Pleural Empyema

Management
Benoit Guery
Maladies Infectieuses
Philippe Ramon
Service 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
3 methods
- Standard culture
- PCA: Pneumococcal
capsular antigen
- 16S rDNA PCR confirmed
by pneumolysin PCR

Le Monnier et al, Clin Inf Dis 2006

Microbiological diagnosis techniques

Latex antigen detection

Se: 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 +/- Metronidazole
Amox-clavulanic acid
 Dosage of the molecule

 Nosocomial
Tazobactam 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
 Localization
free: axillary
loculated: Chest imaging using
ultrasonography and/or computed tomography

 Size: 20 à 24
 Bedside
 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
 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 conditioning
250.000 IU in 10-20 ml isotonic saline
Don’t evacuate before 24 to 48 heures
Constantly associated with fever (38-39°C)
Then evacuate

 Pleural lavage
clamp 4h ( Chest 1996)
Video-assisted thoracic surgery
 Collection<10 cm: unusual
 Visual control of the CT position
 5 mm introducer, 4 mm optical
 Collection>10 cm
 10 mm introducer
 Two or three ports are made in the chest
 One port is utilised for the camera and the others for
grasping instruments
 Free 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  ACCP:
PPE is complicated if  Positive culture
any of the following  pH<7.2
 pH<7.2  Glucose <60mg/dL
 LDH> 1000 IU/L  Effusion>half of the
 Glucose <40mg/dL hemithorax
 Positive culture

Porcel et al, Respir Med 2006

Porcel et al, Respir Med 2006
 Compare Chest Tube +  B score on the Cochrane
Streptokinase (n=9) vs analysis with
VATS (n=11) 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  Surgical decortication
between 1997 and  Group I: 17.1%
2004  Group II: 37.1%
 2 groups
 I: video-assisted
thoracoscopy (chest
tube, fibrin debrided)
 II: chest tube without
 LOS
VAT
 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)

Multivariate analysis: the use of fibrinolysis

is the only independent factor associated
with a favorable outcome

Misthos et al, Eur J Car Thor Surg 2005

 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 intervention
 Failure rate
 Radiologic 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):
 loculated
 Removed debris and liquid (600ml)
 Posterior CT n°24
 Pleural lavage (Noxyflex)
 CT removal on 2/5/96
 Indications
Thoracocentesis

Clear liquid Not clear or purulent effusion

pH>7.20 pH<7.20 Not loculated Loculated

No intervention Reccurent thoracocentesis Drainage Drainage

Pleural lavage Pleural lavage
Fibrinolytics

Failure
VATS
Surgery

Hamm et al, ERJ 1997

 Indications
Thoracocentesis

Clear liquid Not clear or purulent effusion

pH>7.20 pH<7.20 Not loculated Loculated

No intervention Reccurent thoracocentesis Drainage Fibrinolytics 24-48h

Pleural lavage
Drainage VATS
Fibrinolytics Drainage
Pleural lavage Pleural lavage

Failure Failure
VATS Surgery
Surgery