EMPYEMA

1
EMPYEMA

• Thoracic Surgery
• Kaplan M.C

2
Empyema .

• Thoracic empyema
• an accumulation of pus in the pleural space .

3
Etiology.

• Pneumonia ( 62 ) .
• Thoracic and other surgery ( 13 ) .
• Trauma ( 9 ) .
• Pulmonary embolism , tumors and lung abscess
  , fungi , tuberculosis .

4
Pathophysiology .

• Direct contamination .
• Spread of contiguous infection .
• Pleural fluid accumulation imbalance between
  transpleural hydrostatic pressures , vessel
  permeability and lymphatics .

5
Bacteriology .

• Pneumococci and staphylococci are predominant .
• Echerichia coli , Klebsiella , Pseudomonas ,
  Enterobacreriaceae are common gram negative
  organisms .
• Mycobacteria and fungi are rare .

6
Bacteriology .

• Sterile cultures in 18 to 30 .
• Single organisms in 29 to 55 .
• Multiple organisms in 17 to 49 .

7
High ph ( gt 7.3 ), high glucose ( gt 60 mg/dL ) ,
low LDH ( lt 500 U/L ) .
8
Symptoms .

• Uncontrolled infection pain , weight loss ,
  asthenia and fever .
• Restriction and V/P mismatch dyspnea .
• Signs of infection leucocytosis , rise of CRP
  .

9
Epidemiology.

• Elderly and debilitated .
• 82 of patients had one or more underlying
  illnesses .
• Individuals without access to medical care or
  from lowest social class .
• Mortality ranges from 1 to 19 ( for
  immunocompromised up to 40 ) .
• Prognosis worse with hospital-acquired or
  culture-positive empyemas .

10
Stages .

• Initial exudative stage ( 7days ) .
• Fibrinopurulent stage ( 2 weeks ) .
• Final organizational stage ( 3 weeks to months )
  .

11
Initial exudative stage .

• Watery and sterile effusion .
• Free-flowing on lateral decubitus chest x-ray .
• Septations are absent on US or CT .

12
(No Transcript)
13
(No Transcript)
14
Fibrinopurulent stage .

• Fibrin deposition .
• Septations on lateral decubitus chest x-ray , US
  and CT .
• Drop of ph ( lt 7.1 ) , drop of glucose ( lt 40
  mg/dL ) , rise of LDH ( gt 1000 U/L )
• a. increased utilization of glucose by both
  PMN cells and bacteria .
• b. glucose metabolits ( carbon dioxide and
  lactic acid ) increase of purulent collections .
• c. LDH rises in proportion to cell lysis .

15
PA chest x-ray .

16
Final organizational stage .

• Creation of thick , inelastic membranous peel .
• Entrapping and immobilizing the lung .
• Dense , cohesive collections .
• Creation of bronchopleural fistulas or empyema
  necessitatis .
• Sepsis .

17
(No Transcript)
18
(No Transcript)
19
Diagnosis .

• Chest radiography .
• Computed tomography .
• Ultrasonography .
• Thoracentesis
• a. cell count , glucose , LDH , ph .
• b. Gram staining and aerobic and anaerobic
  cultures .
• c. mycobacteria and fungi if indicated
  clinically .

20
Goals of treatment .

• Evacuation of pus .
• Expansion of lung .
• Prevention of ongoing infection .

21
Management .

• Antimicrobial agents .
• Tube thoracostomy .
• CT-guided chest tube insertion and intrapleural
  fibrinolytic debridment .
• VATS thoracoscopy .
• Surgery ( rib resection , decortication ,
  thoracoplasty , open window ) .

22
Antibiotics .

• Early empiric treatment .
• Antibiotics altered according to the patient
  clinical course or results of pleural fluid
  cultures .
• Repeat cultures with any deviation of patients
  clinical status.

23
Tube thoracostomy .

• Large thoracostomy tube .
• Smaller CT-guided chest tubes for multi-loculated
  empyemas .
• Success rates of 50 without further treatment
  .
• Chest tubes kept under suction (?) .

24
Intrapleural fibrinolitic therapy.

• Streprokinase / Urokinase .
• Safe and effective in adults and children .
• Intrapleural hemorrhage and bronchopleural
  fistula are contraindication .

25
(No Transcript)
26
(No Transcript)
27
Keep in mind .

• Early detection of pleural effusions .
• Accurate definition of empyemas stage .
• Appropriate antimicrobial therapy .
• Effective and complete drainage of empyema and
  achievement of lung reexpansion prevents surgery
  .
• Treatment of underlying conditions .
• Adequate nutrition .

28
Our experience .

• 133 patients with empyema treated in our
  department (7 years).
• 88 patients treated by chest tubes with Urokinase
  installations .
• 23 patients operated due to failure of
  fibrinolitic therapy .
• 22 patients operated without initial
  fibrinolitic treatment .

29
Our experience .

• 63 patients with complicated parapneumonic
  effusion ( 47.3) .
• 26 patients after Thoracic Surgery
• ( 19.6 ) .
• 17 patients with traumatic empyema ( 12.8 )
  .
• 27 other causes ( 20.3 ) .

30
Our experience .

• 111 pts ( 70R , 41L ) .
• 85 ( 64.8 ) men and 26 ( 54.8 ) women .
• 614 Urokinase installations ( 5.5 ) .
• 68 pts treated with 1 chest tube 40 with 2
  chest tubes 5 with 3 .
• 17 36F chest tubes 37 32F chest tubes 10 28F
  chest tubes 28 16F chest tubes 58
  percutaneous chest tubes .
• 1688 hospital days ( 15.3 ) .

31
Microbiology .

• Enterococcus 14 .
• Staphylococcus 16 ( MERCA 5 ) .
• Pseudomonas 15 .
• Echericia coli 3 .
• Prevotella 6 .
• Acinetobacter 4 .
• Streptococcus 7 .
• Sterile cultures 39 .

32
Underlying diseases .

• 46 pts with Cancer .
• 20 pts with NIDDM .
• 19 pts with COPD .
• 21 pts with IHD .
• 12 pts with Obesity .
• 2 pts after CVA .
• 1 pt with Multiple Sclerosis .
• 15 pts after chemotherapy .

33
Social status .

• 17 pts with lower social status .
• 9 drug abuse .
• 3 alcoholics .
• 1 with epilepsy .
• 2 with schizophrenia .
• 1 with hydrocephalus .
• 1 with TB .
• 61 smokers .

34
Complications after surgery .

• 5 Clagett procedures .
• 3 AF .
• 1 DVT .
• 1 intrahospital mortality 2 late mortality .
• 1 BPF .
• 2 ARF .
• 2 air leak .
• 2 tracheostomy .
• 8 sepsis .

35
Complications after fibrinolitic therapy .

• 2 AF .
• 1 RF .
• 2 respiratory failure .
• 7 sepsis .
• 3 open drainage .
• 7 home tubes .
• 3 air leak .

36
Etiology.

• Pneumonia ( 62 ) .
• Thoracic and other surgery ( 13 ) .
• Trauma ( 9 ) .
• Pulmonary embolism , tumors and lung abscess
  , fungi , tuberculosis .

37
Stages .

• Initial exudative stage ( 7days ) .
• Fibrinopurulent stage ( 2 weeks ) .
• Final organizational stage ( 3 weeks to months )
  .

38
Goals of treatment .

• Evacuation of pus .
• Expansion of lung .
• Prevention of ongoing infection .

39

• Thanks