3. EMPYEMA
GRAVITY OF PROBLEM
UK : 50,000 PNEUMONIA CASES / YR
57% DEVELOP PLEURAL FLUID
40% GO FOR SURGERY DUE TO
FAILED ICD
20% OVERALL DEATH OCCURES
EMPYEMAS
USA : 60,000CASES OF PLEURAL INFECTION/YR
5. BTS and ACCP criteria
BTS: non purulent
PPE is complicated if
any of the following
• pH<7.2
• LDH> 1000 IU/L
• Glucose <40mg/dL
• Positive culture
Porcel et al, Respir Med 2006
6. BTS and ACCP criteria
ACCP:
• Positive culture
• pH<7.2
• Glucose <60mg/dL
• Effusion>half of the
hemithorax
Porcel et al, Respir Med 2006
8. 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).
9. EMPYEMA - TYPE OF PLEURAL
FLUID IN INFECTION
A) SIMPLE PARAPNEUMONIC EFFUSION
B) COMPLICATED PARAPNUMOPNIC
C) EMPYEMA
10. EMPYEMA - TYPE OF PLEURAL
FLUID IN INFECTION
(A) SIMPLE PARAPNEUMONIC
EFFUSION
CLEAR, pH>7.2, LDH<1000
SUGAR >40. NO ORGANISMS
Resolves with antibiotics alone
11. EMPYEMA - TYPE OF PLEURAL
FLUID IN INFECTION
B) COMPLICATEDPARAPNEUMONIC
CLEAR OR TURBID
pH<7.2,
LDH >1000
GLUCOSE >40
+/- gr stain/culture
Chest tube drainage is needed.
12. EMPYEMA - TYPE OF PLEURAL
FLUID IN INFECTION
C) EMPYEMA
FRANK PUS IN PLEURAL CAVITY
+/- gram stain/CULTURE
NO ADDITIONAL BIOCHEMICAL
TEST NEEDED
CHEST TUBE DRAINAGE
13. Wait et al, Chest 1997 Cheng et al, Chest 2005
18. WHICH PATIENT NEEDS
DIAGNOSTIC TAPPING?
All patient with
pleural effusion in
association with
sepsis or
pneumonic illness
needs diagnostic
sampling.
19. WHICH PATIENT NEEDS
DIAGNOSTIC TAPPING?
d/d between simple v/s
complicated
parapneumonic
effusion is difficult
clinically.
Age, symptoms : pain or
temp or degree of
infiltrates on x-ray
chest does not
differentiate
20. PRIMARY TREATMENT OPTIONS
Antibiotics alone;
Recurrent thoracocentesis
Insertion of chest drain alone or in
combination with fibrinolytics
VATS.
Open decortication
21. INDICATION FOR CHEST TUBE
DRAINAGE
2) Patient with frank purulent,
turbid/cloudy
pleural fluid.
3) Presence of organism by
gm stain or culture.
22. INDICATION FOR CHEST TUBE
DRAINAGE
2) Pleural fluid pH less
than 7.2 should be
carried out in all
nonpurulent –
possibly infected
patient.
23. OTHER INDICATIONS FOR
CHEST TUBE DRAINAGE
1)Loculated pleural
fluid collection
2) Massive non
purulent pleural
effusion with >40%
of hemithorax.
24. Which patients with non-purulent parapneumonic
effusions warrant chest tube drainage?
240 patients with PPE
– 85 uncomplicated PPE
– 67 complicated PPE
– 88 empyema NO PREDICTION
CAN BE MADE FROM
SYMPTOMS OR ON
CLINICAL GROUNDS
Porcel et al, Respir Med 2006
25. EMPYEMA - pH measurement
Pl fluid should be collected in
heparinised syringe collected
anerobically and analysed in blood
gas analyser
Clear fluid suspicious of infection/
turbid fluid should be subjected
Frank pus should not be subjected
pH meter or pH litmus paper
should not be used.
26. EMPYEMA - Antibiotics
All patient should receive
antibiotic
As far as possible should be
guided by culture report
Whenever culture is –ve it should
cover cap and anaerobes.
Hospital acq pneumo needs
broad spectrum antibiotic
27. EMPYEMA - ANTIBIOTICS : CAP :
INTRAVENEOUS
Cefotaxime 1.5 iv tds
Metronidazole 500mg iv tds
Benzyl penicillin 1.2gm iv qds
Ciprofloxacin 400mg iv bd
Meropenam 1gm iv tds
Metronidazole 500mg iv tds
28. EMPYEMA - ANTIBIOTICS
CAP : ORAL
Amoxicillin + clavulinic acid
Metronidazole or Clindamycin
29. ANTIBIOTICS : HOSPITAL ACQUIRED
CULTURE NEGATIVE INFECTIONS
Piperacillin + tazobactam
4.5gm qds iv
Ceftazidime 2gm tds iv
Meropenem 1gm tds iv
+/- metronidazole 400mg
orally or 500mg iv tds
31. EMPYEMA - INTRAPLEURAL
FIBRINOLYTIC AGENT
SK : 2.5 lack u bd for 3days
UK : 1 lack u od for 3 days
To be kept in pleural space
for 2-4 hrs
32. EMPYEMA - INTRAPLEURAL
FIBRINOLYTIC AGENT
May not improve
Patient mortality
Frequency of surgery
Residual lung function
33. EMPYEMA - INTRAPLEURAL
FIBRINOLYTIC AGENT
It shows better
drainage and
breaking of
septas with
improved
radiological
criteria.
34. EMPYEMA - INTRAPLEURAL
FIBRINOLYTIC AGENT
Side effects :
Immunological
reactions
Fever
Local pleural pain
Haemorrage
Occasionally ARDS
35. EMPYEMA - INTRAPLEURAL
FIBRINOLYTIC AGENT
Side effects
? Systemic antibody
response
Next need of
fibrinolytic agent
should be UK or
TPA
36. Prospective study from 2001 to 2004
Cause: bacterial pneumonia
2 groups:
A: CT (70)
B: CT + SK (57)
Misthos et al, Eur J Car Thor Surg 2005
37. 452 patients with pleural
infection
Sk 250 000 IU twice daily
for 3 days
Placebo
Controverses
No difference in
mortality, rate of surgery,
created
radiographic outcomes,
LOS
Serious adverse events
more common with Sk
(chest pain, allergy,
fever)
Maskell et al, NEJM 2005
38. E
C
N
SE
VE
ER
EF
D
F
O
E
M
TI
Cochrane analysis 2007
39. AY
ST
AL
IT
SP
O
H
F
O
N
IO
AT
R
U
D
Cochrane analysis 2007
40. D
U
R
AT
IO
N
O
F
C
H
ES
T
TU
BE
IN
SI
T U
Cochrane analysis 2007
41. Y
ER
G
R
SU
R
FO
D
EE
N
Cochrane analysis 2007
42. O
VE
R
AL
L
TR
EA
TM
EN
T
FA
IL
U
R
E
Cochrane analysis 2007
43. E
G
ALL PARAMETERS
N
AI
IMPROVED WITH
R
D
FIBRINOLYTIC
ID
AGENTS
U
FL
Cochrane analysis 2007
44. EMPYEMA -
BRONCHOSCOPY
* Only be preferred with
high index of
suspicion of
endobronchial
obstruction
* Before surgery
45. EMPYEMA - REFERRAL
FOR SURGICAL
INTERVENTION
Failure of chest
tube drainage,
antibiotic and
fibrinolytic
agent
