AATS Empyema Guidelines 2015 FINAL

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    2015 MFMER | slide-1

    2015 AATS Guidelines for

    Management of Empema

    !n "e#alf of t#e AATS Management of EmpemaGuidelines $or%ing Group

    &' Ro(ert S#en) M'*'+5t#AATS Annual Meeting

    April 2,) 2015Seattle) $A

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    2015 MFMER | slide-2

    !(e.ti/e

    Esta(lis# AATS e/iden.e-(ased guidelines fort#e management of empema

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    2015 MFMER | slide-

    Guidelines $riting Group

    Ro( S#en) M'*'

    T#ora.i. Surger

    Mao lini.

    "en &o3o4er) M'*'

    T#ora.i. Surger

    6A

    Tra/es ra(tree) M'*'

    T#ora.i. Surger

    $as#ington

    #ad *enlinger) M'*'

    T#ora.i. Surger

    MS

    7os#ua E() M'*'

    8nfe.tious *iseases

    6A

    9atri.% Ei%en) M'*'

    8nt Radiolog

    Mao lini.

    Fa(ien Maldonado) M'*'

    8nt 9ulmonar

    Mao lini.

    Su(roto 9aul) M'*'

    T#ora.i. Surger

    ornell

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    Met#ods

    ompre#ensi/e literature sear.#es

    9u(med) Medline

    Re.ommendations made (ased on a re/ie4 of

    t#e data in t#e literature

    ;e/el of e/iden.e supporting re.ommendationsgraded a..ording to standards pu(lis#ed ( t#e8nstitute of Medi.ine 2011 Clinical PracticeGuidelines We Can Trust: Standards forDeveloping Trustworthy Clinical PracticeGuidelines< 444'iom'edu=.pgstandards

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    Met#ods

    9roe.t di/ided into , se.tions and indi/iduals4it# e?pertise in t#at area assigned to re/ie4literature and propose re.ommendations

    tele.onferen.es to organi3e t#e topi.s to (e.o/ered) re/ie4 t#e literature summaries) andproposed re.ommendations

    1 fa.e-to-fa.e .onferen.e to /ote on final

    re.ommendations and re/ie4 final manus.ript

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    Met#ods

    All mem(ers of t#e 4or%ing group re/ie4ed allof t#e proposed re.ommendations and t#e le/elof e/iden.e supporting t#e re.ommendationand /oted on ea.# re.ommendation

    @5 appro/al reBuired for a..epting are.ommendation

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    Empema T#ora.is

    *efined as Cpus in t#e.#estD

    An.ient disease

    ippo.rates .redited4it# first des.ription ofnatural #istor andtreatment

    Most .ommon pre.ursor is

    (a.terial pneumonia andsu(seBuentparapneumoni. effusion

    ippo.rates of &os :>0-@0 "''

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    S.ope of t#e pro(lem

    2)000 patients treated for empema per earin t#e SA

    15 mortalit

    0 reBuire surgi.al drainage of t#e pleuralspa.e

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    8n.iden.e of empema in.reasing in S

    Trends in parapneumoni. empema-related #ospitali3ation SA 1++>-200,*ata from ation4ide 8npatient Sample

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    $#i.# patients are at ris% for empema

    Class I: The presence of a pleural effusion should beinvestigated in all patients presenting with signs andsymptoms of pneumonia, or unexplained sepsis. (L! "#

    Class I: $ailure of a community or healthcare associatedpneumonia to respond clinically to appropriate antibiotictherapy should prompt investigations to identify the presenceof a pleural effusion. (L! "#

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    $#at imaging studies s#ould (e o(tained

    Class I: %leural ultrasound should be routinely performed inaddition to conventional chest &'ray in the evaluation ofpleural space infection, both for diagnostic purposes andimage'guidance for pleural interventions. (L! "#

    Class IIa: Chest computed tomography should be obtainedwhen pleural space infection is suspected. (L! "#

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    o4 are pleural fluid studies useful indiagnosing empema

    Class I: The presence of pus, positive ram)s stain or culturein the pleural fluid establishes the diagnosis of empyemawhich should be treated with tube thoracostomy followed bysurgical intervention when appropriate. (L! "#

    Class I: * pleural p+ -. in a patient with suspected pleuralspace infection predicts a complicated clinical course, andtube thoracostomy should be performed followed by surgicalintervention when appropriate. (L! "#

    Class IIa: * pleural fluid L/+ 0 1222 I34L, glucose 52 mg4dLor a loculated pleural effusion suggests that the pleural

    effusion is unli6ely to resolve with antibiotics alone and werecommend tube thoracostomy (L! "#

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    o4 s#ould pleural fluid .ultures (eo(tained

    Class I: btain pleural fluid cultures only from directaspiration or drainage procedure, not from previously insertedtubes or drains. (L! "#

    Class I: Inoculate freshly drained pleural fluid into aerobic andanaerobic blood culture vials in addition to standard, sterilecontainers used for gram stain and culture. (L! "#

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    8deal anti(ioti. management of empema

    Class IIa: $or community'ac7uired empyema: a parenteralsecond or third generation cephalosporin (e.g ceftriaxone#with metronida8ole or parenteral aminopenicillin with 9'lactamase inhibitor (e.g. ampicillin4sulbactam#. (L! C#

    Class IIa: $or hospital'ac7uired, or post'procedural empyema:include antibiotics active against methicillin resistanttaphylococcus aureus and %seudomonas aeruginosa (e.g.vancomycin, cefepime, and metronida8ole or vancomycin andpiperacillin4ta8obactam ;dosed for activity against %.aeruginosa

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    8deal anti(ioti. management of empema

    Class I: =henever possible, choose antibiotic therapy basedupon culture results. (L! C#

    Class IIa: Consider continuing anaerobic coverage empiricallywhen the anaerobic cultures are negative unless resultsreflect a low probability of anaerobic infection, as in the caseof culture or antigen'identified pneumococcal infection. ( L!C#

    Class IIb: The duration of antibiotic therapy for acute bacterialempyema is influenced by the organism, ade7uacy of sourcecontrol, and clinical response. (L! C#

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    Role of t#ora.entesis in management ofempema

    Class III (no benefit#: Thoracentesis without pleural drainplacement is not recommended for the treatment of %%! orempyema. (L! C#

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    Role of drain pla.ement in management ofempema

    Class I: Image'guided pleural drain placement is useful in thetreatment of pleural infection, particularly in early stage,minimally septated empyema. (L! "#

    Class IIa: mall bore catheters are of uncertain utility incomplex, organi8ed empyema, but can be considered inpatients that are not surgical candidates. (L! C#

    Class I: >outine drain flushing is recommended if small borecatheters are used. (L! "#

    Class I: If tube thoracostomy is chosen as first line therapy,

    close imaging followup is recommended to assess ade7uacyof drainage. %ersistence of undrained fluid should promptmore aggressive management ( L! C#

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    Role of intrapleural fi(rinolti. t#erap inmanagement of empema

    Class IIa: Intrapleural fibrinolytics may be used for selectcomplicated pleural effusions and early empyemas butdefinitive management continues to be surgical adhesiolysiswith or without decortication (L! *#

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    "est surgi.al approa.# to manage stage 88empema

    Class IIa: ?*T should be the first line approach in all patientswith stage II acute empyema (L! "#

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    Surgi.al management of empema

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    o4 s#ould patients 4it# .#roni.empema (e managed

    Class IIa: /ecortication is reasonable in patients with chronicempyemas who are medically operable to tolerate ma@orthoracic surgery. (L! "#

    Class IIb: !pidural catheter placement may be considered inpatients undergoing thoracotomy for empyema if they areotherwise low ris6 for epidural abscess. (L! C#

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    !ptions to manage patients 4it# empema4#o #a/e in.omplete lung e?pansion

    Class IIa: Tissue flaps consisting of pedicled muscle flaps oromentum can be useful to fill empyema cavities where there isspace created by incomplete lung expansion or close abronchopleural fistula. (L! C#

    Class IIb: Thoracoplasty with resection of ribs may beconsidered in select cases to obliterate the infected pleuralspace where previous measures (muscle flaps, open window#have failed. (L! C#

    ! ti t # i i

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    !ptions to manage .#roni. empema inpatients in 4#om de.orti.ation notpossi(le

    Class IIa: pen thoracic window with marsupiali8ation of theinfected thoracic cavity with resection of several ribs anddressing changes is reasonable to be performed in patientswith chronic empyema medically unfit to tolerate decorticationand tissue flap placement or those patients with chronic

    empyema with a bronchopleural fistula. (L! C# Class IIb *n empyema tube draining a chronic empyema cavity

    may be considered in draining chronic infections in whichthere is a small persistently infected space or smallbroncopleural fistula especially in those patients medically

    unfit to tolerate decortication and tissue flap placement. (L!C#

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    Management .#roni. empema

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    o4 s#ould post-pneumone.tomempema (e managed

    Class I: %rompt intervention to identify or rule out thepresence of a bronchopleural fistula and provide drainage ofsepsis is recommended in patients suspected of havingpostpneumonectomy empyema. (L! C#

    Class IIa: *n aggressive surgical approach that includesantibiotics, serial debridement, closure of the bronchopleuralfistula when present and obliteration of the residual pleuralspace using vasculari8ed tissue transposition is a reasonablestrategy to manage postpneumonectomy empyema. (L! C#

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    o4 s#ould empema asso.iated 4it#"9F (e managed

    Class IIa: Closure of bronchopleural fistulae should beattempted using a combination of primary closure andbuttressing with a well vasculari8ed transposed soft tissuepedicle. (L! C#

    Class IIb: Transposition of the omentum is preferred overs6eletal muscle flaps or mediastinal soft tissue and thisshould be attempted after the purulent fluid has beencompletely drained and the pleural cavity has a surface ofgranulation tissue. (L! C#

    Class IIb: %rimary chest closure should be attempted with the

    chest cavity filled with antibiotic solution after granulationtissue has formed in the chest cavity and if the patient ismedically fit to undergo another operation.(L! "#

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    o4 s#ould empema in pediatri. patients(e managed

    Class I: Tube thoracostomy with or without the subse7uentinstillation of fibrinolytic agents should be attempted as theinitial treatment for pediatric patients with an empyema. (L!*#

    Class IIa: Thoracoscopic debridement and drainage isrecommended in pediatric patients not responding ade7uatelyto tube thoracostomy and fibrinolytic instillation.(L! "#

    Class IIa: ?*T debridement is preferred rather than openthoracotomy for the surgical management of empyema in thepediatric population (L! C#

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    e?t Steps

    Guidelines 4ill (e su(mitted to AATS Guidelinesommittee for re/ie4 and .omment

    AATS Guidelines ommittee 4ill t#en present

    final /ersion to AATS oun.ilors for appro/al E?e.uti/e summar of guidelines to (e

    pu(lis#ed in Journal of Thoracic &Cardiovascular Surgery Summer 201>

    Full /ersion 4it# supporting reasoning andreferen.es 4ill (e pu(lis#ed in t#e online/ersion

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    T#an% Hou