EMPYEMA FELICITY MEIKLE FRACS WAIKATO CARDIOTHORACIC UNIT PLEURA

EMPYEMA FELICITY MEIKLE, FRACS WAIKATO CARDIOTHORACIC UNIT

PLEURA • SEROUS MEMBRANE • PLEURAL CAVITY IS POTENTIAL SPACE BETWEEN VISCERAL AND PARIETAL PLEURA • NORMALLY CONTAINS A SMALL AMOUNT OF FLUID • PARIETAL PLEURA VERY SENSITIVE TO PAIN • IMPROVES RESPIRATION AND TRANSMISSION OF FORCES TO LUNGS • HUMANS HAVE SEPARATE PLEURAL CAVITIES

PLEURAL FLUID • SEROUS FLUID • PRODUCED BY PARIETAL PLEURA • REABSORBED BY LYMPHATIC SYSTEM • CONTINUOUSLY PRODUCED AND REABSORBED • REABSORPTION RATE WILL INCREASE UP TO 40 TIMES THE NORMAL RATE BEFORE SIGNIFICANT FLUID IS SEEN

PARAPNEUMONIC EFFUSION • BACTERIAL PNEUMONIA ASSOCIATED WITH PLEURAL EFFUSION (35 -40% OF HOSPITALIZED PNEUMONIA) • PNEUMOCOCCAL – 60% EFFUSION RATE • UNCOMPLICATED – NEGATIVE GRAM STAIN, NO LOCULATIONS, RESOLVE SPONTANEOUSLY • COMPLICATED (20%) – EMPYEMA OR LOCULATED EFFUSIONS, REQUIRE DRAINAGE • LOW PH <7. 2, HIGH LDH >1000 SUGGESTS COMPLICATED EFFUSION

EMPYEMA THORACIS • PURULENT PLEURAL EFFUSION • OLDEST SURGICAL DISEASES • • HIPPOCRATES 400 BC PREDOMINANTLY PARAPNEUMONIC • PULMONARY ABSCESS, SUPPURATIVE PNEUMONIA UNDERLYING CONDITIONS • AGE • ALCOHOLISM, IVDU • CHRONIC PULMONARY DISEASE, - TB, BRONCHIECTASIS • DM, RA • IMMUNOSUPPRESSION - STEROIDS, MALIGNANCY • DEBILITATION, MALNUTRITION • POOR ORAL HYGIENE • GORD/ASPIRATION

OTHER CAUSES - TRAUMA PENETRATING INJURY • 1. 6% INCIDENCE • ORGANIC FOREIGN BODIES BEING CARRIED INTO PLEURAL SPACE HAEMOTHORAX • HAEMOPNEUMOTHORAX MORE LIKELY TO BECOME INFECTED • SECONDARY INFECTION FROM CHEST TUBE – HIGHLIGHTS IMPORTANCE OF STRICT ASEPSIS

OTHER CAUSES - SURGERY • 2 -4% RISK AFTER PULMONARY RESECTION IMPROVED WITH: • SURGICAL TECHNIQUE • PATIENT SELECTION

OTHER CAUSES • RUPTURE OF OESOPHAGUS • INFECTION FROM POSTERIOR REGION OF THE NECK • CHEST WALL INFECTIONS • THORACIC SPINE • SUBPHRENIC INFECTIONS – TEND TO BE REACTIVE • HAEMATOGENOUS SPREAD IN IMMUNOCOMPROMISED PATIENT

BACTERIOLOGY • PRE ANTIBIOTICS ERA – PNEUMOCOCCI 64%, S. PNEUMONIAE (EHLER 1941) • GREATER LUNG DESTRUCTION MORE ABSCESS FORMATION RECENTLY – • NO INOCULATE FOUND IN 80% • STREPTOCOCCUS SPECIES 30% – S PNEUMONIAE/PYOGENES/MILLERI • STAPH AUREUS ~34% - POST OP/TRAUMA • GRAM -VE – KLEBSIELLA, PSEUDOMONAS, HAEMOPHILUS • ANAEROBES 35% - BACTEROIDES, PEPTOSTREPTOCOCCUS • COMPLEX INOCULATES – ASPIRATION PNEUMONIA

STAGES • 3 STAGES OVER 3 -6 WEEK PERIOD • STAGE 1: EXUDATIVE: 2 -5 DAYS - PLEURAL MEMBRANES SWELL AND DISCHARGE THIN EXUDATE, NEUTROPHILS PRESENT, NO ORGANISMS • INCREASED CAPILLARY PERMEABILITY • STAGE 2: FIBRINOPURULENT: 5 -10 DAYS - HEAVY DEPOSITION OF FIBRIN, PLEURAL FLUID TURBID, LOCULATIONS, NO ORGANISMS • BACTERIAL INFECTION • STAGE 3: ORGANISING: WITHIN 3 -4 WEEKS OVER 2 -3 WEEKS – THICK VISCOUS FLUID, THICK FIBROUS PEEL FORMS, LUNG BECOMES TRAPPED

DIAGNOSIS • SUSPECT EMPYEMA IN PATIENTS WITH ACUTE RESPIRATORY TRACT ILLNESS AND PLEURAL EFFUSION • PERSISTENT FEVER FOLLOWING AB THERAPY SYMPTOMS • DYSPNOEA - 82% • FEVER - 81% • COUGH - 70% • PLEURITIC PAIN 67% • TACHYPNOEA, TACHYCARDIAC • MALAISE, ANOREXIA, WEIGHT-LOSS • SIGNS – REDUCED CHEST WALL MOVEMENT, BREATH SOUNDS AND DULLNESS

BLOODS • LEUKOCYTOSIS • LEFT SHIFT OF NEUTROPHILS • CRP • BLOOD CULTURES • SPUTUM CULTURE

RADIOLOGY • CXR – PLEURAL EFFUSION (PNEUMONIA/LUNG ABSCESS) • LATERAL FILM – POSTEROLATERAL COLLECTION “PREGNANT LADY SIGN” – INVERTED D SHAPE • DECUBITUS VIEWS TO ASSESS FLUIDITY OF COLLECTION • USS – DIFFERENTIATE BETWEEN CONSOLIDATED LUNG AND FLUID AND GUIDE DRAINAGE UNCOMPLICATED – SIMPLE EFFUSION COMPLICATED – STRANDING, LOCULATIONS EMPYEMA – ECHOGENIC, SEPTATIONS

CT SCAN GOLD STANDARD • VISUALISATION OF THICKENED AND SEPARATED PLEURAL SURFACES • COMPRESSION OF LUNG PARENCHYMA • PLEURAL THICKENING

PLEURAL FLUID • CLEAR – UNCOMPLICATED • TURBID – COMPLICATED • PURULENT - ESTABLISHED EMPYEMA INCREASED LEUKOCYTE ACTIVITY AND INCREASED ACID PRODUCTION WITHIN PLEURAL SPACE LEADS TO REDUCED PH AND INCREASED LDH • PH<7. 2, LDH >1000 U/L, GLUCOSE <3. 4 MMOL/L, WCC >50000 CELLS/UL • EFFUSIONS WITH HIGH PH CAN BE MANAGED WITH ANTIBIOTICS AND REPEAT THORACOCENTESIS (SAHN 1989) • IF PH LOW THEN EFFUSION REQUIRES DRAINAGE WITH CHEST TUBE OR SURGERY (VATS)

EMPYEMA COMPLICATIONS • LUNG FIBROSIS • CONTRACTION OF CHEST WALL • EMPYEMA NECESSITANS • BRONCHOPLEURAL FISTULA • SEPSIS • DISTANT ABSCESS FORMATION • OSTEOMYELITIS • MEDIASTINITIS • PYOPERICARDIUM • TRANS-DIAPHRAGMATIC DRAINAGE • DEATH 5 -20% – ELDERLY, COMORBIDITIES

MANAGEMENT ACUTE EMPYEMA (STAGE 1 AND 2) • ANTIBIOTICS AND FLUID DRAINAGE • REPEAT THORACOCENTESIS IF TOXICITY IS WELL CONTROLLED • CONTROVERSIAL – ONLY USEFUL IF IMPLEMENTED EARLY ENOUGH • MAY DEVELOP MULTILOCULATED COLLECTIONS THAT ARE DIFFICULT TO DRAIN • VATS DRAINAGE MAY IMPROVE SURVIVAL AND SHORTEN HOSPITAL STAY (FERGUSON 1990) • UNILOCULATION OF SPACE • WASHOUT OF SPACE • BETTER DRAIN PLACEMENT

ACCP GUIDELINES • UNCOMPLICATED EFFUSION: <10 MM ON CXR • • ANTIBIOTICS UNCOMPLICATED EFFUSION: >10 MM, PH>7. 2, GLUC >3. 4 • ANTIBIOTICS • THORACOCENTESIS OR INTERCOSTAL DRAIN INSERTION IF LARGE SYMPTOMATIC EFFUSION COMPLICATED EFFUSION: LARGE/LOCULATED EFFUSION PH<7. 2, GLUC<3. 4 • ANTIBIOTICS • THORACOCENTESIS/DRAINAGE • INTRAPLEURAL FIBRINOLYSIS • EARLY SURGICAL INTERVENTION EMPYEMA: PUS • ANTIBIOTICS • DRAINAGE/FIBRINOLYSIS • SURGICAL DECORTICATION

ANTIBIOTIC THERAPY • GUIDED BY LOCAL ANTIBIOTIC RESISTANCE PATTERNS AND POLICIES • COMMON CAUSATIVE ORGANISMS • CAP/HAP/VAP • SEVERITY OF ILLNESS • CAP • • PENICILLIN, CO-AMOXICLAV, CLINDAMYCIN • CEPHALOSPORINS • METRONIDAZOLE HAP • • CONSIDER MRSA IDEALLY SHOULD BE CONTINUED FOR 2 -4 WEEKS

METHODS OF DRAINAGE TUBE THORACOSTOMY (28 -36 FR) • BEWARE OF THE RETRACTED DIAPHRAGM • CAN REVERT TO OPEN SYSTEM BY CUTTING TUBE PIGTAIL CATHETER • OFTEN BLOCK • LESS USEFUL WHEN FLUID THICK • 70 -90% SUCCESS RATE WHEN USED EARLY

VATS • SHOWN TO HAVE REASONABLE SUCCESS RATE (18/18) IN EARLY EMPYEMA (WAKABAYASHI 1991) BENEFITS • DIRECT VISION • BREAK DOWN ALL LOCULATIONS AND EVACUATE PUS • REMOVE FIBRINOUS MEMBRANES • IRRIGATE PLEURAL CAVITY • LUNG RE-EXPANSION • DIRECT DRAINS APPROPRIATELY • MORTALITY 0 -3% IN LARGER STUDIES WITH SUCCESS RATE 80 -97% IN STAGES 2 -3 (LUH 2005, WURNIG 2006, SOLAINI 2007)

STREPTOKINASE? • FIBRINOLYTIC • USED SINCE 1949 • INITIAL PROBLEMS WITH BLEEDING AND ALLERGY DAVIES 1997 • RCT STREPTOKINASE VS SALINE FLUSHES FOR 3 DAYS • 24 PATIENTS • INCREASED FLUID DRAINAGE, GREATER RADIOGRAPHIC IMPROVEMENT WAIT 1997 • COMPARED VATS AND FIBRINOLYTIC THERAPY • VATS IMPROVED EFFICACY, SHORTER HOSPITAL STAY AND LOWER COST

MIST (MANAGEMENT OF INTRAPLEURAL SEPSIS TRIAL) 2005, 2011 I 454 PATIENTS STREPTOKINASE 250000 U BD FOR 3 DAYS VS PLACEBO – NO BENEFIT • PRIMARY END POINT: DEATH&SURGERY = 31% SK VS 27% PLACEBO P 0. 43 • INCREASED SERIOUS ADVERSE EVENTS 7% VS 3% P 0. 08 • NO INCREASED RISK OF BLEEDING DURING SURGERY II DOUBLE BLIND/ DOUBLE DUMMY 193 PATIENTS DNASE 5 MG, T-PA 10 MG BD FOR 3 DAYS • PRIMARY END POINT REDUCTION IN EFFUSION SIZE – TPA/DNASE BETTER THAN PLACEBO OR WITH TPA OR DNASE ALONE • REFERRAL FOR SURGERY LOWER IN TPA/DNASE GROUP THAN PLACEBO. 4%VS 16% P 0. 03 • REDUCED HOSPITAL STAY IN TPA/DNASE GROUP THAN PLACEBO 11. 8 VS 17 DAYS P 0. 006 • MORTALITY RATES SIMILAR 4%(PLACEBO)/8%(T-PA&DNASE)/8%(T-PA)/13%(DNASE) P 0. 46 • PLEURAL THICKENING INCREASES RISK OF FAILURE OF FIBRINOLYTIC THERAPY

OTHER CARE • TREATMENT OF UNDERLYING RESPIRATORY DISEASE • NUTRITION • CHEST PHYSIO • PROMOTE LUNG RE-EXPANSION • PREVENT CHEST WALL COLLAPSE

CHRONIC EMPYEMA • DELAY IN DIAGNOSIS • IMPROPER DRAINAGE • INADEQUATE ANTIBIOTIC THERAPY • CONTINUED REINFECTION • FOREIGN BODY • TB • FUNGAL INFECTION

SIMPLE TREATMENT • ELOESSER FLAP • WINDOW THORACOSTOMY AND RIB RESECTION • MINOR PROCEDURE (UNDER GA) • DEBILITATED PATIENTS • SMALL SPACES • BPF WITH FIXED SPACE • LONG RECOVERY PERIOD

SPACE STERILISATION DRAIN SPACE CLAGGETT PROCEDURE • IRRIGATION WITH ANTISEPTICS AND/OR ANTIBIOTIC SOLUTION (MODIFIED) • USEFUL IN POST PNEUMONECTOMY EMPYEMA (IF NO BRONCHOPLEURAL FISTULA) • IRRIGATE WINDOW THORACOSTOMY (CLASSIC)

SPACE FILLING PROCEDURES • IDEALLY FILL SPACE WITH LUNG • DECORTICATION “IS SELDOM REQUIRED BECAUSE MOST PATIENTS WITH PARAPNEUMONIC EFFUSIONS ARE TREATED BEFORE THIS STAGE” • REMOVAL OF CONSTRICTING PEEL OVER LUNG • EMPYEMECTOMY – REMOVAL OF VISCERAL AND PARIETAL PLEURA WITH CONTENTS OF EMPYEMA INTACT – NOT GENERALLY NECESSARY

DECORTICATION • TIMING CONTROVERSIAL • 3 MONTHS – MAXIMAL FUNCTIONAL RESPIRATORY RECOVERY • EARLY – LESS BLOODY, NOT AS ADHERENT TO LUNG • PERFORMED BEFORE FIBROSIS EXTENDS INTO LUNG TISSUE – LESS CHANCE OF LUNG INJURY • MAY NEED TO REMOVE LUNG TISSUE AT SAME TIME

OTHER OPTIONS? PLEURAL PLOMBAGE • 1930 -1950 • AIR • OLIVE OIL • MINERAL OIL • PARAFIN WAX • RUBBER SHEETS/BALLS • LUCITE BALLS (PMMA) • GLASS BALLS USED INITIALLY • COMPLICATIONS – INFECTION, HAEMORRHAGE, FISTULISATION • THEREFORE NOT AN OPTION FOR PLEURAL INFECTION

MUSCLE TRANSPOSITION • OBLITERATING THE SPACE WITH VIABLE TISSUE • REINFORCEMENT OF STUMP (BRONCHOPLEURAL FISTULA) • TYPE OF MUSCLE FLAP TAKEN DEPENDS ON SIZE AND SHAPE AND LOCATION OF CAVITY • LAT DORSI/SERRATUS/PECTORALIS/INTERCOSTAL • OMENTUM • TAKE CARE TO PRESERVE BLOOD SUPPLY, BULK AND INNERVATION

THORACOPLASTY • RIB RESECTION TO COLLAPSE INFECTED SPACE 1 ST DESCRIBED IN 1879 (ESTLANDER) • ALEXANDER REDEFINED THIS TO A POSTERIOR EXTRAMUSCULOPERIOSTEAL APPROACH • USED FOR TB PREDOMINANTLY • FELT TO BE MUTILATING • SOME USEFULNESS IN POST RESECTIONAL EMPYEMA

ALEXANDER THORACOPLASTY

SURGICAL CONSIDERATIONS • INFECTION MUST BE TREATED • DRAIN • TUBE/OPEN WINDOW THORACOSTOMY • EXTENT OF THORACOPLASTY • APICAL – EXTRAPLEURAL LYSIS TO ALLOW APEX TO COLLAPSE • DISARTICULATE POSTERIOR RIB ENDS • RESECTION OF SCAPULA TIP IF ENTRAPMENT OCCURS • USED IN CONJUNCTION WITH MUSCLE FLAP/OMENTAL TRANSFER • THORACOPLEUROPLASTY (ANDREWS THORACOPLASTY) • USEFUL FOR POST PNEUMONECTOMY EMPYEMA

POST PNEUMONECTOMY EMPYEMA • UNCOMMON • LIFE THREATENING • TREATMENT DEPENDS ON TIMING AND EXTENT OF BPF • DEGREE OF PLEURAL CONTAMINATION • GENERAL CONDITION OF THE PATIENT • CONTROL INFECTION • (CLOSE FISTULA) • STERILISE CLOSED PLEURAL SPACE

BRONCHOPLEURAL FISTULA 4. 5 -20% FOLLOWING PNEUMONECTOMY 0. 5% FOLLOWING LOBECTOMY ETIOLOGY • ENDOBRONCHIAL TB, CONTAMINATION OF PLEURAL SPACE DURING PROCEDURE • DEVASCULARISATION OF BRONCHUS • RIGHT SIDED RESECTION • PREVIOUS RADIOTHERAPY • LONG BRONCHIAL STUMP • CONCOMITANT ILLNESS – DM, STEROIDS, CIRRHOSIS • INFECTION • RESIDUAL TUMOUR AT BRONCHUS • POST PNEUMONECTOMY VENTILATION

SYMPTOMS • COUGHING UP SEROSANGUINOUS FLUID OR PUS • FEVER • MALAISE • GENERAL UNWELLNESS (“FLU LIKE ILLNESS”) • CXR – NEW AIR FLUID LEVEL, SUDDEN DISAPPEARANCE OF PLEURAL EFFUSION OR MEDIASTINAL SHIFT

EMERGENCY MANAGEMENT OF POST PNEUMONECTOMY BPF • PREVENT SOILING OF REMAINING LUNG • NURSE WITH RESECTED SIDE DOWN, • SELECTIVELY INTUBATE REMAINING LUNG • BRONCHOSCOPY • CLOSURE OF FISTULA/BUTTRESS STUMP • IF INFECTED DRAIN SPACE • OPEN/CLOSED

CONCLUSION • COMPLICATED PNEUMONIA IS COMMON. • MORTALITY CONTINUES TO IMPROVE AS TECHNIQUES FOR DEALING WITH EMPYEMA AND ANTIBIOTIC THERAPY IMPROVES 50% -> 5 -20% • ONGOING BATTLE WITH PHYSICIANS WHO DON’T WANT TO TRAUMATISE PATIENTS WITH LARGE BORE DRAINS AND SO INAPPROPRIATELY RELY ON PIGTAIL DRAINAGE • APPROPRIATE TIMING OF SURGERY IS KEY TO OPTIMAL OUTCOME AND AVOIDANCE OF COMPLICATIONS OR DISFIGURING SURGERY. (ARGUMENTATIVE!) • MAY BE A PLACE FOR FIBRINOLYSIS IN COMORBID/INOPERABLE PATIENTS • THORACOPLASTY RESERVED FOR END OF THE LINE TREATMENT FOR PATIENTS WHO CAN TOLERATE THIS PROCEDURE • BEWARE THE POST PNEUMONECTOMY EMPYEMA – CAN BE SUBTLE.