Management of parapneumonic effusion and empyema

Any pleural effusion associated with bacterial pneumonia,lung abscess or bronchiectasis is defined as parapneumonic effusion.Presence of pus in pleural space is called empyema. Pathogenesis,bacteriology,clinical presentation,diagnosis,management has been described in this powerpoint presentation.

1. Management of Parapneumonic Effusion and Empyema Dr Dileep MD Asst. Professor Pulmonary Medicine Mediciti Medical College Hyderabad

2. Definitions Pathogenesis Bacteriology Clinical presentation Diagnosis Management

3. DEFINITIONS Parapneumonic effusion : Any pleural effusion associated with bacterial pneumonia, lung abscess or bronchiectasis Empyema : Pus in the pleural space - Light’s

4. PATHOGENESIS Etiology of pleural infection: Primary: Hematogenous spread of organisms From URTI or gingiva (or) due to Myc.tb Secondary: Pneumonia, lung abscess Bronchiectasis Thoracic surgery Diagnostic procedure inv pleural space Trauma Esophageal rupture Trans diaphragmatic spread

5. BACTERIOLOGY

6. LIGHT’S CLASSIFICATION

7. classification Class 1 Non significant pl.ef Small <10mm on decubitus x-ray No thoracentesis Class 2 Typical parapn . pl.ef . >10mm thick pH>7.2,gl>40mg/dl LDH<3times,gr.st&cul - ve Antibiotics alone Class 3 Borderline complicated pl.ef 7.0<Ph<7.2 Gl >40, LDH>3x ,gr.st&cul-ve Antibiotics +serial thoracentesis Class 4 Simple complicated pl.ef . pH<7.0,gl<40 Gr.st,cul+ve , Not loculated Tube thoracostomy + Antibiotics Class 5 Complex complicated pl.ef . pH<7.0,gl<40 Gr.st,cul+ve, multiloculated Tube thoracostomy + fibrinolytics Class 6 Simple empyema Frank pus ,single locule Tube thoracostomy +/- decortication Class 7 Complex empyema Frank pus , multiple locules Tube thoracostomy +/- Fibrinolytics;often thoracoscopy or decort

8. DIAGNOSIS Clinical Imaging Chest X-ray Ultrasound CT Scanning MRI Pleural fluid aspiration

9. CLINICAL PRESENTATION Immunoncompetent patient with aerobic infection: Acutely ill(similar to pneumonia) pleuritic chest pain, fever spikes and failure to improve on apparently adequate antibiotic therapy Elderly individual, immunocompromised with anaerobic infection : More indolent course, weight loss, cough, unexplained fever

10. Initial Imaging- Chest X-ray : A pleural effusion -obvious on the chest x-ray and the coexistence of pulmonary infiltrates,parapneumonic collection Lateral chest x-rays may confirm pleural fluid not suspected on the chest x-ray PA view Lateral decubitus chest X-ray Volume Required: Decubitus : 20ml Lateral: 50ml PA: 175ml Supine: 175ml

11. Lateral decubitus Lateral

12. Ultrasound: Confirm Presence Estimate Size Identify Septa Other Pathology Guide Drainage All echogenic effusions were caused by exudates and homogeneous echogenic effusions- Empyema or haemorrhage

13. U/S pleural space: marked septations throughout fluid collection

14. Multiple thin llinear septations

15. CT scanning: Confirm Presence Estimate Size Identify Septa Other Pathology Guide Drainage

16. CT scanning can help to differentiate empyema from lung abscess Empyemas - lenticular and compress lung parenchyma Lung abscesses - indistinct boundary between lung parenchyma and collection Collections in the interlobar spaces, paramediastinal pleura, small paravertebral collections can be visualised Management decisions about drainage, drain insertion and subsequent tube positioning and need for surgical intervention

17. Empyema -‘Split pleura’ sign caused by enhancement of both parietal and visceral pleural surfaces Pleural thickening is seen in 86-100% of empyemas and 56% of exudative parapneumonic effusions Pleural thickness on CECT scans is greater in frankly purulent effusions

18. MRI MRI is not routinely indicated and offers no advantage over CT scanning for pleural infection Considered in specific situations - allergy to contrast agents or young/ pregnant patients to minimise ionising radiation exposure MRI -helps to define chest wall involvement with the infection ( eg , empyema necessitans or tuberculous empyema ).

19. Pleural Fluid Aspiration: Diagnostic pleural fluid sampling is recommended in pleural effusion >10 mm depth Small effusions ( ie , <10 mm thickness) will usually resolve with antibiotics alone Pleural fluid pH should be assessed in all non-purulent effusions (<7.2 is indication for ICD) If pH is not available glucose should be measured, glucose level <60 mg/dl, can be used as an alternative to indicate a need for chest drain Gram staining and microbiological culture analysis should be routinely requested on all initial samples

20. Imaging guidance should be used - minimises risks of organ perforation and improves recovery rate of pleural fluid Pleural fluid cytology and acid/alcohol fast bacilli analysis for mycobacteria should be performed if clinically indicated

21. MANAGEMENT Indications for pleural fluid drainage in pleural infection Chest tube drainage Antibiotics Intrapleural fibrinolytics Surgery Thoracoscopy

22. Indications for pleural fluid drainage in pleural infection Patients with frank pus on sampling should receive ICD Presence of organisms on GS and/or culture from a non-purulent pleural fluid indicates pleural infection and should receive ICD Pleural fluid pH <7.2 in patients with suspected pleural infection indicates a need for ICD Pleural fluid glucose < 60 mg/dl Patients with a loculated pleural collection should receive ICD

23. Chest tube drainage A small-bore catheter 10-14 F will be adequate for most cases of pleural infection. However, there is no consensus on size of optimal chest tube for drainage Chest tube insertion should be performed under imaging guidance wherever possible Chest tube insertion should be performed in line with the BTS pleural procedures guidelines and National Patient Safety Agency recommendations

24. Timing of chest drain removal in pleural infection After radiological confirmation of successful pleural drainage- Reduction in the size of the pleural collection on the chest x-ray or thoracic ultrasound objective evidence of sepsis resolution -improvement in temperature and clinical condition and decreasing inflammatory markers ( eg , CRP) In patient observation for 24 h after drain removal is usual, a longer period of rehabilitation may be necessary for some patients

25. Antibiotics All patients should receive antibiotics targeted to treat bacterial profile of modern pleural infection and based on local antibiotic policies and resistance patterns Antibiotics to cover anaerobic infection be used in all cases with either clindamycin or metronidazole Macrolide antibiotics are not indicated unless there is evidence for ‘atypical’ pathogens Where possible, antibiotic choice should be guided by bacterial culture results and advice from a microbiologist

26. Antibiotic penetration into pleural space in descending order Metronidazole > Penicillin > Clindamycin > Vancomycin > Ceftriaxone > Gentamycin Penicillin allergic- can be treated by clindamycin alone or in combination with ciprofloxacin or a cephalosporin When bacterial cultures are negative, antibiotics should cover both common community-acquired bacterial pathogens and anaerobic organisms Empirical antibiotic treatment for hospital-acquired empyema should include treatment for MRSA ,Gram negative and anaerobic bacteria

27. IV antibiotics should be changed to oral therapy once there is clinical and objective evidence of improvement in sepsis Prolonged courses of antibiotics may be necessary and can often be administered as an outpatient after discharge At least 4 to 6 weeks of therapy is required, and a longer course may be necessary unless there is prompt resolution of fever and leukocytosis

28. Intrapleural fibrinolytics There is no indication for routine use of intrapleural fibrinolytics in patients for pleural infection It is not associated with reduced mortality, frequency of surgery, length of hospital stay or long-term radiological & lung function outc . (MIST-1 trial) Occasionally be indicated for physical decompression of multiloculated pleural fluid collections that are responsible for dyspnoea or respiratory failure

29. Doses of fibrinolytics used in studies have varied but include Streptokinase 250 000 IU daily or 250 000 IU 12-hourly or urokinase 100 000 IU daily retained for 2-4 h in the pleural space Combination therapy with fibrinolytics and fluid viscosity and biofilm -disrupting agents such as streptodornase and deoxyribonuclease ( DNase ) may be beneficial MIST-2 trial - Results from trial suggests that a combination of intrapleural tPA and DNase may provide superior drainage to a fibrinolytic alone

30. Persistent sepsis and pleural collection Patients with persistent sepsis and a residual pleural collection should undergo further radiological imaging Should be discussed with a thoracic surgeon to consider all surgical options The diagnosis should be reviewed and a further chest x-ray and CT scan or thoracic ultrasound performed CECT accurately identifies chest tube position, anatomy of effusion, pleural thickening, endobronchial obstruction and mediastinal pathology

31. Bronchoscopy should only be performed in patients where there is high index of suspicion of bronchial obstruction The choice of antibiotic should be reviewed and prolonged course administered where appropriate Patients should receive surgical treatment if they have persisting sepsis with a persistent pleural collection, despite ICD and antibiotics Failure of sepsis to resolve within 5-7 days is suggested as an appropriate period following which a surgical opinion be sought

32. Surgical Options: VATS is used as 1 st line therapy , open thoracic drainage or thoracotomy and decortication remain alternatives In patients unable to tolerate GA, placement of additional image-guided small-bore catheter, a larger bore ICD or intrapleural fibrinolytic could be considered after discussion with surgeon Less radical surgical interventions - rib resection and placement of a large-bore drain may be considered in frail patients under epidural an For some patients, palliative treatment and active symptom control measures will be appropriate

33. Thoracoscopy Thoracoscopy can be used in management of early empyema , mainly to achieve early and complete drainage In cases with multiple loculations , it is possible to open these spaces to remove the fibrinopurulent membranes by forceps and to create a single cavity that can then be successfully drained and irrigated If performed for this indication, thoracoscopy should be carried out early in the course of empyema , before the adhesions become too fibrous and adherent to perform pleuroscopy

34. It is particularly advisable for frail patients at high surgical risk Thus, if indication for ICD is present and if facilities are available, thoracoscopy can be performed at the time of ICD insertion Large prospective randomised comparator trials are needed to elucidate role of local thoracoscopy

35. Parapneumonic Effusion/ Empyema Purulent/turbid/Cloudy ICD Gram Stain + ve Culture + ve PH<7.2 > 10mm thick Glucose >40 mg/dl, pH > 7.2 Gram 's stain & culture negative Antibiotics Alone Loculated ICD Ongoing sepsis and persistent pleural collection ICD Ongoing sepsis and persistent pleural collection Review of the Diagnosis –CECT thorax -ICD position, anatomy, pleural thickening, endobronchial obstruction and mediastinal path. Failure of sepsis to resolve within 5-7 days Surgical Intervention

36. REFERENCES BTS Guidelines for the management of Pleural Infections Murray and Nadal ’ Text Book of respiratory Medicine Pleural Diseases 6 th Edition Richard W.Light Upto date C Ravaglia et al. Respiration 84 (3), 219-224. 2012 Jul 24.

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