Pleural EmpyemaManagement

Benoit Guery Maladies Infectieuses

Philippe RamonService d’endoscopie Respiratoire

CHRU Lille

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).

Goals of the treatment

Treat the infection

Drain the purulent effusion adequately and

completely

Re-expand the lung to fill the pleural space

Eliminate complications and avoid chronicity

The infection

Bacteriological data

Pleural Ponction : Exsudate Direct analysis, Gram stain Aerobic and anaerobic cultures (Bactec) If possible before antibiotic treatment

Results Mono or polymicrobial ( 4-30%) Variations between series Variations between underlying conditions

Wait et al, Chest 1997 Cheng et al, Chest 2005

Maskell et al, NEJM 2005

Bacteriological data. Streptococcus pneumoniae: 15-20%

Increased resistance

Staphylococcus:15-30% Streptococcus spp Gram Negative: 20-50%

Klebsiella, Enterobacter, Pseudomonas, Hemophilus, E.Coli

Anaerobes: Fusobacterium, Bacteroides fragilis

Microbiological diagnosis techniques

Le Monnier et al, Clin Inf Dis 2006

3 methods- Standard culture - PCA: Pneumococcal capsular antigen - 16S rDNA PCR confirmed by pneumolysin PCR

Microbiological diagnosis techniques

Latex antigen detectionSe: 90%Sp: 95%

Le Monnier et al, Clin Inf Dis 2006

Antibiotic treatment As soon as the bacteriologic sample

are recovered Pneumonia

Amoxicillin, 3GC or 3GC +/- MetronidazoleAmox-clavulanic acid

Dosage of the molecule

NosocomialTazobactam or Imipenem+/- Aminoglycoside or Quinolone

Not Pneumococcus directed molecules

Adapted to the laboratory results

Adequate drainage

Available techniques

Primary treatment options

Antibiotics alone; Recurrent thoracocentesis Insertion of chest drain alone or in

combination with fibrinolytics VATS. Open decortication

Thoracocenthesis

Big caliber needle Mostly diagnosis technique Therapeutically used if the liquid remains

fluid Theoretically allows pleural lavage

Chest Tube As soon as the liquid is thick

Localizationfree: axillaryloculated: Chest imaging using

ultrasonography and/or computed tomography

Size: 20 à 24

Bedside

Pleural Lavage

Isotonic saline +/- Noxyflex (noxytioline)

Modalités3 way stopcockDirectly through the CT: 250 to 500 ml Cautiously if suspicion of broncho-pleural fistula

Timing:Immediately after CT placement+++Once a day until the liquid is clear

NOXYFLEX (noxytioline)

Local disinfectant (formaldéhyde) 2,5 g diluted in a least 100ml isotonic

saline Maximum: 5g/day Incompatible with iodine

polyvidone,chlorhexidin, chlorine solution, lactic acid

Fibrinolytics

Urokinase: 100 000 or 300 000 IU conditioning

Streptokinase: 250000 IU conditioning250.000 IU in 10-20 ml isotonic salineDon’t evacuate before 24 to 48 heuresConstantly associated with fever (38-39°C)Then evacuate

Pleural lavageclamp 4h ( Chest 1996)

Video-assisted thoracic surgery

Collection<10 cm: unusualVisual control of the CT position

5 mm introducer, 4 mm optical

Collection>10 cm10 mm introducerTwo or three ports are made in the chestOne port is utilised for the camera and the others for

grasping instrumentsFree fluid is evacuated and loculations drained under

thoracoscopic visualisation. Fibrinous adhesions are separated and the pleural debris

removed from the pleural lining using endoscopic grasping forceps or by extensive irrigation and suction.

Following the procedure, one or two chest drains are then placed in the portholes.

Local antibiotics

Usually Rifampin or Colimycin Still debated Do not replace systemic treatment

Physiotherapy

Key to a correct evolution After CT removal Often and for a long time….. Decrease surgery Decrease long term pain and functionnal

limitations

Therapeutic choices

Guidelines to predict which patients with non-purulent parapneumonic effusions warrant

chest tube drainage 240 patients with PPE

85 uncomplicated PPE 67 complicated PPE 88 empyema

Porcel et al, Respir Med 2006

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

ACCP: Positive culture pH<7.2 Glucose <60mg/dL Effusion>half of the

hemithorax

Porcel et al, Respir Med 2006

Porcel et al, Respir Med 2006

Compare Chest Tube + Streptokinase (n=9) vs VATS (n=11)

B score on the Cochrane analysis with methodological concerns: Small number Patient selection Unclear allocation and

outcome assessor blinding

But: VATS is superior to CT for large loculated pleural empyemas Duration CT LOS

Wait et al, Chest 1997 Cochrane 2005

Prospective study between 1997 and 2004

2 groups I: video-assisted

thoracoscopy (chest tube, fibrin debrided)

II: chest tube without VAT

Surgical decortication Group I: 17.1% Group II: 37.1%

LOS Group I: 8.3 days Group II: 12.8 days

Bilgin et al, ANZ J Surg 2006

Hypothesis: Urokinase is effective through the lysis and not the volume effect

Randomized double blind study UK (15 patients) for 3

days, 100 000 IU in 100 ml NS

Control (16 patients), 100 ml NS for 3 days

Complete drainage UK: 13/15 (86%) NS: 4/16 (25%)

Bouros et al, AJRCCM 1999

Cochrane analysis 2007

Cochrane analysis 2007

Cochrane analysis 2007

Cochrane analysis 2007

Cochrane analysis 2007

Cochrane analysis 2007

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

Multivariate analysis: the use of fibrinolysisis the only independent factor associatedwith a favorable outcome

452 patients with pleural infection Sk 250 000 IU twice daily

for 3 days Placebo

No difference in mortality, rate of surgery, radiographic outcomes, LOS

Serious adverse events more common with Sk (chest pain, allergy, fever)

Maskell et al, NEJM 2005

Meta-analysis with 5 properly randomized trials comparing fibrinolytic agents to placebo

575 patients

Tokuda et al, Chest 2006

Only one study analyzed… no differences observed on the parameters

Cochrane analysis 2007

Fibrinolytics vs VATS

60 children matched No difference

LOS after interventionFailure rateRadiologic outcome at 6 month

Treatment cost with UK ($6 914)< VATS ($10 146)

Sonnappa et al, AJRCCM 2006

Case report 1

50 yo Left Pneumococcus empyema Admitted on the 4th day D2 streptase instillation D3 VATS+2 CT CT removal on D8 Discharged on D12

Case report 2

76 yo March 96: Pneumonia April 96 : Left lung effusion No fever, CRP 29, fibrinogen 7g/l Exsudate, LDH 7200, glucose 0,24g/l

cytology PMN, negative direct examination

VATS (25/4/96): loculatedRemoved debris and liquid (600ml)Posterior CT n°24

Pleural lavage (Noxyflex) CT removal on 2/5/96

Indications

Hamm et al, ERJ 1997

Thoracocentesis

Clear liquid Not clear or purulent effusion

pH>7.20 pH<7.20

No intervention Reccurent thoracocentesis

Not loculated Loculated

Drainage Pleural lavage

DrainagePleural lavageFibrinolytics

FailureVATSSurgery

IndicationsThoracocentesis

Clear liquid Not clear or purulent effusion

pH>7.20 pH<7.20

No intervention

Not loculated Loculated

Drainage Pleural lavage

Fibrinolytics 24-48h

DrainageFibrinolyticsPleural lavage

VATSDrainagePleural lavage

FailureVATSSurgery

FailureSurgery

Reccurent thoracocentesis