The management of empyema the practical vs. ideal approach R. Masekela University of Pretoria

Case presentation

Patient A.K 11 month old baby boy Main Complaint : Coughing - two weeks non productive Fever - two weeks Vomiting - after coughing Diarrhoea - one week, brown and loose no blood noted in stool 3 weeks before admission to primary care hospital was seen with a cough and fever and treated with Amoxycillin and Paracetamol. Did not improve after a week and was taken back.

Diagnosis with bronchopneumonia and a pleural effusion Ampicillin and Amikacin for 6 days Vancomycin for 2 days PMH : No previous admissions, healthy Family history : no atopy, no asthma No TB contacts

On Examination Mass 10kg, 100% expected Length 78cm, 100% expected Vitals : RR 60, Pulse 110, Temp 37.5, BP 90/40 Sats 90% 5% dehydrated Chest: Grunting, Nasal flaring, subcostal recessions, bilateral scattered crepitations, decreased air entry right lower lobe and stony dullness right base

30/5/07

ICD inserted

19/522/530/5 Hb MCV Platelets WCC Neutrophils10.23 Lymphocytes4.53 Monocytes2.01 Na K CL CO Urea9.11.5<1.0 Creatinine Anion Gap CRP ESR69 NGA - AFB-ve Pleural pus specimen - 31/05/07 Cultured Staph. Aureus R - Penicillin/ampicillin R - Erythromycin R - Clindamycin S - Cloxacillin

1/06/07

HISTORY  460 BC  Em=within  Pyema=accumulation of pus  Hippocratic physicians recommended treating empyema with open drainage  “those diseases that medicines do not cure are cured by the knife”

HISTORY cont’d  Hewitt described a method of closed drainage of the chest in which a rubber tube was placed into the empyema cavity and drained via the water seal drainage  Early 20th century introduction of surgical therapies for empyema thoracoplasty, decortication.

Empyema  Empyema: presence of pus in the pleural space  Boys affected more than girls  First world 0.6-3% bacterial pneumonias Megan et al Curr Opinion Pediatr 2007  HIV positive 8% of South African children Zar et al. Acta Paediatrica 2001

Normal pleural fluid  Pleural space potential space 10-24µm  ml/kg pleural fluid  Starlings forces: filtration and reabsorption  pH 7.6

Light’s criteria  Pleural fluid protein: serum protein > O.5  Pleural fluid : serum LDH >0.6  Pleural fluid LDH > 2/3 upper limit of serum LDH Light R. Chest 1995;108:

Other minor criteria  Cholesterol > 45mg/dl  Protein content > 3.0 g/dl  pH <7.2  Glucose < 50% serum

Parapneumonic pleural effusions  3 groups or stages based on pathogenesis:  Uncomplicated parapneumonic effusion  Complicated parapneumonic effusion  Thoracic empyema.

Exudative stage  Sterile pleural fluid accumulates in pleural space.  Pleural fluid originates in lung interstitial spaces and in capillaries of visceral pleura due to increased permeability.  Pleural fluid ↓ WBC ↓ LDH level, glucose and pH levels are normal  Effusions resolve with antibiotic therapy.

Fibropurulent stage  Bacterial invasion of the pleural space occurs → accumulation of neutrophils, bacteria and cellular debris  Deposition of fibrin  loculations  Pleural fluid pH 1000IU/l

Organizational stage  Fibroblasts grow into the exudates from both the visceral and parietal pleural surfaces  They produce an inelastic membrane called pleural peel.  Thick pleural fluid

Complications  Dissect into lung parenchyma → bronchopleural fistulas and pyopneumothorax  Dissection through chest wall (empyema necessitatis) RARE  Dissection into abdominal cavity

Organisms  Strep. pneumonia HIV infection 41X risk of invasive disease and more resistance Mahdi et al PIDJ 2000 Incidence increasing in developing world  S. aureus Increasing incidence CA-MRSA in HIV-infected children 50% in Natal blood culture positive. McNally et al. Lancet of 100 empyema. Goel et al. J Tropical Peadiatr 1999  H. influenza type b  Gram negatives Pseudomonas Klebsiella E.coli

Organisms  Tuberculosis Rare cause but common PPE  Fungi  Viral  Atypical organism Mycoplasma

Clinical manifestations  Aerobic bacterial pneumonia An acute febrile illness with chest pain, sputum production, and leukocytosis. A complicated parapneumonic effusion with presence of a fever lasting more than 48 hours after initiation of antibiotic therapy.

Clinical manifestation  Anaerobic bacterial infection Usually presents with subacute illness. symptoms persisting for more than 7 days.  60% of patients have weight loss. Poor oral hygiene Factors predisposing to recurrent aspiration.

Chest x-rays  PA and lateral decubitus  Adult studies sensitivity 67% and specificity 70% Heffner JE. Clinics Chest Med 1999;20:  PA at least 400ml fluid vs. 50ml lateral decubitus  Assess for loculations

Ultrasound  Classification Stage 1: anechoic fluid Stage 2: loculations Stage 3: solid peel  Guide placement of intercostal drain Hogan MJ, Cooley BD. Paediatric Resp Reviews 2008;9:77-84

Ultrasound  Size of effusion  Differentiate consolidation from empyema  Unreliable predictor of disease severity

CT scan  Anatomical Parenchymal lesions Endobronchial lesions Mediastinal lesions Lung abscess

Management  IV antibiotics and intercostal drainage  Fibrinolytics  Video -Assisted Thoracoscopic Surgery (VATS)  Open thoracotomy and decortication

Management  Supportive  Bed rest  Analgesia  Oxygen  Fluids  Identify the cause  Malnutrition  TB  HIV

Antibiotic therapy Zampoli M, Zar H. SAJCH 2007;1(3):121-8

Fibrinolytics  Degrade fibrin, blood clots and pleural loculi in pleural space  Streptokinase: U/kg in 20-50ml saline once daily for 3 days (vial U R1400, 1 million units R2700)  Urokinase: u in 40ml saline (> 1 year) or in 10 ml BD for 3 days(< 1 year)  tPA 0.1mg/kg in 10-30ml saline dwell time 1 hour (50mg vial R3100)

Fibrinolytic therapy versus conservative managements: Cochrane review  Seven studies 761 participants  No significant difference in risk of death (RR 1.08;95% CI )  Reduction in risk of treatment failure (RR 0.63;95% CI )  Fibrinolytics confer significant benefit and reduce requirement for surgical intervention (in early studies published) Cameron R, Davies HR. Cochrane review April Issue 2

VATS  Can be done as primary procedure  Experienced surgeon necessary  Benefits lower mortality Re-intervention Reduced length of hospital stay Reduced hospital costs

Aziz et al Surgical infections 2008;9(3):317-23

Thoracotomy  Treatment of choice if no experience or success with VATS  Early and accurate diagnosis and therapy  Attempt “mini” vs. full procedure  Mortality reduced

Ideal approach Fuller MK, Helmrath MA. Curr Opinion Pediatrics 2007;19:

Practical  Early diagnosis CXR include lateral decubitus Early antibiotics Early chest drainage  Loculations Early referral Thoracotomy if no improvement with ICD placement and correct antibiotics

Prognosis  Favourable in patients started on appropriate antibiotic  Early chest tube drainage is beneficial.  Decortication or open drainage has decreased mortality and morbidity.

Prognosis  Mortality 6-12%  Complications Bronchopleural fistula Tension pneumatocoele Fibrothorax

4/06/07

Acknowledgements  Prof R Green  Dr O Kitchin  Dr S Risenga  Dr Moodley  ICU staff