PowerPoint presentation on Pleural Empyema by Dr.Tinku Joseph

1. PLEURAL EMPYEMAPLEURAL EMPYEMA
DR.TINKU JOSEPH
MD (chest), FCCP (USA)
Senior Resident
Department of Pulmonary Medicine
CMC Vellore
Email -: tinkujoseph2010@gmail.com

2. Contents
•
Definition
•
Etiology
•
Stages
•
Symptoms & signs
•
Complications
•
Investigations
•
Management

3. Pleural Empyema / Pyothorax /
Purulent Pleuritis / Empyema Thoracis
 Accumulation of Pus in the Pleural cavity.

4. Etiology (Introduction of infection)
EMPYEMA
NON TRAUMATIC TRAUMATIC
THORACIC
SEPSIS
EXTRATHORACIC
SEPSIS IATROGENIC
NON-
IATROGENIC
SUBPHRENIC
ABSCESS,
HEPATIC
ABSCESS
MEDIASTINITIS
PULMONARY
DISEASE
OSTEOMYELI
TIS
LUNG
RESECTION,
OESOPHAGEAL
TEARS,
PARACETESIS
THORACIS,
LIVER BIOPSY
STABBINGS,G
UNSHOT
WOUNDS,ETC
PNEUMONIA, TB,
BRONCHIECTASIS
,LUNG ABCESS
STERNUM,
VERTEBRAE,
RIBS

5. 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

6. Influence of predisposing factors
 In adults – empyema arises as a complication of
CAP,often pneumococcal.
 Frank aspiration – anaerobes.
 Aerobic gram negative bacilli infection likely to affect
pleura – from below diaphragm or as a result of
oesophageal instrumentation.
 Mycobacteria and fungi more common in
immunocompromised.

7. Uncommon microbial causes
 Tuberculous
 Fungal – Aspergillous,Cryptococcus,Blastomyces,
Histoplasmosis.
 Actinomyces – aerobic gram negative filamentous
bacteria.
 Clostridia – anaerobic organism.
 Hydatid disease – Echinococcus.
 Lung fluke – Paragonimus westermani.
 Protozoa – Trichomonas,Entamoeba histolytica.

8. Pathology-Stages
 Acute (exudative) stage: Approximately in 7 days.
 Infected by pathogenic organism, pleural
membranes becomes edematous and produce
exudation of proteinaceous fluid that starts to fill
the pleural cavity.
 Pleura fills with thin serous fluid that shows
relatively low white cell count.
 Visceral pleura and underlying lung remains mobile.

9. Stages cont,
 Transitional (Fibrinopurulent) stage: From day 7 to 21 day.
 If infection proceeds unchecked by antimicrobials.
 Thick, Opaque fluid with positive culture (pus) and
Deposition of thin fibrin layer over the pleura.(mainly
parietal pleura).
 Empyema fluid now becomes more thicker and turbid.
 Higher white cell count.
 Lung movements in this later stages become
increasingly restricted.
 Progressive loculation and formation of pouches in
the pleura.

10. Stages cont,
 Stage of vascularization:
 Fibrinous layers starts to organize as collagen.
 Becomes vascularized by ingrowth of capillaries.

11. Stages cont,
 Organizing (chronic) Stage: after 21 days.
 Usually 4-6 weeks.
 Empyema cavity becomes surrounded by a cortex.
 Contains frank pus.
 Inner layers shows inflammatory cells.
 Outer layers gets fibrous – exerts restrictive effect.
 Compressing the underlying lung (trapped lung
effect).
 Draws the ribs together producing chest deformity.
 Later on gets calcified – fibrothorax.

12. Symptoms & signs
 Depends on nature of infecting organism
 competence of patients immune system.
 Ranges from complete absence of symptoms to a
severe illness with all usual manifestations of systemic
toxicity.
 Fever
 Cough & Expectoration.
 Pleuretic chest pain.
 Dyspnoea
 Easy fatiguability.
 Loss of weight.
 Night sweating.

13. • Finger clubbing.
• Signs of pleural effusion.
• Empyema necessitants.

14. Complications
 Rupture into the lung; BronchoPleural fistula.
 Spread to the subcutaneous tissue; Empyema
necessitans.
 Septicaemia & septic shock.

15. Diagnosis
 LRTI – possibility of complicating empyema.
 History and physical findings may be suggestive.
 CXR,USG,CT.
 Thoracentesis- PH < 7.4
Glucose <40 mg/dl
LDH> 1000 iu/dl
Protein > 2.5 gm/dl
Sp.gravity >1.018
 Other findings (non specific):neutrophil leucocytosis
and hypoalbuminaemia.

16.  Chest x ray
 In early stages same as
uncomplicated pleural
effusion.
 As time passes, fibrosis
develops around empyema
cavity.
 Fluid contained in one
location.
 Homogenous shadow
extending upwards.

19. • Lateral cxr – opacity
convex anteriorly.
• Tapering at its upper and
lower ends
• Extending into the thorax.
• D – shaped shadow.

20.  Other findings on cxr
 Air fluid level –
pneumothorax,BPF,Iatrogenic, gas
forming organisms such as clostridia.
 Underlying pulmonary shadowing -:
delayed resolution of
pneumonia,lung abcess,tumours of
lung,mediastinum,pleura.
 Hydatid cyst,partial lung collapse.
 USG – pockets of fluid.
 CT thorax – similarly
helpful,inflamatory
lymphadenopathy

22. Post pneumonectomy empyema nessitants.

23. Pleural Empyema
Management

24. 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.

25. Antimicrobial Therapy
 Choice of antibiotic – microbiological C/S testing.
 Anaerobes- may be treated with Benzylpenicillin.
 If resistant – add metronidazole.
 Better response – Clindamycin + Penicillin ( active
against Bacteroids fragilis and other penicillin-
resistant anaerobes.(Arch Intern med
1995,150:1700).
 Amoxyclav.(Beta lactam inhibitors).
 Ampicillin+Sulbactam.
 Piperacillin,Ticarcillin.(combined with tazobactum).
 Imipenam,meropenam(anaerobes as well as Gram
+/-)

26.  Cefoxitin – most potent cephalosporin.
 Chloramphenicol- very effective,but not routinely given
due to fear of bone marrow suppression.
 Macrolides,Quinolones not so effective.
 Pneumococcus
 Responds to high dose benzylpenicillin
initially,continuing with oral phenoxy methyl
penicillin(penicillin V) or amoxycillin.
 Alternatives for penicillin allergic individuals- Cefradin or
Clarithromycin.

27.  Staphylococcus aureus
 Dicloxacillin,oxacillin for parenteral use.
 First generation cephalosporins – cefradine.
 MRSA- vancomycin,Linezolid.
 Gram negative aerobes
 Serious aerobic infections may be treated with the
combination of a third generation cephalosporin –
Ceftazidime and an amynoglycoside such as gentamycin.
 Mixed infection,including anaerobes – piperacillin.

28.  Adults with empyema who are admitted from the
community, and in whom infecting organism have not
yet been identified may be treated initially with a
combination that includes co-amoxyclav,metronidazole
and flucloxacillin.
 This regimen is modified in the light of cultures and the
patients clinical response.
 Duration of therapy is likely to be several weeks.
 It can be continued for at least 3 weeks after all
drainage has ceased.

29. BTS guidelines for the management of empyema
Origin of infection Intravenous antibiotic
treatment
Oral antibiotic treatment
Community acquired culture
negative pleural infection
Cefuroxime 1.5 g tds iv +
metronidazole 400 mg tds
orally or 500 mg tds iv
Amoxycillin 1 g tds +
clavulanic acid 125 mg tds
Benzyl penicillin 1.2 g qds iv
+ ciprofloxacin 400 mg bd iv
Amoxycillin 1 g tds +
metronidazole 400 mg tds
Meropenem 1 g tds iv +
metronidazole 400 mg tds
orally or 500 mg tds iv
Clindamycin 300 mg qds
Hospital acquired culture
negative pleural infection
Piperacillin + tazobactam 4.5
g qds iv
Not applicable
Ceftazidime 2 g tds iv,
Meropenem 1 g tds iv ±
metronidazole 400 mg tds
orally or 500 mg tds iv

30. Tuberculous Empyema
 Rare entity.
 Purulent fluid loaded with tuberculous organisms.
 Usually develops in fibrous scar tissue resulting from
pleurisy, artificial pneumothorax or thoracoplasty.
 Underlying pleura is heavily calcified.
 Sub acute or chronic illness
 Fatigue, low grade fever and weight loss.
 Radigraphically – obvious pleural effusion, pleural
thickening.
 CT scan – thick calcified pleural rind and rib thickening
surrounded by loculated pleural fluid.

31. Tuberculous Empyema
 Diagnosis – thoracentesis, AFB smear and culture.
 Treatment – intensive chemotherapy coupled with
serial thoracentesis can be curative at times.
 Multiple drug regimen at their maximal tolerated
dosages.
 Strong tendency to develop resistant organisms.
 ATT frequently do not reach there normal levels in
the pleural space owing to the thick, fibrous and often
calcified pleura.
 VATS/Decortication.

32.  Aspergillus – amphotericin or itraconazole.
 Cryptococcosis- in immunocompromised patient is
treated with amphotericin and flucytosine
 Blstomycosis,Coccidiomycosis –
amphotericin/Itraconazole.
 Actinimycosis – high doze Benzyl penicillin followed by
prolonged therapy with oral amoxycillin.
 Nocardia – co-trimoxazole,sulfadiazine or imipenam.
 Clostridial empyemas- high dose benzyl penicillin/
metronidazole or imipenam.
 Salmonella – ciprofloxacin or ceftazidime.

33.  Hydatid infection – surgical excision with
albendazole cover.
 Paragonimus westermani – praziquantel.
 Trichomonas – metronidazole.
 Empyema complicating amoebiasis – metronidazole
and diloxanide furoate.

34. Primary treatment options
• Antibiotics alone;
• Recurrent thoracocentesis
• Insertion of chest drain alone or in combination
with fibrinolytics
• VATS.
• Open decortication

35. Thoracocenthesis
 Big caliber needle.
 Repeated aspiration is carried out.
 Use of Abrams punch biopsy needle
is useful initially. Wide callibre
allow easy aspiration and also
permits pleural biopsy.
 Mostly diagnosis technique
 Therapeutically used if the liquid
remains fluid
 Helps in pleural lavage also.

36. Chest Tube
 Closed tube thoracostomy.
 As soon as the fluid is thick.
 Localization
 loculated: Chest imaging using
ultrasonography and/or
computed tomography
 Size: 20 - 28 F
 Passed under USG guidance,helps in
breaking fibrinous septa and pus
rapidly gets removed
 Bedside

37. Pleural Lavage
 Isotonic saline
 +/- Noxyflex (noxytioline)
 Modalités
 3 way stopcock
 Directly 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

38. Fibrinolytics
Intrapleural Streptokinase;
• Indications
 Acute or fibrino purulent stage
 Presence of loculations.
 Incomplete drainage after tube insertion
• Contraindications:
 Chronic stage
 Post-operative empyema
 Empyema with BPF.

39. Fibrinolytics
 Was reported in 1949.
 Then was abandoned due to allergic reactions,but taken
up again due to availability of purer forms of
streptokinase,urokinase.
 (Davies RJO,Trail ZC Thorax 1997; 52:416.)
 Urokinase: 100 000 or 300 000 IU .
 Streptokinase: 250000 IU .
 250.000 IU in 10-20 ml isotonic saline.
 Don’t evacuate before 24 to 48 hours.
 Constantly associated with fever (38-39°C).
 Then evacuate.

40.  Local antibiotics
 Intrapleural instillation of antibiotics, especially
metronidazole,Colimycin.
 Still debated.
 Do not replace systemic treatment.

41. Video-assisted thoracic surgery
 VATS.
 If closed drainage does not result in
prompt re-expansion of the lung and
especially if loculi have been identified
by USG.
 Decision to intervene early is made.
 Debridement and drainage.
 Breakage of loculi,evacuating pus,debris
and freeing lung.
 Helps in re expansion of lung.

42. Compare Chest Tube + Streptokinase
(n=9) vs VATS (n=11)
Wait et al, Chest 1997

43. Bronchoscopy
 Recommended following the successful conclusion
of closed drainage.
 In order to exclude any endobronchial causes of
obstruction, such as tumour or foreign body.

44. Open drainage
 If empyema persists both clinically and radiologically.
 In whom closed drainage has proved unsuccessful.
 If VATS unavailable, unsuccessful or considered
inappropriate.
 Rib Resection Drainage.
 Eloesser Flap .

45. Rib Resection Drainage
 Performed under LA/GA
 when the pus is thick and loculated.
 Resection of the lowest rib above and below which
pus can be aspirated.
 Open all the intact cyst that leads to conversion of
empyema with free pus.
 Then place wide bore tube surrounded by gauze in
the unsutured wound.
 Daily dressing.
 Gradual obliteration of empyema space.
 Antibiotics should continue for 6 weeks.

46. Rib Resection Drainage

47.  An earlier form of treatment involved
surgical removal of most of the ribs
on the infected side of the thorax,
causing a permanent collapse of the
lung and obliteration of the infected
pleural space.
 This would leave the patient with a
large portion of the upper chest
removed, giving the impression that
the shoulder had been detached from
the body.
 Rarely performed today, the surgery
was common during WORLD WAR 1

48. Eloesser Flap Drainage
 When drainage is protracted.
 Patient remains too ill.
 Unsuitable for thoracotomy.
 Then a more permanent fenestration or open
window thoracostomy may be performed.

49.  Once the ribs have been
resected, the skin overlying the
thoracostomy is marsupialized
to the parietal pleura to permit
packing and open pleural
drainage.
 Pleurocutaneous fistula.
 Stoma may be closed if the
underlying lung re-expands or
may be left permanently open
with daily dressing changes.

51. Open chest drainage (Eloesser flap).a) Photograph shows a
right Eloesser flap 8 months .b) after creation that was
closed with a muscle flap

52. Decortication
 Elective surgical procedure.
 Unsuitable for patients who are ill and toxic.
 Fibrous wall of the empyema cavity,reffered to as
cortex is exposed at thoracotomy is stripped off and
adjacent visceral and parietal pleura may be left
intact.
 Indications
 Closed drainage/thoracoscopic methods have been
unsuccessful.
 Patients who has entered a chronic phase in which
underlying lung does not expand because of failure
of cortex to become reabsorbed.

53.  There is no optimal time for decortication.
 Some surgeons arguing for early intervention and
others opting for a conservative approach.
 Early surgical intervention in pleural empyema.thorac cardiovascular surg
1985.

54. Decortication

56. Thoracoplasty
 Rarely used now a days.
 To obliterate an empyema space
following pneumonectomy.
 Manage a persistent empyema
cavity in patients where
extensive ipsilateral
parenchymal disease would
prevent re expansion after
decortication.

57. Physiotherapy
 Key to a correct evolution
 After CT removal
 Often and for a long time…..
 Decrease surgery
 Decrease long term pain and functional limitations.

58. Indications
Thoracocentesis
Clear liquid Not clear or purulent effusion
pH>7.20 pH<7.20
No intervention
Not loculated Loculated
Drainage
Pleural lavage
Fibrinolytics 24-48h
Drainage
Fibrinolytics
Pleural lavage
VATS
Drainage
Pleural lavage
Failure
VATS
Surgery
Failure
Surgery
Reccurent
thoracocentesis
Hamm et al, ERJ 1997