1. EMPYEMA Thoracic Surgery Kaplan M.C

2. Empyema. Thoracic empyema – an accumulation of pus in the pleural space.

3. Etiology. Pneumonia ( 62% ). Thoracic and other surgery ( 13% ). Trauma ( 9% ). Pulmonary embolism, tumors and lung abscess, fungi, tuberculosis.

4. Pathophysiology.  Direct contamination.  Spread of contiguous infection.  Pleural fluid accumulation : imbalance between transpleural hydrostatic pressures, vessel permeability and lymphatics.

5. Bacteriology.  Pneumococci and staphylococci are predominant.  Echerichia coli, Klebsiella, Pseudomonas, Enterobacreriaceae are common gram negative organisms.  Mycobacteria and fungi are rare.

6. Bacteriology.  Sterile cultures in 18% to 30%.  Single organisms in 29% to 55%.  Multiple organisms in 17% to 49%.

7. High ph ( > 7.3 ), high glucose ( > 60 mg/dL ), low LDH ( < 500 U/L ).

8. Symptoms.  Uncontrolled infection : pain, weight loss, asthenia and fever.  Restriction and V/P mismatch : dyspnea.  Signs of infection : leucocytosis, rise of CRP.

9. Epidemiology.  Elderly and debilitated.  82% of patients had one or more underlying illnesses.  Individuals without access to medical care or from lowest social class.  Mortality ranges from 1% to 19% ( for immunocompromised up to 40% ).  Prognosis worse with hospital-acquired or culture-positive empyemas.

10. Stages.  Initial exudative stage ( 7days ).  Fibrinopurulent stage ( 2 weeks ).  Final organizational stage ( 3 weeks to months ).

11. Initial exudative stage.  Watery and sterile effusion.  Free-flowing on lateral decubitus chest x-ray.  Septations are absent on US or CT.

14. Fibrinopurulent stage.  Fibrin deposition.  Septations on lateral decubitus chest x-ray, US and CT.  Drop of ph ( 1000 U/L ) : a. increased utilization of glucose by both PMN cells and bacteria. b. glucose metabolits ( carbon dioxide and lactic acid ) increase of purulent collections. c. LDH rises in proportion to cell lysis.

15. PA chest x-ray. 

16. Final organizational stage.  Creation of thick, inelastic membranous peel.  Entrapping and immobilizing the lung.  Dense, cohesive collections.  Creation of bronchopleural fistulas or empyema necessitatis.  Sepsis.

19. Diagnosis.  Chest radiography.  Computed tomography.  Ultrasonography.  Thoracentesis : a. cell count, glucose, LDH, ph. b. Gram staining and aerobic and anaerobic cultures. c. mycobacteria and fungi if indicated clinically.

20. Goals of treatment.  Evacuation of pus.  Expansion of lung.  Prevention of ongoing infection.

21. Management.  Antimicrobial agents.  Tube thoracostomy.  CT-guided chest tube insertion and intrapleural fibrinolytic debridment.  VATS thoracoscopy.  Surgery ( rib resection, decortication, thoracoplasty, open window ).

22. Antibiotics.  Early empiric treatment.  Antibiotics altered according to the patient clinical course or results of pleural fluid cultures.  Repeat cultures with any deviation of patients clinical status.

23. Tube thoracostomy.  Large thoracostomy tube.  Smaller CT-guided chest tubes for multi-loculated empyemas.  Success rates of 50% without further treatment.  Chest tubes kept under suction (?).

24. Intrapleural fibrinolitic therapy.  Streprokinase / Urokinase.  Safe and effective in adults and children.  Intrapleural hemorrhage and bronchopleural fistula are contraindication.

27. Keep in mind.  Early detection of pleural effusions.  Accurate definition of empyemas stage.  Appropriate antimicrobial therapy.  Effective and complete drainage of empyema and achievement of lung reexpansion prevents surgery.  Treatment of underlying conditions.  Adequate nutrition.

28. Our experience.  133 patients with empyema treated in our department (7 years).  88 patients treated by chest tubes with Urokinase installations.  23 patients operated due to failure of fibrinolitic therapy.  22 patients operated without initial fibrinolitic treatment.

29. Our experience.  63 patients with complicated parapneumonic effusion ( 47.3%).  26 patients after Thoracic Surgery ( 19.6% ).  17 patients with traumatic empyema ( 12.8% ).  27 other causes ( 20.3% ).

30. Our experience.  111 pts ( 70R, 41L ).  85 ( 64.8 ) men and 26 ( 54.8 ) women.  614 Urokinase installations ( 5.5 ).  68 pts treated with 1 chest tube ; 40 with 2 chest tubes ; 5 with 3.  17 36F chest tubes ; 37 32F chest tubes ; 10 28F chest tubes ; 28 16F chest tubes ; 58 percutaneous chest tubes.  1688 hospital days ( 15.3 ).

31. Microbiology.  Enterococcus 14.  Staphylococcus 16 ( MERCA 5 ).  Pseudomonas 15.  Echericia coli 3.  Prevotella 6.  Acinetobacter 4.  Streptococcus 7.  Sterile cultures 39.

32. Underlying diseases.  46 pts with Cancer.  20 pts with NIDDM.  19 pts with COPD.  21 pts with IHD.  12 pts with Obesity.  2 pts after CVA.  1 pt with Multiple Sclerosis.  15 pts after chemotherapy.

33. Social status.  17 pts with lower social status.  9 drug abuse.  3 alcoholics.  1 with epilepsy.  2 with schizophrenia.  1 with hydrocephalus.  1 with TB.  61 smokers.

34. Complications after surgery.  5 Clagett procedures.  3 AF.  1 DVT.  1 intrahospital mortality ; 2 late mortality.  1 BPF.  2 ARF.  2 air leak.  2 tracheostomy.  8 sepsis.

35. Complications after fibrinolitic therapy.  2 AF.  1 RF.  2 respiratory failure.  7 sepsis.  3 open drainage.  7 home tubes.  3 air leak.

36. Etiology. Pneumonia ( 62% ). Thoracic and other surgery ( 13% ). Trauma ( 9% ). Pulmonary embolism, tumors and lung abscess, fungi, tuberculosis.

37. Stages.  Initial exudative stage ( 7days ).  Fibrinopurulent stage ( 2 weeks ).  Final organizational stage ( 3 weeks to months ).

38. Goals of treatment.  Evacuation of pus.  Expansion of lung.  Prevention of ongoing infection.

39.  Thanks