EMPYEMA MANAGEMENT 21ST.pptx..............

Empyema management

1. EMPYEMA MANAGEMENT DR ASHWINI JK (JR2) MODERATOR- DR VINAY JADAV

2. Terminologies Parapneumonic effusion- pleural fluid collection in association with underlying pneumonia. Uncomplicated parapneumonic effusion- sterile, free flowing effusion with low white cell count. Complicated parapneumonic effusion (CPE)- sterile invasion of bacteria into pleural space with fibrin deposition and increase in wbc count. Septations and loculations present. Empyema- late stage of CPE with presence of pus in the pleural space.

3. STAGING 1)EXUDATIVE: Inflammatory process leading to accumulation of clear fluid with a low white cell count within the pleural cavity ( simple parapneumonic effusion ). 2)FIBROPURULENT: there is deposition of fibrin in the pleural space leading to formation of septations and loculations. There is an increase in white cells, with the fluid thickening ( complicated parapneumonic effusion ) and eventually becoming overt pus ( empyema ). 3)ORGANISATIONAL: fibroblasts infiltrate the pleural cavity, and the thin intrapleural membranes are reorganised to become thick and non-elastic (the ‘‘ peel ’’). These solid Fibrous pleural peels may prevent lung re-expansion(‘‘ trapped lung ’’), impair lung function, and create a persistent pleural space with ongoing potential for infection. At this stage spontaneous healing may occur or a chronic empyema may develop.

4. PATHOPHYSIOLOGY

5. Following initiation of appropriate therapy, the inflammation recedes PMN predominance of the effusion decreases. An influx of macrophages assists in the clearance of PMN. Migration of pleural mesothelial cells into areas of denuded mesothelium results in the reepithelialization of the pleura and recovery of normal function. The mechanisms that lead to either the development of pleural fibrosis or pleural repair with normal recovery are not well understood. PATHOPHYSIOLOGY CONTD.

6. ETIOLOGY Pneumonia Lung abscesses contiguous infections of the esophagus, mediastinum, or subdiaphragmatic region, may extend to involve the pleura. retropharyngeal, retroperitoneal, or paravertebral processes can also cause increased permeability. Host factors like infection, trauma, or malignancy, may allow accumulation of fluid in the pleural space, which becomes secondarily infected.

7. Bacteriology of pleural space The most common implicated organisms are  S pneumoniae , S aureus , and group A streptococci Serotype 1, 5 and 14 were most frequent in pneumococcal empyema. (all of which are included in Prevnar 13 vaccine) In developing countries S.aureus is the predominant organism esp in hot and humid months when staphylococcal skin infections are more prevalent. Klebsiella spp and Pseudomonas aeruginosa seen associated with PEM. H influenzae is rare after advent of vaccine Anaerobic infections secondary to aspiration fungal or mycobacterial infections in immunosuppressed patients Due to use of oral antibiotics before the recognition of effusion the incidence of these organisms are not known.

8. Microbial pattern at our institution PLEURAL FLUID ISOLATES- 1) S.AUREUS 2) PNEUMOCOCCI EMPYEMA- 1) MRSA 2) PNEUMOCOCCI 3) E.COLI ICD- 1) PSEUDOMONAS 2) ACINETOBACTER

9. Age related Demographics Pre-school children

10. DIAGNOSIS Clinical presentation Classic symptoms of pneumonia (cough, dyspnoea , fever, malaise, loss of appetite) although more unwell Spiking fever and lack of improvement after 48 hours of antibiotic treatment may signal the presence of an effusion. Abdominal pain and vomiting. (when lower lobes are involved) Splinting of the affected side. Symptoms may be blunted, and fever may not be present in patients who are immunocompromised. Antibiotic history is important and underlying rarer conditions (such as tuberculosis, immunodeficiency, inhaled foreign body, and malignancy) must be considered.

11. Source- AATS Expert Consensus Guidelines Recommendations The presence of a pleural effusion should be investigated in all patients presenting with signs and symptoms of pneumonia or unexplained sepsis. Failure of a community- or healthcare-associated pneumonia to respond clinically to appropriate antibiotic therapy

12. Physical examination Unilateral signs of fullness of chest, decreased chest expansion, dullness to percussion, crackles and reduced or absent breath sounds. Child’s state of hydration and scoliosis should also be examined.

13. Source: BRITISH THORACIC GUIDELINES

14. INVESTIGATIONS CONTD. BLOOD TESTS Acute phase reactants such as WBC, total neutrophil count, CRP, ESR, and procalcitonin help distinguish bacterial from viral infections. Blood cultures should be performed in all patients with parapneumonic effusion

15. MICROBIOLOGY Non- pleural fluid When available, sputum should be sent for bacterial culture. Mantoux testing and sputum for acid-fast bacilli should be performed if risk factors for TB are present. Pleural fluid If there is any indication the effusion is not secondary to infection, consider a small volume diagnostic tap for cytological analysis before chest drain insertion, avoiding general anaesthesia /sedation Aspirated pleural fluid should be sent for differential cell count Lymphocyte predominance- TB and malignancy must be excluded. PF for Gram stain and bacterial culture confirms diagnosis of empyema. Anaerobic and aerobic cultures of PF aspirate, not from the drain.

16. Recommendations Purulence of the pleural fluid or a positive Gram’s stain or culture from the pleural fluid establishes the diagnosis of empyema and should prompt tube thoracostomy drainage. A pleural pH <7.2 in a patient with suspected pleural space infection predicts a complicated clinical course, and tube thoracostomy should be performed followed by surgical intervention when appropriate. A pleural fluid LDH >1000 IU/L, glucose, <40 mg/dL, or a loculated pleural effusion suggests that the pleural effusion is unlikely to resolve with antibiotics alone, hence tube thoracostomy is recommended. Source- AATS Expert Consensus Guidelines

17. Biochemistry Biochemical analysis of pleural fluid is unnecessary in the management of uncomplicated parapneumonic effusions/empyema. Protein levels or Light’s criteria differentiate exudates from transudates, while infection is indicated by pleural acidosis associated with raised LDH and low glucose levels. In terms of treatment, the pH may even guide the need for tube drainage, suggested by pH ,7.2

18. Imaging Chest radiograph: Obliteration of the costophrenic angle is the earliest sign and a rim of fluid may be seen ascending the lateral chest wall ( meniscus sign ) If the child is supine, the appearance can be of a homogeneous increase in opacity over the whole lung field without blunting of the CP angle. A lateral chest radiograph rarely adds anything extra, although can sometimes be helpful in differentiating pleural from intrapulmonary shadows scoliosis

19. 2) Ultrasound Used to confirm the presence of a pleural fluid collection. To determine the size of the effusion, loculations. To determine the echogenicity of the fluid (echoic- exudative, anechoic- transudative) To guide thoracocentesis or drain placement. Fibrinous septations are better visualised using ultrasound than CT scans

20. 3) CT Chest CT scans should not be performed routinely. CECT helps in delineating loculated pleural fluid To detect the cause of effusion- airway or parenchymal lung abnormalities, Mediastinal pathology. In complicated cases including initial failure to aspirate pleural fluid and failing medical management and in immunocompromised children where a CT scan could reveal other serious clinical problems. Before surgery (either open thoracotomy or thoracoscopy) to delineate the anatomy further and to check for an intrapulmonary abscess. Source: BRITISH THORACIC GUIDELINES

21. 4) Bronchoscopy There is no indication for flexible bronchoscopy and it is not routinely recommended. The possibility of foreign body aspiration must be considered in younger children and would be an indication for bronchoscopy

22. MANAGEMENT OF EMPYEMA

23. Source: BTS GUIDELINES

24. Source: IAP STG

25. 1. INITIAL SUPPORTIVE TREATMENT Oxygen (SpO2 92%) I/V fluids when indicated Initiate intravenous antibiotics Paracetamol for fever, analgesics for pain due to intercostal drainage (ICD) Exercises that help in lung expansion (incentive spirometry and deep breathing exercises) may improve drainage through ICD. There is no role for chest physiotherapy or inhaled bronchodilators

26. 2. When to refer a child? Referral to a respiratory paediatrician should be involved early in the care of all patients requiring chest tube drainage for a pleural infection.

27. 3. Conservative management (antibiotics +/- simple drainage) Majority of the studies suggest that, overall, 60–80% of cases will respond to conservative medical management but hospital admission may be long. (median- 14days) Therefore in view of prolonged duration of illness and hospital stay early active treatment may be considered. Effusions which are enlarging and/or compromising respiratory function should not be managed by antibiotics alone. 3.1 Is there a role for repeated thoracocentesis? If a child has significant pleural infection, a drain should be inserted at the outset and repeated taps are not recommended. Source: BRITISH THORACIC GUIDELINES

28. 4.Antibiotics Following should be considered 1) Patient’s clinical history, 2) local antimicrobial resistance patterns, 3) Institutional antibiotic stewardship, and 4)pharmacologic characteristics of the antibiotics.

29. A) Following community acquired pneumonia parenteral second- or third-generation cephalosporin ( eg , ceftriaxone) with metronidazole or aminopenicillin with b-lactamase inhibitor ( eg , ampicillin/sulbactam) Clindamycin is a suitable alternative to metronidazole for most UGI and respiratory anaerobic infections. Even when there is a positive, monomicrobial, aerobic culture to direct therapy, it often is reasonable to continue anaerobic coverage because of the frequency with which anaerobes infect empyemas and because of the inconsistent success at culturing these organisms.

30. (B) Hospital acquired pneumonia and following surgery/trauma/aspiration vancomycin and piperacillin/tazobactam will cover the added risk of methicillin-resistant S aureus and Pseudomonas. Aminoglycosides are inactivated in empyema fluid and are not recommended . There is no evidence that direct administration of antibiotics into the pleural space increases microbial clearance C) Mycobacterium tuberculosis Mycobacterial treatment should not be started empirically unless there is very strong circumstantial evidence. A tuberculosis specialist should be involved with the care.

31. 4.2 Continuation of antibiotic treatment Where possible, antibiotic choice should be guided by microbiology results. If the pleural fluid is culture positive, further antibiotic management should take into account antibiotic sensitivities Due to the frequency of culture negative cases, the initial blind antibiotic treatment is continued , if clinical improvement is seen. There are no data from RCT on appropriate length of treatment. According to BTS, many UK centres continue with iv antibiotics until the child is afebrile or at least until the chest drain is removed. Source: BRITISH THORACIC GUIDELINES

32. Transition to oral antibiotics If the patient has responded to therapy, there has been source control, the isolated organism is susceptible to orally bioavailable agents, and the patient is tolerating oral intake, then a transition to oral therapy can be made. Oral antibiotics such as co-amoxiclav are then given at discharge for 1–4 weeks, but longer if there is residual disease. Source: BRITISH THORACIC GUIDELINES

33. 5. Drain insertion Recommendations Image-guided pleural drain placement is useful in the treatment of early-stage, minimally septated empyema. In septated effusions, placement of small bore catheters are recommended in patients that are not surgical candidates. Routine drain flushing is recommended to prevent occlusion Any undrained loculations should be pursued aggressively with additional or larger drains. Tube thoracostomy with or without the subsequent instillation of fibrinolytic agents should be attempted as the initial treatment for pediatric patients with an empyema Source- AATS Expert Consensus Guidelines

34. 5.1. Who should insert the drain? Rigid large bore drains will be inserted by paediatric surgeons or ( paediatric trained) thoracic surgeons, and it would be expected to be inserted in the postoperative period following cardiac or thoracic surgery. Pigtail or small bore soft drains (inserted by the Seldinger technique) will be used by respiratory Paediatricians . Source: BRITISH THORACIC GUIDELINES

35. 5.2. Pre-drainage check list- Routine measurement of the platelet count and clotting studies are not recommended unless there are known risk factors. Where possible, any coagulopathy or platelet defect should be corrected before chest drain insertion Radiological investigations- USG and CT Informed consent

36. 5.3. Anaesthesia General anaesthesia is usually considered safer than iv sedation in children who have respiratory compromise and it is the preferred option for non-cooperative children. If not general anaesthesia , i /v should be given by trained personnel only. Resuscitation and monitoring equipment, with oxygen and suction should be available.

37. 5.4 Drain insertion site Small bore percutaneous drains should be inserted at the optimum site suggested by chest ultrasound. Large bore surgical drains should also be inserted at the optimum site suggested by ultrasound but preferentially placed in the mid axillary line through the ‘‘safe triangle’’

38. 5.5. Drain size Small bore tubes can be used in patients amenable to tube thoracostomy alone. Since there is no evidence that large bore chest drains confer any advantage, small drains (including pigtail catheters) should be used whenever possible to minimise patient discomfort. Majority of paediatricians now use smaller catheters(8–12 Fr) and these are as effective as larger bore tubes. The children are more comfortable and tolerate the procedure better with faster recovery. USG guided insertion of small pigtail catheters for treatment of early loculated empyema has been well studied in children and found to be effective.

39. 5.6. Chest tube insertion Neither substantial force nor a trocar should ever be used to insert a drain For inserting small bore drains- the Seldinger technique is used A chest radiograph must be performed after the procedure to check the drain position and to ensure a pneumothorax An effectively functioning drain should not be repositioned solely because of its radiographic appearance.

40. 5.7. Securing the Drain Drain incision should be closed by a non-absorbable suture, however it is not necessary for small drains The use of a ‘‘purse string’’ suture is controversial. Some believe they should not be used as they convert a linear wound into a circular one which is painful and may leave an unsightly scar. The alternative view is that a ‘‘purse string’’ suture is the best way of securing a drain. A stay suture can be placed through the skin and then criss-crossed up the drain ensuring it is not too tight or it can occlude a soft drain. Steristrips may be useful and a transparent adhesive dressing is often used to allow inspection of the drain site. Large amounts of tape and padding may restrict chest wall movement and increase moisture collection.

41. 5.8. Management of closed system drainage All chest tubes should be connected to a unidirectional flow drainage system (such as an underwater seal bottle) which must be kept below the level of the patient’s chest at all times The drainage system attached to the chest drain should allow unidirectional flow of air or fluid out of the chest. The underwater seal bottle, with a tube placed under water at a depth of approximately 1–2 cm, has a side vent which either allows escape of air or is connected to a suction pump. If air bubbles into the bottle it indicates air in the pleural space—a pyopneumothorax Continuous bubbling may be seen in patients on suction when the drain is partly out of the thorax and one of the tube holes is open to the atmosphere.

42. 5.8. Management of closed system drainage All chest tubes should be connected to a unidirectional flow drainage system (such as an underwater seal bottle) which must be kept below the level of the patient’s chest at all times The drainage system attached to the chest drain should allow unidirectional flow of air or fluid out of the chest. The underwater seal bottle, with a tube placed under water at a depth of approximately 1–2 cm, has a side vent which either allows escape of air or is connected to a suction pump. If air bubbles into the bottle it indicates air in the pleural space—a pyopneumothorax Continuous bubbling may be seen in patients on suction when the drain is partly out of the thorax and one of the tube holes is open to the atmosphere.

43. 5.9 Should the drain be under suction? There is little evidence to guide recommendations but it is commonly believed that it improves drainage. 5.10 Clamping the drain A bubbling chest drain should never be clamped. A clamped drain should be immediately unclamped if a patient complains of breathlessness or chest pain. There is no need to clamp the drain before its removal in empyema.

44. 5.11. How much pleural fluid can be removed initially? The drain should be clamped for 1 hour once 10 ml/kg are initially removed. 5.12. The blocked drain When there is a sudden cessation of fluid draining, the drain must be checked for obstruction (blockage or kinking) by flushing.

45. 5.13.When should the drain be removed? The drain should be removed once there is clinical resolution. A drain that cannot be unblocked should be removed but replaced if significant pleural fluid remains. It can be useful to get ultrasonographic evidence to confirm the absence of fluid when nothing is draining, to ensure the fluid is not simply loculated and cannot reach the tip of the drain. The chest tube should be removed either while the patient performs Valsalva’s manoeuvre or during expiration, with a brisk firm movement. The exit wound in smaller drains is not surgically closed. The surgically placed drains may have a closure suture which should be approximated while the drain is being removed. A chest radiograph should be taken shortly afterwards to ensure a pneumothorax has not developed during removal. Source: BRITISH THORACIC GUIDELINES

46. 6.Should intrapleural fibrinolytic drugs be used? Because fibrin deposition and the formation of loculations and adhesions characterize the fibrinopurulent phase of empyema, it seems reasonable that fibrinolytic therapy may successfully treat this disease before there is an established pleural rind. Intrapleural fibrinolytics shorten hospital stay and are recommended for any complicated parapneumonic effusion or empyema . There have been seven paediatric case series in children where they are treated with streptokinase, urokinase, or alteplase. All indicate increased pleural drainage with these agents and overall a successful outcome without surgery in 90% .

47. Source: BRITISH THORACIC GUIDELINES, IAP STG

48. 6.1.Which fibrinolytic agent should be used? There is no evidence that any of the three fibrinolytics are more effective than the others, but only urokinase has been studied in a randomised controlled trial in children so is recommended. A recombinant human protein alteplase (tissue type plasminogen activator) is an upcoming alternative. 6.2. Dosage and frequency Urokinase should be given twice daily for 3 days (6doses in total) using 40000 units in 40 ml 0.9% saline for children aged 1 year or above 10000 units in 10 ml 0.9% saline for children aged under 1 year, With a 4 hour dwell time urokinase 25 000–100 000 units was used once daily with a 1 hour dwell time. Source: BRITISH THORACIC GUIDELINES

49. 6.3. Side effects Streptokinase is a bacterial derived protein which is antigenic. Intrapleurally given streptokinase generates a systemic antibody response similar to that found when the drug is given systemically. Fever after intrapleural injection as been well reported. Urokinase is a non-antigenic protein derived from human urine. Rare immediate hypersensitivity reactions have been reported in adults. There is a case report of significant bleeding when urokinase was used 24 hours after traumatic blunt drain insertion. Minor side effects like discomfort during intrapleural injection and transient blood staining of the drainage fluid have been mentioned in paediatric studies

50. 7.When to refer the patient to the surgical team Patients should be considered for surgical treatment if they have persisting sepsis in association with a persistent pleural collection, despite chest tube drainage and antibiotics. persistent radiological abnormality in a symptom-free well child is not an indication for surgery.

51. Video-assisted thoracoscopic surgery (VATS) achieves debridement of fibrinous pyogenic material, breakdown of loculations, and drainage of pus from the pleural cavity under direct vision. It leaves three small scars. .

52. Mini-thoracotomy achieves debridement and evacuation in a similar manner to VATS but it is an open procedure leaving a small linear scar along the rib line. Decortication involves an open posterolateral thoracotomy and excision of the thick fibrous pleural rind with evacuation of pyogenic material. It is a longer and more complicated procedure leaving a larger linear scar along the rib line VATS debridement is preferred rather than open thoracotomy for the surgical management of empyema

53. Early v late surgery There are no comparative trails in children to support this debate. Although there is one small trial in adults directly comparing surgical with medical therapy. Which showed surgical patients had shorter drainage and shorter hospital stay. The failure rate of medical management is low nowadays in children, so the approach of early surgery for all would inevitably mean more patients undergoing surgery. Although late presenting cases, when multiloculated, are more likely to require surgery

54. Early use of VATS enhances the chance of full expansion of the collapsed lung, and drainage of the empyema fluid is significantly improved when performed under direct vision. Loculi can be separated which allows full expansion of the lung. While early VATS is effective, the failure rate is higher in organized empyema.

55. Is thoracoscopic surgery preferable to open thoracotomy? There are limited studies which favoured the VATS approach, claiming reduced duration of hospital stay, postoperative antibiotics, and chest tube drain requirements. Contraindications for VAT debridement include an inability to develop a pleural window to access the pleural cavity, the presence of thick pyogenic material, and/or fibrotic pleural rinds. Mini-thoracotomy and debridement of the empyema is safe and curative. open formal thoracotomy procedures should be reserved for late presenting empyema with significant pleural fibrous rind, complex empyema, and chronic empyema.

56. Organised empyema with a thick fibrous peel in a symptomatic child may require formal thoracotomy and decortication . Chest physiotherapy is not beneficial and should not be performed in children with empyema. Early mobilisation and exercise is recommended

57. Follow up Children should be followed up after discharge until they have recovered completely and their chest radiograph has returned to near normal. Underlying diagnoses—for example, immunodeficiency, cystic fibrosis—may need to be considered

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