Pleural Empyema Management - Infectio
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Transcript Pleural Empyema Management - Infectio
Pleural Empyema
Management
Benoit Guery
Maladies Infectieuses
Philippe Ramon
Service d’endoscopie Respiratoire
CHRU Lille
Empyema formation
Exudative 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).
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
The infection
Bacteriological data
Pleural Ponction :
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
Wait et al, Chest 1997
Cheng et al, Chest 2005
Maskell et al, NEJM 2005
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
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
Microbiological diagnosis techniques
Latex antigen detection
Se: 90%
Sp: 95%
Le Monnier et al, Clin Inf Dis 2006
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
Adequate drainage
Available techniques
Primary treatment options
Antibiotics alone;
Recurrent thoracocentesis
Insertion of chest drain alone or in
combination with fibrinolytics
VATS.
Open decortication
Thoracocenthesis
Big caliber needle
Mostly diagnosis technique
Therapeutically used if the liquid remains
fluid
Theoretically allows pleural lavage
Chest Tube
As soon as the liquid is thick
Localization
free: axillary
loculated: Chest imaging using
ultrasonography and/or computed tomography
Size: 20 à 24
Bedside
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
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
Fibrinolytics
Urokinase: 100 000 or 300 000 IU
conditioning
Streptokinase: 250000 IU conditioning
250.000 IU in 10-20 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)
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.
Local antibiotics
Usually Rifampin or Colimycin
Still debated
Do not replace systemic treatment
Physiotherapy
Key to a correct evolution
After CT removal
Often and for a long time…..
Decrease surgery
Decrease long term pain and functionnal
limitations
Therapeutic choices
Guidelines to predict which patients with nonpurulent parapneumonic effusions warrant
chest tube drainage
240 patients with PPE
85 uncomplicated PPE
67 complicated PPE
88 empyema
Porcel et al, Respir Med 2006
BTS and ACCP criteria
BTS: non purulent
PPE is complicated if
any of the following
ACCP:
Positive culture
pH<7.2
pH<7.2
Glucose <60mg/dL
LDH> 1000 IU/L
Effusion>half of the
Glucose <40mg/dL
hemithorax
Positive culture
Porcel et al, Respir Med 2006
Porcel et al, Respir Med 2006
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
Prospective study
between 1997 and
2004
2 groups
Surgical decortication
Group I: 17.1%
Group II: 37.1%
I: video-assisted
thoracoscopy (chest
tube, fibrin debrided)
II: chest tube without
VAT
LOS
Group I: 8.3 days
Group II: 12.8 days
Bilgin et al, ANZ J Surg 2006
Hypothesis:
Urokinase is effective
through the lysis and
not the volume effect
Randomized double
blind study
UK (15 patients) for 3
days, 100 000 IU in
100 ml NS
Control (16 patients),
100 ml NS for 3 days
Complete drainage
UK: 13/15 (86%)
NS: 4/16 (25%)
Bouros et al, AJRCCM 1999
Cochrane analysis 2007
Cochrane analysis 2007
Cochrane analysis 2007
Cochrane analysis 2007
Cochrane analysis 2007
Cochrane analysis 2007
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
452 patients with pleural
infection
Sk 250 000 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
Meta-analysis with 5 properly randomized trials
comparing fibrinolytic agents to placebo
575 patients
Tokuda et al, Chest 2006
Only one study analyzed… no differences
observed on the parameters
Cochrane analysis 2007
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
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
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
VATS (25/4/96):
loculated
Removed debris and liquid (600ml)
Posterior CT n°24
Pleural lavage (Noxyflex)
CT removal on 2/5/96
Indications
Thoracocentesis
Clear liquid
pH>7.20
pH<7.20
No intervention Reccurent thoracocentesis
Not clear or purulent effusion
Not loculated
Loculated
Drainage
Pleural lavage
Drainage
Pleural lavage
Fibrinolytics
Failure
VATS
Surgery
Hamm et al, ERJ 1997
Indications
Thoracocentesis
Clear liquid
pH>7.20
pH<7.20
No intervention Reccurent thoracocentesis
Not clear or purulent effusion
Not loculated
Drainage
Pleural lavage
Loculated
Fibrinolytics 24-48h
Drainage
VATS
Fibrinolytics Drainage
Pleural lavage Pleural lavage
Failure
VATS
Surgery
Failure
Surgery