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
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 1876- 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 0.1-0.2 ml/kg pleural fluid Starlings forces: filtration and reabsorption pH 7.6
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 2007 67 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;20:607-622 PA at least 400ml fluid vs. 50ml lateral decubitus Assess for loculations
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: 15 000U/kg in 20-50ml saline once daily for 3 days (vial 750 000U R1400, 1 million units R2700) Urokinase: 40 000u in 40ml saline (> 1 year) or 10 000 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 0.69-1.68) Reduction in risk of treatment failure (RR 0.63;95% CI 0.46-0.85) Fibrinolytics confer significant benefit and reduce requirement for surgical intervention (in early studies published) Cameron R, Davies HR. Cochrane review April 23 2008 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
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.