BackgroundBacterialpneumoniawith associated pleural empyema is
the most common cause ofpleural effusionfound in the pediatric
population. Parapneumonic effusions are predominately exudative and
occur in as many as 50-70% of patients admitted with a complicated
pneumonia.See the image below.Most parapneumonic effusions treated
with the appropriate antimicrobials of sufficient duration resolve
without the development of complications or sequelae. The series of
radiographs represent a patient treated with thoracentesis alone.
Figure A illustrates the patient at presentation. Note the amount
of fluid present. In Figure B, the radiograph demonstrates
progression of the pleural fluid accumulation with further airspace
disease and scoliosis noted. Despite the radiographic evidence of
disease progression, the patient was clinically improving. Figure C
illustrates the radiograph at follow-up, 6 months following
completion of therapy. Resolution of the parapneumonic effusion
with no evidence of pleural thickening or fibrosis occurred.The
pulmonary infections of these patients extend into the pleural
space and require more extensive therapy, with associated increased
morbidity and extended hospital stay. Involvement of the pleural
space with pulmonary infections has been recognized since ancient
times. Aristotle identified the increased morbidity and mortality
associated with empyema and described drainage of empyema fluid
with incision. The practice of surgical drainage as part of therapy
for empyema has continued into the era of modern medicine. In his
1901 text,The Principles and Practice of Medicine,Sir William
Osler, MD, stated that empyema should be treated as an ordinary
abscess, "with incision and drainage."[1]Of note, Osler underwent a
rib resection for his own postpneumonic empyema, from which he
ultimately expired.Complicated parapneumonic effusions are
appearing more frequently by most accounts, with reported increases
in incidence rates in both in Europe and the United States. In
England, the rate of admission with a diagnosis of empyema
increased over the last decade, most notably in children aged 1-4
years. In addition, the identification ofStreptococcus pneumoniaeas
the primary pathogen has also been reported, both in both the
United States and abroad. Whereas the overall rate of parapneumonic
effusions may have stabilized over the last decade, the rate of
bacterial resistance, specifically
methicillin-resistantStaphylococcus aureus, has
predominated.[2]
Ro
Most parapneumonic effusions treated with the appropriate
antimicrobials of sufficient duration resolve without the
development of complications or sequelae. The series of radiographs
represent a patient treated with thoracentesis alone. Figure A
illustrates the patient at presentation. Note the amount of fluid
present. In Figure B, the radiograph demonstrates progression of
the pleural fluid accumulation with further airspace disease and
scoliosis noted. Despite the radiographic evidence of disease
progression, the patient was clinically improving. Figure C
illustrates the radiograph at follow-up, 6 months following
completion of therapy. Resolution of the parapneumonic effusion
with no evidence of pleural thickening or fibrosis occurred
PatofisiologiThe definition of a parapneumonic effusion is a
pleural effusion associated with either bacterial pneumonia or lung
abscess or, rarely, external introduction of organisms associated
with chest wall trauma. The development of parapneumonic effusions
is gradual, with the pleural fluid collection most commonly divided
into 3 stages. The progression of pleural fluid collection evolves
from stage 1-3.In stage 1, the exudative stage, the pleural
inflammation from a contiguous infection results in increased
permeability and a small fluid collection. At this stage, the
effusion is thin and amenable to thoracentesis alone, contains
neutrophils, has normal pH and glucose levels, and is often
sterile. Stage 2, the fibrinopurulent stage, is characterized by
invasion of the organism into the pleural space, progressive
inflammation, and significant polymorphonuclear (PMN) leukocyte
invasion. The increase in fibrin deposition also results in
partitions or loculations within the pleural space. Inflammation is
characterized by progressive decreases in the pleural fluid glucose
and pH levels and increased protein and lactate dehydrogenase (LDH)
levels. The last stage, stage 3, is the organizing stage, in which
a pleural peel is created by the resorption of fluid and is
associated with fibroblast proliferation that can result in
parenchymal entrapment.[3]Empyema is defined by the presence of
intrapleural pus and, for definition purposes, represents an
advanced parapneumonic effusion. Complicated parapneumonic
effusions (CPE) refer to those fluid collections that require
thoracentesis, tube thoracostomy, or surgery for their
resolution.The accumulation of pleural effusions can rapidly occur
in the presence of infection. The pleural surface is a mesothelial
membrane that covers the lungs and chest wall. The resultant
pleural space is a potential space, containing only small volumes
of transudative fluid, with a protein content of less than 1.5
g/dL. This fluid is normally composed of lymphocytes, macrophages,
and mesothelial cells, with an absence of neutrophils. Interaction
of the mesothelium with the invading bacteria, PMNs, and resultant
inflammatory mediators can increase pleural permeability. Further
PMN recruitment ensues, which results in the increased production
of neutrophil chemotactic mediators, ultimately leading to
significant pleocytosis.Activation of the coagulation cascade is
common with pleural empyema. The pleural inflammatory response
favors increased procoagulant activity, as well as depressed
fibrinolytic activity, which favors fibrin deposition. Loculations
result with these fibrin strands covered rapidly by a meshwork of
fibroblasts that both proliferate and deposit basement membrane
proteins onto the surface of the pleura. These proteins obscure the
separation of the visceral and parietal pleura and lead to the
formation of the pleural peel.Following initiation of appropriate
therapy, the inflammatory cellular and cytokine production recedes,
and the PMN predominance of the parapneumonic effusion decreases.
An influx of macrophages assists in the clearance of PMNs, with
resolution of the inflammatory process. Migration of pleural
mesothelial cells into areas of denuded mesothelium results in the
reepithelialization of the pleura and recovery of normal function;
however, following exuberant pleural inflammation, the potential
for pleural fibrosis and restrictive lung disease is enhanced. The
mechanisms that lead to either the development of pleural fibrosis
or pleural repair with normal recovery are not well understood and
need further investigation and characterization.EpidemiologiUnited
StatesParapneumonic effusions are predominately exudative and occur
in as many as 50-70% of patients admitted with a complicated
pneumonia. These patients have extension of their pulmonary
infection into the pleural space and require more extensive
therapy, with associated increased morbidity and extended hospital
stay. Although incidence rates appear to be increasing, they remain
at approximately 10 cases per 10,000.[2]InternationalWith an
increased incidence of pneumonia andtuberculosisworldwide, the
frequency of CPE is likely to be even higher. Literature emerging
from Asia suggests empyema is a significant concern, although these
retrospective reviews cannot accurately describe the incidence, and
variable rates of identification suggest more standardized
practices are needed.[4]Mortality/MorbidityEarly recognition of
pneumonia with parapneumonic effusion, effective intervention to
identify the infecting organism, and initiation of definitive
therapy reduce the morbidity and complications associated with this
process.AgeThe bacteriology of the infection varies with patient
age. In the pediatric population, the most commonly implicated
organisms areS pneumoniae, S aureus,and group A streptococci. The
latter may be observed as a complication of an infectious skin
disorder, such asvaricella,impetigo, or infectious
eczema.Haemophilus influenzaeis rarely encountered since the advent
of theH influenzaeB vaccine. Methicillin-resistantS Aureusis a
concern in the older age group.Manifestasi klinisClinical
manifestations of empyema include the following: Most patients with
empyema present with clinical manifestations of bacterial
pneumonia. Their symptoms are characterized by an acute febrile
response, pleuritic chest pain, cough, dyspnea, and, possibly,
cyanosis. The inflammation of the pleural space may cause abdominal
pain and vomiting. Patients frequently exhibit characteristic
splinting of the affected side. Symptoms may be blunted, and fever
may not be present in patients who are immunocompromised.
Pfysical examination findings can vary as well. Auscultation
reveals crackles, decreased breath sounds, and, possibly, a pleural
rub, if the process is recognized before a large amount of fluid
accumulates. Dullness to percussion and decreased breath sounds are
likely but difficult to elicit in the younger child, who, because
of discomfort, may be less cooperative with the examination.
Physical findings and presentation may vary depending on the
organism and the duration of the illness.
Etiologi Increased pleural permeability associated with
pneumonia or lung abscesses, as well as contiguous infections of
the esophagus, mediastinum, or subdiaphragmatic region, may extend
to involve the pleura. Similarly, retropharyngeal, retroperitoneal,
or paravertebral processes may extend to adjacent structures and
involve the pleura, as well. Host factors that contribute to
alterations in pleural permeability, such as noninfectious
inflammatory diseases, infection, trauma, or malignancy, may allow
accumulation of fluid in the pleural space, which becomes
secondarily infected. The bacteriology of the pleural space varies
with patient age. In the pediatric population, the most common
implicated organisms areS pneumoniae, S aureus,and group A
streptococci.H influenzaeis rarely observed since the advent of
theH influenzaeB vaccine. Because of the use of oral antibiotics
before the recognition of the parapneumonic effusion, most
specimens cultured are sterile; thus, the relative incidences of
the aforementioned organisms are not known. Anaerobic infections
secondary to aspiration and fungal or mycobacterial infections in
immunosuppressed patients are also reported. Finally,Mycoplasma
pneumoniae,viruses, and atypical pneumonias can also present with
exudative pleural effusions, although mononuclear cells primarily
characterize them.
dd Heart Failure, Congestive Hemothorax Nephrotic Syndrome
Pleural Effusion Pulmonary Infarction Pulmonary SequestrationLabThe
following studies are indicated in empyema: CBC count Blood
culture: Blood culture is obtained to assist in the identification
of the offending organism. In pediatric patients, in whom sputum
production is uncommon, identifying the cause of the pulmonary
symptoms early in the course of a pulmonary infection is difficult.
However, with parapneumonic effusions, the patient may become
bacteremic as the organism invades into the pleural space, and a
blood culture may reveal the organism. Serum lactate dehydrogenase
(LDH) level Total protein level Glucose concentration Bacterial,
mycobacterial, and fungal cultures Serologic studies of the
aspirated pleural fluid pH level Amylase concentration Lipid stain
or triglyceride level Cell count and differential: Although the
pleural fluid obtained at thoracentesis is typically purulent, with
an elevated WBC count and a predominance of polymorphonuclear cells
(PMNs), an effusion evaluated early in the infectious process may
well be more transudative, with a less cellular WBC count and a
differential that is less PMN predominant. Regardless of the cell
count and differential, the treatment should be based on clinical
course, pending the culture results. Cytokine analyses of pleural
fluid have been performed in experimental settings and may prove to
add prognostic value on the degree of inflammation present and may
be beneficial in determining treatment course in the near
future.
Radiologi Radiologic evaluation is the primary tool for the
diagnosis of a parapneumonic effusion. Standard chest radiography
is the first step to assess for pleural fluid. See the image
below.Radiographic imaging of a parapneumonic effusion may be
useful in assessing the stage of the effusion and the type of
drainage needed. In Figure A, the left heart border is obscured,
and more than 50% of the left hemithorax is filled with an
effusion, as evidenced by a fluid meniscus. In Figure B, the
effusion is demonstrated to be fluid because it layers out on a
decubitus film. In Figure C, the lateral radiograph again
demonstrates the fluid meniscus and filling of the posterior
sulcus. These findings suggest tube thoracostomy placement may be
sufficient to drain this pleural process. Examination should
include upright views of the chest to examine the diaphragmatic
margins, which are obliterated with pleural fluid collections.
Because as much as 400 mL may be required before these costophrenic
angles are obscured in older children and adolescents, further
diagnostic imaging may be needed. In cases in which the effusion is
moderate, radiography may reveal displacement of the mediastinum to
the contralateral hemithorax, as well as scoliosis. Indistinct
diaphragmatic contours merit lateral decubitus views of the chest.
Free-flowing pleural effusions suggest less complicated
parapneumonic processes, which may not require extensive diagnostic
and therapeutic interventions. Ultrasonography that reveals the
absence of loculations suggests that effective treatment can be
achieved without surgical intervention. The absence of free
layering fluid on the decubitus films does not exclude the
possibility of a loculated pleural effusion.[5] Consider
ultrasonography or CT imaging to identify the presence of
consolidated lung or fibrinous septations. In patients with complex
fluid collections, chest CT imaging has emerged as the study of
choice. Chest CT imaging can be used to detect and define pleural
fluid and image the airways, guide interventional procedures, and
discriminate between pleural fluid and chest consolidation.
Ket gambar 2
Radiographic imaging of a parapneumonic effusion may be useful
in assessing the stage of the effusion and the type of drainage
needed. In Figure A, the left heart border is obscured, and more
than 50% of the left hemithorax is filled with an effusion, as
evidenced by a fluid meniscus. In Figure B, the effusion is
demonstrated to be fluid because it layers out on a decubitus film.
In Figure C, the lateral radiograph again demonstrates the fluid
meniscus and filling of the posterior sulcus. These findings
suggest tube thoracostomy placement may be sufficient to drain this
pleural process.
Px lainleural fluid polymerase chain reaction (PCR), latex
agglutination (or counter immunoelectrophoresis [CIE] for specific
bacteria) may be helpful if the cause of the infection cannot be
ascertained from stain or culture results.
Prosedur
Thoracentesis can provide both significant diagnostic
information and therapeutic relief for parapneumonic effusions. The
presence of pus establishes the presence of an empyema, and the
determination of the Gram stain, cell differential, and chemistries
helps to guide therapy. Performing thoracentesis before the
initiation of antibiotics increases the diagnostic yield of the
fluid cultures and allows for more specific antimicrobial
therapy.
TalakTreatment of parapneumonic effusions should address control
of the infection and often involves drainage of the pleural fluid
and reexpansion of the affected lung tissue. Appropriate antibiotic
selection should be based on the Gram stain and culture of the
pleural fluid; however, because a large number of patients may have
already received antibiotics at the time of thoracentesis, an
empiric selection of the most appropriate antibiotics is necessary.
Base the choice on the most common pathogens that cause pneumonia
within the patient's age range and geographic location. When the
organism is identified, change the antibiotics to most specifically
cover for the pathogen. Patients with empyema should receive a
longer course of therapy analogous to necrotizing pneumonia, but
the response to therapy determines the duration of treatment. The
patient receives 10-14 days of intravenous antibiotics and receives
treatment until he or she is afebrile, off supplemental oxygen, and
appropriately responds to therapy. Continuation of oral antibiotics
may be recommended for 1-3 weeks after discharge but is not
required for less complicated infections. The most controversial
area in the management of parapneumonic effusions is the
identification of patients who would benefit from pleural drainage
and the selection of the appropriate drainage intervention. No
clinical studies have effectively contrasted antibiotic treatment
without drainage to currently available drainage techniques.
However, long-term follow-up studies show no differences in
pulmonary function or exercise capacity between the groups. The
therapeutic discussion rests on available clinical, radiologic, and
laboratory evidence; host factors; and individualization to make
the appropriate decision. The pulmonologist, intensivist,
interventional radiologist, or surgeon can perform simple tube
thoracostomy with an underwater seal. Diagnostic thoracentesis and
chest tube drainage are effective therapies in more than 50% of
patients. Prompt drainage of a free-flowing effusion prevents the
development of loculations and a fibrous peel. Remove the tube when
the lung re-expands and drainage ceases. If the fluid is not free
flowing, undertake further radiologic imaging to better define the
pleural space disorder. Clinical resolution is not hastened by
chest physical therapy used as an adjunct to standard treatment in
children hospitalized with acute pneumonia.[6] In addition to the
benefit of CT and ultrasonographic imaging to characterize
loculated pleural effusions, the radiologist has become
significantly involved in the treatment of complicated
parapneumonic effusions (CPE). The ability of the interventional
radiologist to assist in the placement of small-bore catheters,
specifically localized to loculated pleural fluid collections, has
helped to facilitate drainage. Furthermore, with smaller diameter
tubes, patients have tolerated tube placement better, with less
associated morbidity. In addition, radiologists can lyse adhesions
directly using imaging during the tube placement. Finally,
interventional radiologists, using fibrinolytics, have further
improved the care of the complicated empyema by improved management
of loculations and amelioration of fibrous peel formation and
fibrin deposition. Numerous studies have documented the
effectiveness of intrapleural fibrinolytics to treat obstructed
thoracostomy tubes, increase drainage in multiloculated effusions,
and to lyse adhesions; however, initial studies report on the use
of urokinase, the fibrinolytic most commonly described prior to
1998, evolving to the use of tissue plasminogen activator (tPA),
which has become the most frequently used treatment. Increased use
of tPA has shown it to be well tolerated, effective, and less
costly than surgery.[7, 8]Randomized trials of chest tube drainage
with fibrinolytics versus simple drainage and surgical therapy need
to be undertaken to fully assess the relative clinical value of
fibrinolytic therapy in the more complicated patient.Surgical
careControversy continues regarding the surgical treatment of CPE.
For the uncomplicated free-flowing parapneumonic effusion, surgical
intervention is rarely needed; however, the multiloculated
persistently symptomatic effusion, for which initial therapy may
have been delayed, is likely to require more than conservative
management. The surgical literature supports the use of thoracotomy
to remove the pleural peel and lyse the adhesions, if the patient
does not respond promptly to treatment. Length of stay and
long-term morbidity are reduced by this more aggressive approach,
but this must be contrasted with the increased cost and short-term
morbidity associated with thoracotomy and decortication. This
treatment regimen is very effective, with a reported 95% success
rate for patients with fibrinopurulent effusions. Because no
prospective comparative studies have contrasted the current
techniques, decortication is likely to remain a treatment of choice
for advanced empyema. Video-assisted thoracoscopic surgery (VATS)
has proven to be an effective and less-invasive replacement for the
limited decortication procedure.[9, 10]Thoracoscopic debridement
closely imitates open thoracotomy and drainage. Mechanical removal
of purulent material and the breakdown of adhesions can be easily
accomplished via this route. VATS results in more rapid relief of
symptoms, earlier hospital discharge, and significantly less
discomfort and morbidity. Despite the benefits, a small percentage
of patients still progress to require thoracotomy. As with
fibrinolytic therapy, those patients in which this therapy has been
most effective are those slightly less affected in whom earlier and
potentially more aggressive treatment has been initiated. The
definitive approach is thoracotomy drainage with mechanical release
of the pleural peel and lysis of adhesions. Studies of
decortication and debridement report 95% effectiveness for empyemas
in the fibrinopurulent stage. These outcomes are determined by
selected clinical outcomes, such as resolution of symptoms;
however, these studies are subject to selection bias and do not
account for the morbidity associated with the procedure, as well as
increased costs associated with an operative procedure and the
associated anesthesia risk. Furthermore, most children heal well in
the long run, even without immediate surgical intervention. A
meta-analysis reviewed the differences between primary operative
treatment with nonoperative management and revealed striking
reductions in length of stay, duration of tube thoracostomy, and
duration of antibiotics.[11]However, these data are susceptible to
critics who point out the same concerns regarding selection biases
that have been listed above. An additional review of surgical
options demonstrated that early VATS resulted in shortening
hospitalization times, but other outcomes such as duration of
symptoms or antibiotic use were less dramatic between surgical
treatments. In conclusion, early intervention of any sort is likely
to improve outcomes, but early VATS is the surgical approach now
most preferred in managing children with empyema. Alternative
procedures, such as rib resection and open drainage or pleural
obliteration, are rarely needed in the pediatric population. To
most effectively determine the optimal therapeutic intervention, a
carefully designed, multicentered, randomized, clinical trial would
help to develop evidence-based standards for the treatment of
complicated parapneumonic effusion in children. Marhuenda et al
conducted a prospective, randomized, multicenter clinical trial
comparing the efficacy of drainage plus urokinase therapy with that
of video-assisted thoracoscopic surgery in the treatment of
pediatric parapneumonic empyema.[12]The study included a total of
103 patients (age, younger than 15 years); 53 patients were
randomly assigned to receive treatment with thoracoscopy, and 50
were assigned to treatment with urokinase. There were no
differences in demographic characteristics or in the main baseline
characteristics between the 2 groups. No statistically significant
differences were found between the thoracoscopy group and the
urokinase group in the median postoperative stay (10 vs 9 days),
the median hospital stay (14 vs 13 days), or the number of days
febrile after treatment (4 vs 6 days). A second intervention was
required in 15% of the children in the thoracoscopy group and in
10% in the urokinase group. The investigators concluded that
drainage plus therapy withurokinaseisaseffective as video-assisted
thoracoscopic surgery as first-line treatment of septated
parapneumonic empyema in children.[12] Proesmans et al reported on
the use of a standardized medical treatment of parapneumonic
empyema as a first-step nonsurgical approach in a tertiary care
center.[13]The purpose of the study was to evaluate the need for
surgery and to collect data on disease course, outcome, and
microbiology. The study cohort consisted of 132 children treated
for parapneuonic empyema between 2006 and 2013. Of the 132
children, 20% required surgical intervention. Median duration of
in-hospital fever was 5 days. The duration of fever correlated with
pleural LDH levels and pleural glucose levels and was inversely
correlated with pleural pH. On the basis of pleural polymerase
chain reaction results, 85% of the cases were caused
byStreptococcus pneumoniae(40% were of serotype 1). After
introduction of a standardized primary medical approach (chest
drainage with or withoutfibrinolysis), the need for surgical rescue
interventions remained at 20%overall.[13]
Konsultasi Consultants may include pediatric surgeons (thoracic
or general), interventional radiologists, intensivists, and
pulmonologists.
Activitypatients should perform as much activity as can be
tolerated. Encourage the facilitation of deep breathing and airway
clearance. Use analgesics on an individual basis to facilitate
airway clearance.
