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EMPYEMA GUIDELINESDr.PREETHAM KUMAR REDDYCONSULTANT PEDIATRICIAN & INTENSIVISTRAINBOW CHILDREN’S HOSPITAL
Empyema
• Pus and fluid from infected tissue in the pleural cavity.
• Also called empyema thoracis, or empyema of the chest.
• Empyema has a number of causes but is most frequently a complication of pneumonia.
Thoracic Empyema
Thoracic Empyema-- Stage 1
• Exudative effusion.
• Increased permeability of the inflammatory and swollen pleural surface.
• Corresponds to the uncomplicated parapneumonic effusion.
• Sterile, fibrin and PMN may present.
Uncomplicated Effusion
• Nonpurulent. • -ve Gram’s stain -ve culture. • Free flowing• pH 7.3• normal glucose level• LDH <1000 IU/L. • Most resolve with appropriate antibiotics
treatment and resolution of the pulmonary infection.
• Progress from stage 1 to 2 may occur quickly, often within 24–48 h .
Thoracic Empyema-- Stage 2
• Fibropurulent / true empyema / complicated pleural effusion.
• Initial-- fluid is clear :
WBC > 500 cell/μL
Protein> 2.5 g/dL
pH< 7.2,
LDH< 1000 IU/L, fibrin deposits. • Angioblastic and fibroblastic proliferation,
heavy fibrin deposition on both pleura, particularly the parietal pleura.
• Later–
• fluid purulent
• WBC 15000,
• ph <7.0,
• glucose < 50 mg/dL
• LDH > 1000 IU/L.
Thoracic Empyema-- Stage 3
• 1 week after infection-- collagen organization, entrapment of the underlying lung.
• 3-4 week-- mature, turns into a peel. • peel prevents entry of anti-microbial drugs in
the pleural space and contributes to drug resistance.
• Thickened pleural peel restricts lung movement and leads to trapped lung and fibrothorax
Etiology
• Pneumococcal infection remains the most common isolated cause in developed countries, with Staphylococcus aureus the predominant pathogen in the developing world.
Jaffe et al. Pediatr Pulmonol. 2005; 40:148-156.
US prevalence
• After prevnar (1999-2000 vs 2001-2002)• 1) Patients admitted with empyema (per 10
000 admissions) decreased from 23 to 12.6• 2) Prevalence of S pneumoniae has
decreased from 66% to 27% • 3) S aureus has become the most common
pathogen isolated (18% vs 60%), with 78% of those being methicillin resistant.
• Schultz et al.Pediatrics. 2004 Jun;113(6):1735-40
265 children with empyema admitted to the PGIMER, 1989–98
• Culture positivity had decreased significantly (48% v 75%) over the years.
• Staphylococcus aureus commonest (77%) aetiological agent;
• Streptococcus pneumoniae cases seen during the winter and spring season.
• Gram negative rods grew in 11%.• Community acquired MRSA in 3 patients • Baranwal et al .Arch Dis Child. 2003 November; 88(11): 1009–1014.
Diagnostic Evaluation
• Radiographic Studies
PA and decubitus x-ray
• First step in diagnosis
Fluid layer is seen on dependent side
USG
• Very useful tool for diagnosis, guidance of thoraco-centesis, or pleural catheter placement.
• Sonography can distinguish solid from liquid pleural abnormalities with 92% accuracy compared to 68% accuracy with chest X-ray. When both are combined, accuracy rises to 98%
• USG shows limiting membranes suggesting the presence of loculated collections even when they are invisible by CT scan.
CT scan
Chest CT Scan
• Defines effusion
• consolidation
• abscess
• necrosis
• adhesions
• Guides interventions
Is CT Scan necessary
• Unnecessary for most cases of pediatric empyema
• Has a role in complicated casesInitial failure to aspirate pleural fluid failing medical management and particularly in immunocompromised
children where a CT scan could reveal other serious clinical problems.
Goal of treatment
1. Control of infection
2. Drainage of pus
3. Expansion of lungs
Stage 1/exudative stage
Free-flowing serous effusion pH>7.20, Sugar >60 mg/dL, LDH >3 times the upper limit of normal
Management with • Antibiotics • Drainage if effusion is significant• Give consideration to early active treatment as
conservative treatment results in prolonged duration of illness and hospital stay.
Empirical antibiotics
• Anti Staph antibiotic + Cephalosporin + Aminoglycoside
• Suspected anaerobic infection Clindamycin should be added
Antibiotics
• Parenteral therapy to be continued for 48-72 hours after abatement of fever and then oral therapy can be used to complete the course.
• Antibiotic to be continued until patient is afebrile, WBC count is normal, radiograph shows considerable
clearing • Duration of oral therapy is 1- 4 weeks.
Drainage Options
• Simple thoracocentesis Necessary for analyzing pleural fluid & to direct antibiotic therapy
• Chest tube placementIndicated for all large transudative effusions & the early exudative phase of parapneumonic pneumonias
• Repeated thoracocentesis is rarely successful
Empyema drainage
• CT or USG guided drainage if empyema collection is small
• 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
• The addition of fibrinolytic therapy may improve drainage during the fibrinopurulent stage
Who what where
• Chest drains should be inserted by adequately trained personnel to reduce the risk of complications.
• Small bore percutaneous drains should be inserted at the optimum site suggested by chest ultrasound
• The drain should be removed once there is clinical resolution or drainage is < 50 ml.
Safe triangle for insertion of chest drains
Stage 2/fibronopurulent stage
Uncomplicated<7.20, Sugar <60 mg/dL, LDH >3 times the upper limit of normal
• Antibiotics• Chest tube• Drainage• Consider fibrinolytics
Complicated
pH <7.00,Sugar <60 mg/dL, LDH>3 times the upper limit
• Antibiotics
• Chest tube drainage, consider
• fibrinolytics or
• VATS
Fibrinolytics
• There is no evidence that any of the three fibrinolytics are more effective than the others, only urokinase studied in a RCT in children so is recommended.
• tPA is used in US• Thompson et al Thorax 2002;57:343-347;
Stage 3/organizing stage Fibrinous peel, lung entrapment
• Antibiotics
• VATS
• if unsuccessful decortication
Ampofo et al. Pediatr Infect Dis J. 2007 May ; 26(5): 445–446.
Indications for SurgicalTreatment
• Gates et al (2004) in a retrospective review found that 80% of children with empyema did not require surgical intervention
• Lack of clinical & radiological response to medical treatment
• Complex empyema with significant lung pathology
Systematic Review of Optimal Treatment (Gates et al, 2004)
44 studies describing treatment of empyema in 1369 infants & children (retrospective reviews)
4 treatment strategies: chest tube drainage, chest tube + fibrinolytics, open thoracotomy + decortication & VATS
LOS was the only statistically significant difference between 4 strategies
VATS LOS = 10.5 days vs. CT 16.4 days or fibrinolytic 18.9 days
Thank You