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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

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slide3

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.

slide4

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
slide5

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

slide8

Pleural pus specimen - 31/05/07

Cultured Staph. Aureus

R - Penicillin/ampicillin

R - Erythromycin

R - Clindamycin

S - Cloxacillin

history
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
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
  • 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
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
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
Other minor criteria
  • Cholesterol > 45mg/dl
  • Protein content > 3.0 g/dl
  • pH <7.2
  • Glucose < 50% serum
parapneumonic pleural effusions
Parapneumonic pleural effusions
  • 3 groups or stages based on pathogenesis:
  • Uncomplicated parapneumonic effusion
  • Complicated parapneumonic effusion
  • Thoracic empyema.
exudative stage
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
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
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
Complications
  • Dissect into lung parenchyma→ bronchopleural fistulas and pyopneumothorax
  • Dissection through chest wall (empyema necessitatis) RARE
  • Dissection into abdominal cavity
organisms
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
organisms1
Organisms
  • Tuberculosis
    • Rare cause but common PPE
  • Fungi
  • Viral
  • Atypical organism
    • Mycoplasma
clinical manifestations
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
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
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
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

ultrasound1
Ultrasound
  • Size of effusion
  • Differentiate consolidation from empyema
  • Unreliable predictor of disease severity
ct scan
CT scan
  • Anatomical
    • Parenchymal lesions
    • Endobronchial lesions
    • Mediastinal lesions
    • Lung abscess
management
Management
  • IV antibiotics and intercostal drainage
  • Fibrinolytics
  • Video -Assisted Thoracoscopic Surgery (VATS)
  • Open thoracotomy and decortication
management1
Management
  • Supportive
      • Bed rest
      • Analgesia
      • Oxygen
      • Fluids
  • Identify the cause
      • Malnutrition
      • TB
      • HIV
antibiotic therapy
Antibiotic therapy

Zampoli M, Zar H. SAJCH 2007;1(3):121-8

fibrinolytics
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
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

slide35
VATS
  • Can be done as primary procedure
  • Experienced surgeon necessary
  • Benefits
    • lower mortality
    • Re-intervention
    • Reduced length of hospital stay
    • Reduced hospital costs
thoracotomy
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
Ideal approach

Fuller MK, Helmrath MA. Curr Opinion Pediatrics 2007;19:328-332

practical
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
Prognosis
  • Favourable in patients started on appropriate antibiotic
  • Early chest tube drainage is beneficial.
  • Decortication or open drainage has decreased mortality and morbidity.
prognosis1
Prognosis
  • Mortality 6-12%
  • Complications
    • Bronchopleural fistula
    • Tension pneumatocoele
    • Fibrothorax
acknowledgements
Acknowledgements
  • Prof R Green
  • Dr O Kitchin
  • Dr S Risenga
  • Dr Moodley
  • ICU staff