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
