empyeme-2007-guery

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Pleural Empyema

ManagementBenoit Guery

Maladies InfectieusesPhilippe Ramon

Service dendoscopie Respiratoire

CHRU Lille


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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 septaewhich cause the fluid to become loculated

Organisational stage Proliferation of fibroblasts on the pleural surfaces,

which form an inelastic covering preventing adequatelung expansion (fibrothorax).


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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


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The infection


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Bacteriological data

Pleural Ponction :Exsudate

Direct analysis, Gram stain

Aerobic and anaerobic cultures (Bactec) If possible before antibiotic treatment

ResultsMono or polymicrobial ( 4-30%)

Variations between seriesVariations between underlying conditions


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


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Maskell et al, NEJM 2005


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Bacteriological data.

Streptococcus pneumoniae: 15-20% Increased resistance

Staphylococcus:15-30%

Streptococcus spp Gram Negative: 20-50%

Klebsiella, Enterobacter, Pseudomonas,

Hemophilus, E.Coli

Anaerobes: usobacterium, Bacteroides fragilis


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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


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Microbiological diagnosis techniques

Latex antigen detectionSe: 90%Sp: 95%

Le Monnier et al, Clin Inf Dis 2006


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Antibiotic treatment

As soon as the bacteriologic sampleare recovered

PneumoniaAmoxicillin, 3GC or 3GC +/- Metronidazole

Amox-clavulanic acidDosage of the molecule

Nosocomial Tazobactam or Imipenem +/- Aminoglycoside or Quinolone

Not Pneumococcus directed molecules

Adapted to the laboratory results


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Adequate drainage

Available techniques


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Primary treatment options

Antibiotics alone;

Recurrent thoracocentesis

Insertion of chest drain alone or incombination with fibrinolytics

VATS.

Open decortication


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Thoracocenthesis

Big caliber needle

Mostly diagnosis technique

Therapeutically used if the liquid remainsfluid

Theoretically allows pleural lavage


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Chest Tube

As soon as the liquid is thick

Localization

free: axillary

loculated: Chest imaging usingultrasonography and/or computed tomography

Size: 20 24

Bedside


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Pleural Lavage

Isotonic saline

+/- Noxyflex (noxytioline)

Modalits 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


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NOXYFLEX (noxytioline)

Local disinfectant (formaldhyde)

2,5 g diluted in a least 100ml isotonic

saline Maximum: 5g/day

Incompatible with iodine

polyvidone,chlorhexidin, chlorine solution,lactic acid


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Fibrinolytics

Urokinase: 100 000 or 300 000 IUconditioning

Streptokinase: 250000 IU conditioning

250.000 IU in 10-20 ml isotonic saline

Dont evacuate before 24 to 48 heures

Constantly associated with fever (38-39C)

Then evacuate

Pleural lavage clamp 4h ( Chest 1996)


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Video-assisted thoracic surgery

Collection10 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 graspingforceps or by extensive irrigation and suction.

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


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Local antibiotics

Usually Rifampin or Colimycin

Still debated

Do not replace systemic treatment


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Physiotherapy

Key to a correct evolution

After CT removal

Often and for a long time.. Decrease surgery

Decrease long term pain and functionnal

limitations


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Therapeutic choices


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BTS and ACCP criteria

BTS: non purulentPPE is complicated ifany of the following

pH 1000 IU/L

Glucose


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Porcel et al, Respir Med 2006


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Prospective studybetween 1997 and2004

2 groups I: video-assisted

thoracoscopy (chesttube, fibrin debrided)

II: chest tube withoutVAT

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


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Hypothesis:

Urokinase is effectivethrough the lysis andnot the volume effect

Randomized doubleblind study UK (15 patients) for 3

days, 100 000 IU in100 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


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Cochrane analysis 2007


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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


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452 patients with pleuralinfection Sk 250 000 IU twice daily

for 3 days

Placebo

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

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

Maskell et al, NEJM 2005


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Meta-analysis with 5 properly randomized trialscomparing fibrinolytic agents to placebo

575 patients

Tokuda et al, Chest 2006


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Only one study analyzed no differences

observed on the parameters



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Fibrinolytics vs VATS

60 children matched

No difference

LOS after interventionFailure rate

Radiologic outcome at 6 month

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

Sonnappa et al, AJRCCM 2006


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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


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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 directexamination


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VATS (25/4/96):

loculated

Removed debris and liquid (600ml)

Posterior CT n24

Pleural lavage (Noxyflex)

CT removal on 2/5/96


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Indications

Hamm et al, ERJ 1997

Thoracocentesis

Clear liquid Not clear or purulent effusion

pH>7.20 pH


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Indications

Thoracocentesis

Clear liquid Not clear or purulent effusion

pH>7.20 pH

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