69.9
71.9
.30
Platelets
961
729
844
WCC
27.88
16.70
16.77
Pleural pus specimen - 31/05/07
Cultured Staph. Aureus
R - Penicillin/ampicillin
Neutrophils
10.23
Lymphocytes
4.53
R - Erythromycin
Monocytes
2.01
R - Clindamycin
S - Cloxacillin
Na
145
140
140
K
4.7
3.2
4.8
CL
108
105
105
CO2
14
20
16
Urea
9.1
1.5
<1.0
Creatinine
83
23
30
Anion Gap
28
18
24
CRP
221.5
72.8
144.4
ESR
NGA - AFB
69
-ve
-ve
1/06/07
HISTORY
460 BC
Em=within
Pyema=accumulation of
pus
Hippocratic physicians
recommended treating
empyema with open
drainage
“those diseases that
medicines do not cure are
cured by the knife”
HISTORY cont’d
1876- Hewitt described a method of
closed drainage of the chest in which a
rubber tube was placed into the empyema
cavity and drained via the water seal
drainage
Early 20th century introduction of surgical
therapies for empyema
thoracoplasty, decortication.
Empyema
Empyema: presence of pus in the pleural space
Boys affected more than girls
First world 0.6-3% bacterial pneumonias
Megan et al Curr Opinion Pediatr 2007
HIV positive 8% of South African children
Zar et al. Acta Paediatrica 2001
Normal pleural fluid
Pleural space potential space 10-24µm
0.1-0.2 ml/kg pleural fluid
Starlings forces: filtration and
reabsorption
pH 7.6
Light’s criteria
Pleural fluid protein: serum protein > O.5
Pleural fluid : serum LDH >0.6
Pleural fluid LDH > 2/3 upper limit of
serum LDH
Light R. Chest 1995;108:299-301
Other minor criteria
Cholesterol > 45mg/dl
Protein content > 3.0 g/dl
pH <7.2
Glucose < 50% serum
Parapneumonic pleural effusions
3 groups or stages based on
pathogenesis:
Uncomplicated parapneumonic effusion
Complicated parapneumonic effusion
Thoracic empyema.
Exudative stage
Sterile pleural fluid accumulates in pleural space.
Pleural fluid originates in lung interstitial spaces
and in capillaries of visceral pleura due to
increased permeability.
Pleural fluid ↓ WBC ↓ LDH level, glucose and pH
levels are normal
Effusions resolve with antibiotic therapy.
Fibropurulent stage
Bacterial invasion of the pleural space occurs →
accumulation of neutrophils, bacteria and cellular
debris
Deposition of fibrin loculations
Pleural fluid pH <7.2 , glucose levels ↓, LDH level
>1000IU/l
Organizational stage
Fibroblasts grow into the exudates from
both the visceral and parietal pleural
surfaces
They produce an inelastic membrane
called pleural peel.
Thick pleural fluid
Complications
Dissect into lung parenchyma→
bronchopleural fistulas and
pyopneumothorax
Dissection through chest wall (empyema
necessitatis) RARE
Dissection into abdominal cavity
Organisms
Strep. pneumonia
HIV infection 41X risk of invasive disease and more resistance
Mahdi et al PIDJ 2000
Incidence increasing in developing world
S. aureus
Increasing incidence CA-MRSA in HIV-infected children 50% in
Natal blood culture positive. McNally et al. Lancet 2007
67 of 100 empyema. Goel et al. J Tropical Peadiatr 1999
H. influenza type b
Gram negatives
Pseudomonas
Klebsiella
E.coli
Organisms
Tuberculosis
Rare cause but common PPE
Fungi
Viral
Atypical organism
Mycoplasma
Clinical manifestations
Aerobic bacterial pneumonia
An acute febrile illness with chest pain, sputum
production, and leukocytosis.
A complicated parapneumonic effusion with
presence of a fever lasting more than 48 hours
after initiation of antibiotic therapy.
Clinical manifestation
Anaerobic bacterial infection
Usually presents with subacute illness.
symptoms persisting for more than 7 days.
60% of patients have weight loss.
Poor oral hygiene
Factors predisposing to recurrent aspiration.
Chest x-rays
PA and lateral decubitus
Adult studies sensitivity 67% and specificity 70%
Heffner JE. Clinics Chest Med 1999;20:607-622
PA at least 400ml fluid vs. 50ml lateral decubitus
Assess for loculations
Ultrasound
Classification
Stage 1: anechoic fluid
Stage 2: loculations
Stage 3: solid peel
Guide placement of intercostal drain
Hogan MJ, Cooley BD. Paediatric Resp Reviews 2008;9:77-84
Ultrasound
Size of effusion
Differentiate consolidation from empyema
Unreliable predictor of disease severity
CT scan
Anatomical
Parenchymal lesions
Endobronchial lesions
Mediastinal lesions
Lung abscess
Management
IV antibiotics and intercostal drainage
Fibrinolytics
Video -Assisted Thoracoscopic Surgery (VATS)
Open thoracotomy and decortication
Management
Supportive
Bed rest
Analgesia
Oxygen
Fluids
Identify the cause
Malnutrition
TB
HIV
Antibiotic therapy
Zampoli M, Zar H. SAJCH 2007;1(3):121-8
Fibrinolytics
Degrade fibrin, blood clots and pleural loculi in
pleural space
Streptokinase: 15 000U/kg in 20-50ml saline
once daily for 3 days (vial 750 000U R1400, 1
million units R2700)
Urokinase: 40 000u in 40ml saline (> 1 year) or
10 000 in 10 ml BD for 3 days(< 1 year)
tPA 0.1mg/kg in 10-30ml saline dwell time 1 hour
(50mg vial R3100)
Fibrinolytic therapy versus conservative
managements: Cochrane review
Seven studies 761 participants
No significant difference in risk of death (RR
1.08;95% CI 0.69-1.68)
Reduction in risk of treatment failure (RR
0.63;95% CI 0.46-0.85)
Fibrinolytics confer significant benefit and reduce
requirement for surgical intervention (in early
studies published)
Cameron R, Davies HR. Cochrane review April 23 2008 Issue 2
VATS
Can be done as primary procedure
Experienced surgeon necessary
Benefits
lower mortality
Re-intervention
Reduced length of hospital stay
Reduced hospital costs
Aziz et al Surgical infections 2008;9(3):317-23
Thoracotomy
Treatment of choice if no experience or
success with VATS
Early and accurate diagnosis and therapy
Attempt “mini” vs. full procedure
Mortality reduced
Ideal approach
Fuller MK, Helmrath MA. Curr Opinion Pediatrics 2007;19:328-332
Practical
Early diagnosis
CXR include lateral decubitus
Early antibiotics
Early chest drainage
Loculations
Early referral
Thoracotomy if no improvement with ICD
placement and correct antibiotics
Prognosis
Favourable in patients started on
appropriate antibiotic
Early chest tube drainage is beneficial.
Decortication or open drainage has
decreased mortality and morbidity.
Prognosis
Mortality 6-12%
Complications
Bronchopleural fistula
Tension pneumatocoele
Fibrothorax
4/06/07
Acknowledgements
Prof R Green
Dr O Kitchin
Dr S Risenga
Dr Moodley
ICU staff
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