1. Pleural Empyema Management
Benoit Guery
Maladies Infectieuses
Philippe Ramon
Service d’endoscopie Respiratoire
CHRU Lille

2. Empyema formation Exudative stage Fibrinopurulent 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 septae which cause the fluid to become loculated
Organisational stage
Proliferation of fibroblasts on the pleural surfaces, which form an inelastic covering preventing adequate lung expansion (fibrothorax).

3. 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

4. The infection

5. Bacteriological data Pleural Ponction : Results Exsudate
Direct analysis, Gram stain
Aerobic and anaerobic cultures (Bactec)
If possible before antibiotic treatment
Results
Mono or polymicrobial ( 4-30%)
Variations between series
Variations between underlying conditions

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

7. Maskell et al, NEJM 2005

8. Bacteriological data. Streptococcus pneumoniae: 15-20%
Increased resistance
Staphylococcus:15-30%
Streptococcus spp
Gram Negative: 20-50%
Klebsiella, Enterobacter, Pseudomonas, Hemophilus, E.Coli
Anaerobes:
Fusobacterium, Bacteroides fragilis

9. Microbiological diagnosis techniques
3 methods
- Standard culture
- PCA: Pneumococcal
capsular antigen
- 16S rDNA PCR confirmed
by pneumolysin PCR
Le Monnier et al, Clin Inf Dis 2006

10. Microbiological diagnosis techniques
Latex antigen detection
Se: 90%
Sp: 95%
Le Monnier et al, Clin Inf Dis 2006

11. Antibiotic treatment As soon as the bacteriologic sample are recovered
Pneumonia
Amoxicillin, 3GC or 3GC +/- Metronidazole
Amox-clavulanic acid
Dosage of the molecule
Nosocomial
Tazobactam or Imipenem
+/- Aminoglycoside or Quinolone
Not Pneumococcus directed molecules
Adapted to the laboratory results

12. Adequate drainage
Available techniques

13. Primary treatment options
Antibiotics alone;
Recurrent thoracocentesis
Insertion of chest drain alone or in combination with fibrinolytics
VATS.
Open decortication

14. Thoracocenthesis Big caliber needle Mostly diagnosis technique
Therapeutically used if the liquid remains fluid
Theoretically allows pleural lavage

15. Chest Tube As soon as the liquid is thick Localization Size: 20 à 24
free: axillary
loculated: Chest imaging using ultrasonography and/or computed tomography
Size: 20 à 24
Bedside

16. Pleural Lavage Isotonic saline +/- Noxyflex (noxytioline) Modalités
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

17. NOXYFLEX (noxytioline)
Local disinfectant (formaldéhyde)
2,5 g diluted in a least 100ml isotonic saline
Maximum: 5g/day
Incompatible with iodine polyvidone,chlorhexidin, chlorine solution, lactic acid

18. Fibrinolytics Urokinase: 100 000 or 300 000 IU conditioning
Streptokinase: IU conditioning
IU in ml isotonic saline
Don’t evacuate before 24 to 48 heures
Constantly associated with fever (38-39°C)
Then evacuate
Pleural lavage
clamp 4h ( Chest 1996)

19. Video-assisted thoracic surgery
Collection<10 cm: unusual
Visual control of the CT position
5 mm introducer, 4 mm optical
Collection>10 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 grasping forceps or by extensive irrigation and suction.
Following the procedure, one or two chest drains are then placed in the portholes.

20. Local antibiotics Usually Rifampin or Colimycin Still debated
Do not replace systemic treatment

21. Physiotherapy Key to a correct evolution After CT removal
Often and for a long time…..
Decrease surgery
Decrease long term pain and functionnal limitations

22. Therapeutic choices

23. Guidelines to predict which patients with non-purulent parapneumonic effusions warrant chest tube drainage
240 patients with PPE
85 uncomplicated PPE
67 complicated PPE
88 empyema
Porcel et al, Respir Med 2006

24. BTS and ACCP criteria
BTS: non purulent PPE is complicated if any of the following
pH<7.2
LDH> 1000 IU/L
Glucose <40mg/dL
Positive culture
ACCP:
Positive culture
pH<7.2
Glucose <60mg/dL
Effusion>half of the hemithorax
Porcel et al, Respir Med 2006

25. Porcel et al, Respir Med 2006

26. Compare Chest Tube + Streptokinase (n=9) vs VATS (n=11)
B score on the Cochrane analysis with methodological concerns:
Small number
Patient selection
Unclear allocation and outcome assessor blinding
But: VATS is superior to CT for large loculated pleural empyemas
Duration CT
LOS
Wait et al, Chest 1997
Cochrane 2005

27. Prospective study between 1997 and 2004
2 groups
I: video-assisted thoracoscopy (chest tube, fibrin debrided)
II: chest tube without VAT
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

28. Randomized double blind study
Hypothesis: Urokinase is effective through the lysis and not the volume effect
Randomized double blind study
UK (15 patients) for 3 days, IU in 100 ml NS
Control (16 patients), 100 ml NS for 3 days
Complete drainage
UK: 13/15 (86%)
NS: 4/16 (25%)
All patients had inadequate drainage
Bouros et al, AJRCCM 1999

29. Cochrane analysis 2007

30. Cochrane analysis 2007

31. Cochrane analysis 2007

32. Cochrane analysis 2007

33. Cochrane analysis 2007

34. Cochrane analysis 2007

35. Prospective study from 2001 to 2004 Cause: bacterial pneumonia
2 groups:
A: CT (70)
B: CT + SK (57)
Multivariate analysis: the use of fibrinolysis
is the only independent factor associated
with a favorable outcome
Misthos et al, Eur J Car Thor Surg 2005

36. 452 patients with pleural infection
Sk IU twice daily for 3 days
Placebo
No difference in mortality, rate of surgery, radiographic outcomes, LOS
Serious adverse events more common with Sk (chest pain, allergy, fever)
Maskell et al, NEJM 2005

37. Meta-analysis with 5 properly randomized trials comparing fibrinolytic agents to placebo
575 patients
Tokuda et al, Chest 2006

38. Only one study analyzed… no differences observed on the parameters
Cochrane analysis 2007

39. Fibrinolytics vs VATS 60 children matched No difference
LOS after intervention
Failure rate
Radiologic outcome at 6 month
Treatment cost with UK ($6 914)< VATS ($10 146)
Sonnappa et al, AJRCCM 2006

40. 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

45. 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 direct examination

47. Pleural lavage (Noxyflex) CT removal on 2/5/96
VATS (25/4/96):
loculated
Removed debris and liquid (600ml)
Posterior CT n°24
Pleural lavage (Noxyflex)
CT removal on 2/5/96

50. Indications Thoracocentesis Clear liquid
Not clear or purulent effusion
pH>7.20
pH<7.20
Not loculated
Loculated
No intervention
Reccurent thoracocentesis
Drainage
Pleural lavage
Drainage
Pleural lavage
Fibrinolytics
Failure
VATS
Surgery
Hamm et al, ERJ 1997

51. Indications Thoracocentesis Clear liquid
Not clear or purulent effusion
pH>7.20
pH<7.20
Not loculated
Loculated
No intervention
Reccurent thoracocentesis
Drainage
Pleural lavage
Fibrinolytics 24-48h
Drainage
Fibrinolytics
Pleural lavage
VATS
Drainage
Pleural lavage
Failure
VATS
Surgery
Failure
Surgery