Options In The Management of Empyema Thoracis

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OPTIONS IN THE MANAGEMENT OF EMPYEMA THORACIS: 

OPTIONS IN THE MANAGEMENT OF EMPYEMA THORACIS Dr Arojuraye S.A Moderator: Dr Aminu M.B Cardiothoracic Unit Surgery Department ABUTH-Zaria

Outline : 

Outline Introduction Relevant anatomy Aetiology Pathophysiology Diagnosis Complications Management options Special situations in empyema Prognosis Local experience Conclusion

Introduction : 

Introduction Empyema thoracis Pyogenic disease of the pleura Major problem for centuries in tropical Africa Children : inadequate pneumonia Rx

Introduction : 

Introduction Definition Pus in the pleural space, Weese et al. definition ► pleural fluid with: ● SG > 1.018, ● WBC > 500 cells/mm 3 , ● Protein > 2.5 g/dl.

Introduction : 

Introduction Definition Vianna definition: pleural fluid on which ● Bacterial cultures are positive or ● WBC > 15,000/mm 3 & ● Protein > 3.0 g/dl. Empyema ► Complicated parapneumonic effusion

Introduction.. : 

Introduction.. History Hippocrates ►►► 19 th century : Rx unchanged Bowditch in US & Trousseau in France popularized the use of thoracentesis 1876 Hewitt was the first to use the water seal for chest tubes

Introduction.. : 

Introduction.. History 1890s: two articles described thoracoplasty. the initial reports for decortication. 1950: Tillett & Sherry proposed fibrinolytics 1950s & 1980: the pleural fluid glucose, pH & LDH were proposed as an indicator for tube thoracostomy & poor prognosis.

Relevant Anatomy: 

Relevant Anatomy

Relevant Anatomy: 

Relevant Anatomy

Aetiology : 

Aetiology Lung Chest wall Postoperative Oesophagus Diaphragm Trauma Septicaemia Pneumonia & TB are the most common cause

Aetiology..: 

Aetiology.. Microbiology Streptococcus pneumonia , Staphylococcus aureus, E. coli, Klebsiella pneumoniae, Haemophilus influenzae. Staph. aureus (90% of causes in children)

Pathophysiology : 

Pathophysiology American Thoracic Society (ATS) Exudative stage Fibrinopurulent stage Organizational stage

Pathophysiology.. : 

Pathophysiology.. Exudative stage Day 1 – 3 Simple Sterile para-pneumonic effusion Low leucocyte count. Thin fluid, easily aspirated with needle.

Pathophysiology.. : 

Pathophysiology.. Exudative stage The pleural fluid: Negative bacterial studies, Glucose level > 60 mg/dl, pH > 7.20, LDH < 3 ( upper limit of serum) Poor / no Rx ►► second stage

Pathophysiology.. : 

Pathophysiology.. Fibrinopurulent stage Day 4 – 14 The pleural fluid: Positive bacterial studies, Glucose < 60 mg/dl, PH < 7.20, LDH > 3(upper normal limit for serum)

Pathophysiology.. : 

Pathophysiology.. Fibrinopurulent stage Large quantities of pus formation. Bacterial invasion and fibrin deposition Thickening of exudate. Formation of loculations and septae Needle aspiration difficult Effusion not drained ►► third stage

Pathophysiology.. : 

Pathophysiology.. Fibrinopurulent Stage loculations in a parapneumonic effusion

Pathophysiology.. : 

Pathophysiology.. Organizational stage Day 14 – 28 Fibroblasts grow on pleural surfaces Inelastic membrane ( Pleural Peel). Restriction of lung expansion (‘ trapped lung’ ) Needle aspiration may yield a dry tap. Peel must be removed ►► cure

Stages : 

Stages Clinical stages Acute stage : within the first 2 weeks of onset. Chronic Stage : > 3 weeks formation of thick peel & loculations.

Stages.. : 

Stages.. Causes of chronicity Inadequate Tube Drainage. Chronic Disease( T.B. or Fungal Infection) Immunosupression Presence of FB within the pleural space.

Clinical features: 

Clinical features History Trauma , fever, pleuritic chest pain & dypsnea Drenching night sweat & contact with a person with chronic cough (TB) Comorbidities Hx suggestive of Immunosupression

Clinical features: 

Clinical features Examination Features of toxicity (acute type) Decreased chest wall movement Dullness on percussion Absence of breath sounds.

Investigations: CXR: 

Investigations: CXR

Investigations: CT: 

Investigations: CT

Investigations: USS: 

Investigations: USS

Investigations: Thoracentesis: 

Investigations: Thoracentesis

Investigations..: 

Investigations.. Others Bronchoscopy FBC+Diff, ESR, FBS Blood culture Mantoux test Sputum AAFB, m/c/s Abd . USS

Complications : 

Complications Broncho-pleural fistula Empyema Necessitans Septicaemia & septic shock.

Management : 

Management Goals for successful therapy ● Sterilisation of the pleural cavity. ● Complete drainage of the pleural fluid. ● Re-expansion of the lung. ● Obliteration of the space

Management : 

Management Principles 1. Appropriate Antibiotic therapy. 2. Drainage of empyema. 3. Supportive care ● Oxygen, IVF ● Pain and fever management ● Care of the chest drain ● Proper positioning of the patient. 4. Rehabilitation : Physiotherapy, Nutrition 5. Treatment of the underlying cause

Management Options: 

Management Options Light’s classification Class 1: Nonsignificant parapneumonic effusion Class 2: Typical parapneumonic effusion Class 3: Borderline complicated parapneumonic effusion

Management Options..: 

Management Options.. Light’s classification Class 4: Simple Complicated Parapneumonic Effusion Class 5: Complex Complicated Parapneumonic Effusion Class 6 : Simple Empyema Class 7: Complex Empyema

Management Options..: 

Management Options.. Therapeutic thoracentesis Tube thoracostomy Intrapleural fibrinolytics VATS with lysis of adhesions Open drainage Decortication

Management Options..: 

Management Options.. Therapeutic Thoracentesis Parapneumonic effusions Rx : 19th century 1962, ATS recommended repeated thoracentesis for nontuberculous empyema in the exudative phase

Management Options..: 

Management Options.. Therapeutic Thoracentesis 1968, Snider & Salleh recommended: two therapeutic thoracentesis for empyema but if failed ►► tube thoracostomy Outdated treatment : multiple aspirations ►►► pneumothorax or loculations.

Management Options..: 

Management Options.. Tube Thoracostomy Most common method Large tubes (28-36F) is recommended Correct positioning of the tube is more important than its size

Management Options..: 

Management Options.. Tube Thoracostomy Unsatisfactory pleural drainage ►► ● T ube in the wrong location ● Loculations ● F ibrinous coating of the visceral pleura ● Tube blockage Inadequate drainage ►► USS / CT

Management Options..: 

Management Options.. Tube Thoracostomy - open For chronic empyema, shorten drainage tube when tract form & cavity walled off. Tube is transected 10cm from the chest wall & allow to drain to dressing. Tube is removed when effluent is 10ml/day

Management Options..: 

Management Options.. Intrapleural Fibrinolytics Drainage of parapneumonic effusion is difficult. Tillet & Sherry in 1950 ►► Streptokinase & Streptodornase. Abandoned due to systemic side effects Now being used in some cases

Management Options..: 

Management Options.. VATS with Lysis of Adhesions VATS is preferred because if the lung cannot be expanded, the VATS can be converted to a full thoracotomy. A chest CT scan should be obtained before VATS to provide anatomic information.

Management Options..: 

Management Options.. VATS with Lysis of Adhesions ● loculi in the pleural space can be broken ● pleural space can be drained & ● chest tube can be optimally placed ● in trapped lung, an attempt can be made to perform a decortication.

Management Options..: 

Management Options.. Lysis of adhesions using VATS.

Management Options..: 

Management Options.. Open drainage 2 types of procedures: ● with tubes ● without tubes (Eloesser flap)

Management Options..: 

Management Options.. Open drainage ● open drainage with tubes Resecting segments of 1 – 3 ribs Inserting one or more short, large-bore tubes Tubes are irrigated daily with a mild antiseptic

Management Options..: 

Management Options.. Open drainage: open drainage with rib resection

Management Options..: 

Management Options.. Open drainage ● open drainage with tubes Drainage can be collected in a colostomy bag Advantage over closed-tube drainage ►► drainage is more complete & the patient is freed from attachment to the chest tube bottles

Management Options..: 

Management Options.. Open drainage ● Eloesser flap ≥ 2 overlying ribs are resected A skin & muscle flap ►► the tract between the pleural space & the surface of the chest Advantage ►► it creates a skin-lined fistula that provides drainage without tubes.

Management Options..: 

Management Options.. Open drainage ● Eloesser flap Can be more easily managed by the patient Permits gradual obliteration of the empyema space. Disadvantage: open procedure ►► open chest wound for a prolonged period

Management Options..: 

Management Options.. Open drainage ● Eloesser flap Early open drainage ►► the pleural space is exposed to atmospheric pressure ►► Pn eumothorax Before open drainage procedures: expose chest tube to atmospheric pressure determine radiologically ►► lung collapse.

Management Options..: 

Management Options.. Open drainage: Eloesser flap

Management Options..: 

Management Options.. Decortication Major thoracic operation via thoracotomy Experienced anaesthetics Blood transfusion

Management Options..: 

Management Options.. Decortication Should not be performed on debilitated patients Not just to remove thickened pleura because such thickening usually resolves spontaneously Definitive Rx for chronic empyema

Management Options..: 

Management Options.. Decortication

Management Options..: 

Management Options..

Special Situations in Empyema: 

Special Situations in Empyema Empyema in Children Incidence of anaerobic infection is ↓ , whereas that of H. influenzae is ↑. Complicated parapneumonic effusions can lead to scoliosis. Diagnostic thoracentesis in children requires sedation

Special Situations in Empyema..: 

Special Situations in Empyema.. Empyema in Children Almost always in good general health and the final results are usually excellent. BTS guidelines on the management of pleural infection in children: ● USS to confirm the presence of pleural collection & to guide thoracentesis

Special Situations in Empyema..: 

Special Situations in Empyema.. BTS guidelines on the management of pleural infection in children: ● Biochemical analysis of pleural fluid is unnecessary; ● Enlarging effusions should not be managed by antibiotics alone; ● Significant pleural infection ►► chest tube;

Special Situations in Empyema..: 

Special Situations in Empyema.. BTS guidelines on the management of pleural infection in children: ● Small chest tubes to minimize discomfort; ● Thick or loculated effusion ►► fibrinolytics ● P ersisting sepsis due to persistent pleural fluid collection, despite a chest tube & antibiotics ►► Surgery

Special Situations in Empyema..: 

Special Situations in Empyema.. Empyema Associated with Bronchopleural Fistula ● Bronchopleural fistula + infected pleural fluid is a medical emergency. ● Incomplete drainage ► overwhelming pneumonia. ● L arge amounts of sputum only when lying in one position suggest a bronchopleural fistula.

Special Situations in Empyema..: 

Special Situations in Empyema.. Empyema Associated with Bronchopleural Fistula ● Erect radiograph ► presence of an air-fluid level in the pleural space. ● D ifficult to determine whether the air-fluid levels are in the lung parenchyma or in the pleural space? ►► Bilateral decubitus CXR, USS or CT.

Special Situations in Empyema..: 

Special Situations in Empyema.. Empyema Distal to an Obstructed Bronchus ● C ontraindication to the placement of chest tubes b cs b ronchial obstruction will prevent expansion of the lung underlying the pleural effusion ● Rx : radiotherapy, an endobronchial stent, or laser therapy + Antibiotics ● Chest tube after relieve of obstruction

Prognosis : 

Prognosis American College of Chest Physicians (2000), categorize risk for poor outcome in patients with parapneumonic effusion and empyema : Pleural space anatomy (A) Pleural fluid bacteriology (B) Pleural fluid biochemistry (C)

Prognosis.. : 

Prognosis.. Pleural space Anatomy Pleural fluid Bacteriology Pleural fluid Biochemistry Category Risk of Poor Outcome A ₒ: Minimal free-flowing effusion < (10mm on lat. Decubitus) B ᵪ : culture & Gram stain result unknown pH: unknown 1 Very low A1 : Small to moderate free flowing effusion (> 10mm < ½ hemithorax) B ₒ: Negative culture & Gram stain C ₒ: pH ≥ 7.20 2 Low A 2: Large free flowing effusion ( ≥ ½ hemithorax), loculations or thick parietal pleura B1: Positive culture & Gram stain B2: pus C1: pH < 7.20 3 4 Moderate High

Prognosis.. : 

Prognosis.. Pleural fluid is pus Pleural fluid bacterial smears are positive Pleural fluid glucose is less than 60 ml/dl Pleural fluid bacterial cultures are positive

Prognosis.. : 

Prognosis.. Pleural fluid pH < 7.20 Pleural fluid LDH > 3(upper limit of normal) Loculated pleural fluid Significant scoliosis, parenchymal entrapment & anaerobic infection (additional in children)

Local Experience: 

Local Experience Empyema thoracis in Zaria; a preliminary report. S.A Edaigbini, I.Z Delia & M.B Aminu 26patients (Jan. 2008 – March 2010)

Local Experience: 

Local Experience 26% : TB, 38% : post pneumonic, 11.5% : postoperative, 11.5% : AIDS and 7.7% : trauma 5 decortications, 2 rib resections & open drainage and others ► tube thoracostomy.

Conclusion : 

Conclusion Empyema is never primary! But a sign of underlying disease. Definitive treatment is more successful with utilized early in disease course. Research is ongoing to help determine complicated effusions earlier so as to improve the physician 'ability to intervene earlier in the natural history of parapneumonic effusions.

References : 

References PROCEEDINGS OF THE AMERICAN THORACIC SOCIETY VOL 3, pp 75–80, 2006. Richard W. Light, Division of Allergy, Critical Care, Pulmonary Disease, & Critical Care Medicine, Vanderbilt University, Nashville, Tennessee PLEURAL DISEASES, 5th Edition. Light, Richard W.2007 SCHWARTZ’S PRINCIPLES OF SURGERY 8 TH EDITION, F. Charles Brunicardi, M.D., F.A.C.S. October 2004 DAVEY’S COMPANION TO SURGERY IN AFRICA 3 RD EDITION, Adelola Adeloye et al PRINCIPLES & PRACTICE OF SURGERY INCLUDING PATHOLOGY IN THE TROPICS, 4 th Edition. E.A Badoe , E.Q Archampong & J.T Rocha- Afodu EMPYEMA THORACIS IN ZARIA; A PRELIMINARY REPORT. S.A Edaigbini, I.Z Delia, M.B Aminu . Nigerian Journal of Surgery. Dec. 2011. Vol 17, No 2