Pleural Empyema Management

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Pleural EmpyemaManagement

• Benoit Guery
• Maladies Infectieuses
• Philippe Ramon
• Service dendoscopie Respiratoire
• CHRU Lille

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Empyema formation

• Exudative stage
• fibrinous material forms on both pleural
  surfaces.
• As more fibrin is deposited
• Fibrinopurulent stage
• may last several weeks
• pleural surfaces may be joined by fibrinous
  septae which cause the fluid to become loculated
• Organisational stage
• Proliferation of fibroblasts on the pleural
  surfaces, which form an inelastic covering
  preventing adequate lung expansion (fibrothorax).

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Goals of the treatment

• Treat the infection
• Drain the purulent effusion adequately and
  completely
• Re-expand the lung to fill the pleural space
• Eliminate complications and avoid chronicity

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The infection
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Bacteriological data

• Pleural Ponction
• Exsudate
• Direct analysis, Gram stain
• Aerobic and anaerobic cultures (Bactec)
• If possible before antibiotic treatment
• Results
• Mono or polymicrobial ( 4-30)
• Variations between series
• Variations between underlying conditions

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Wait et al, Chest 1997
Cheng et al, Chest 2005
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Maskell et al, NEJM 2005
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Bacteriological data.

• Streptococcus pneumoniae 15-20
• Increased resistance
• Staphylococcus15-30
• Streptococcus spp
• Gram Negative 20-50
• Klebsiella, Enterobacter, Pseudomonas,
  Hemophilus, E.Coli
• Anaerobes
• Fusobacterium, Bacteroides fragilis

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Microbiological diagnosis techniques
3 methods - Standard culture - PCA Pneumococcal
capsular antigen - 16S rDNA PCR confirmed
by pneumolysin PCR
Le Monnier et al, Clin Inf Dis 2006
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Microbiological diagnosis techniques
Latex antigen detection Se 90 Sp 95
Le Monnier et al, Clin Inf Dis 2006
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Antibiotic treatment

• As soon as the bacteriologic sample are recovered
• Pneumonia
• Amoxicillin, 3GC or 3GC /- Metronidazole
• Amox-clavulanic acid
• Dosage of the molecule
• Nosocomial
• Tazobactam or Imipenem
• /- Aminoglycoside or Quinolone
• Not Pneumococcus directed molecules
• Adapted to the laboratory results

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Adequate drainage

• Available techniques

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Primary treatment options

• Antibiotics alone
• Recurrent thoracocentesis
• Insertion of chest drain alone or in combination
  with fibrinolytics
• VATS.
• Open decortication

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Thoracocenthesis

• Big caliber needle
• Mostly diagnosis technique
• Therapeutically used if the liquid remains fluid
• Theoretically allows pleural lavage

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Chest Tube

• As soon as the liquid is thick
• Localization
• free axillary
• loculated Chest imaging using ultrasonography
  and/or computed tomography
• Size 20 à 24
• Bedside

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Pleural Lavage

• Isotonic saline
• /- Noxyflex (noxytioline)
• Modalités
• 3 way stopcock
• Directly through the CT 250 to 500 ml
• Cautiously if suspicion of broncho-pleural
  fistula
• Timing
• Immediately after CT placement
• Once a day until the liquid is clear

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NOXYFLEX (noxytioline)

• Local disinfectant (formaldéhyde)
• 2,5 g diluted in a least 100ml isotonic saline
• Maximum 5g/day
• Incompatible with iodine polyvidone,chlorhexidin,
  chlorine solution, lactic acid

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Fibrinolytics

• Urokinase 100 000 or 300 000 IU conditioning
• Streptokinase 250000 IU conditioning
• 250.000 IU in 10-20 ml isotonic saline
• Dont evacuate before 24 to 48 heures
• Constantly associated with fever (38-39C)
• Then evacuate
• Pleural lavage
• clamp 4h ( Chest 1996)

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Video-assisted thoracic surgery

• Collectionlt10 cm unusual
• Visual control of the CT position
• 5 mm introducer, 4 mm optical
• Collectiongt10 cm
• 10 mm introducer
• Two or three ports are made in the chest
• One port is utilised for the camera and the
  others for grasping instruments
• Free fluid is evacuated and loculations drained
  under thoracoscopic visualisation.
• Fibrinous adhesions are separated and the pleural
  debris removed from the pleural lining using
  endoscopic grasping forceps or by extensive
  irrigation and suction.
• Following the procedure, one or two chest drains
  are then placed in the portholes.

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Local antibiotics

• Usually Rifampin or Colimycin
• Still debated
• Do not replace systemic treatment

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Physiotherapy

• Key to a correct evolution
• After CT removal
• Often and for a long time..
• Decrease surgery
• Decrease long term pain and functionnal
  limitations

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Therapeutic choices
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Guidelines to predict which patients with
non-purulent parapneumonic effusions warrant
chest tube drainage

• 240 patients with PPE
• 85 uncomplicated PPE
• 67 complicated PPE
• 88 empyema

Porcel et al, Respir Med 2006
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BTS and ACCP criteria

• BTS non purulent PPE is complicated if any of
  the following
• pHlt7.2
• LDHgt 1000 IU/L
• Glucose lt40mg/dL
• Positive culture

• ACCP
• Positive culture
• pHlt7.2
• Glucose lt60mg/dL
• Effusiongthalf of the hemithorax

Porcel et al, Respir Med 2006
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Porcel et al, Respir Med 2006
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• Compare Chest Tube Streptokinase (n9) vs VATS
  (n11)

• B score on the Cochrane analysis with
  methodological concerns
• Small number
• Patient selection
• Unclear allocation and outcome assessor blinding
• But VATS is superior to CT for large loculated
  pleural empyemas
• Duration CT
• LOS

Wait et al, Chest 1997
Cochrane 2005
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• Prospective study between 1997 and 2004
• 2 groups
• I video-assisted thoracoscopy (chest tube,
  fibrin debrided)
• II chest tube without VAT

• Surgical decortication
• Group I 17.1
• Group II 37.1
• LOS
• Group I 8.3 days
• Group II 12.8 days

Bilgin et al, ANZ J Surg 2006
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• Hypothesis Urokinase is effective through the
  lysis and not the volume effect
• Randomized double blind study
• UK (15 patients) for 3 days, 100 000 IU in 100 ml
  NS
• Control (16 patients), 100 ml NS for 3 days
• Complete drainage
• UK 13/15 (86)
• NS 4/16 (25)

Bouros et al, AJRCCM 1999
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Cochrane analysis 2007
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Cochrane analysis 2007
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Cochrane analysis 2007
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Cochrane analysis 2007
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Cochrane analysis 2007
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Cochrane analysis 2007
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• Prospective study from 2001 to 2004
• Cause bacterial pneumonia
• 2 groups
• A CT (70)
• B CT SK (57)

Multivariate analysis the use of fibrinolysis is
the only independent factor associated with a
favorable outcome
Misthos et al, Eur J Car Thor Surg 2005
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• 452 patients with pleural infection
• Sk 250 000 IU twice daily for 3 days
• Placebo
• No difference in mortality, rate of surgery,
  radiographic outcomes, LOS
• Serious adverse events more common with Sk (chest
  pain, allergy, fever)

Maskell et al, NEJM 2005
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• Meta-analysis with 5 properly randomized trials
  comparing fibrinolytic agents to placebo
• 575 patients

Tokuda et al, Chest 2006
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• Only one study analyzed no differences observed
  on the parameters

Cochrane analysis 2007
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Fibrinolytics vs VATS

• 60 children matched
• No difference
• LOS after intervention
• Failure rate
• Radiologic outcome at 6 month
• Treatment cost with UK (6 914)lt VATS (10 146)

Sonnappa et al, AJRCCM 2006
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Case report 1

• 50 yo
• Left Pneumococcus empyema
• Admitted on the 4th day
• D2 streptase instillation
• D3 VATS2 CT
• CT removal on D8
• Discharged on D12

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Case report 2

• 76 yo
• March 96 Pneumonia
• April 96 Left lung effusion
• No fever, CRP 29, fibrinogen 7g/l
• Exsudate, LDH 7200, glucose 0,24g/l cytology PMN,
  negative direct examination

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• VATS (25/4/96)
• loculated
• Removed debris and liquid (600ml)
• Posterior CT n24
• Pleural lavage (Noxyflex)
• CT removal on 2/5/96

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Indications
Thoracocentesis
Clear liquid
Not clear or purulent effusion
pHgt7.20
pHlt7.20
Not loculated
Loculated
No intervention
Reccurent thoracocentesis
Drainage Pleural lavage
Drainage Pleural lavage Fibrinolytics
Failure VATS Surgery
Hamm et al, ERJ 1997
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Indications
Thoracocentesis
Clear liquid
Not clear or purulent effusion
pHgt7.20
pHlt7.20
Not loculated
Loculated
No intervention
Drainage Pleural lavage
Fibrinolytics 24-48h
Reccurent thoracocentesis
Drainage Fibrinolytics Pleural lavage
VATS Drainage Pleural lavage
Failure VATS Surgery
Failure Surgery