EMPYEMA THORACIS
the role of VATS
Empyema Thoracis
Defined as “pus in the
chest”
Ancient disease
Hippocrates credited with
first description of natural
history and treatment
Most common precursor
is bacterial pneumonia
and subsequent
parapneumonic effusion
Hippocrates of Kos 460-370 B.C.
Empyema
Aetiology
Empyema is always secondary to infection in a neighboring
structure, usually the lung;
1-Bacterial pneumonia &tuberculosis.
2-Over 40% of patients with community-acquired pneumonia
develop an associated pleural effusion
And 15% of them develop secondary bacterial infection and
empyema.
3-Infection of haemothorax,& rapture of subphrenic abscess.
4-Delay in the diagnosis and instigation of appropriate therapy.
The Stages of Empyema
Stage I - “Exudative”
sterile pleural fluid develops secondary to inflammation
without fusion of the pleura
Stage II - “Fibrinopurulent”
a fibrinous peel develops on both pleural surfaces
limiting lung expansion
Stage III - “Organizing”
in-growth of capillaries & fibroblasts into the fibrinous
peel
Clinical features
Systemic features ;
1-Pyrexia,usually high and remittent
2-Rigors,sweating,malaise and weight loss
3-Polymorphonuclear leucocytosis, high (C-Reactive Protein)
CRP.
Local feature ;
1-Pleural pain; breathlessness; cough and sputum usually
because of underlying lung disease; copious purulent sputum if
empyema rupture into a bronchus (bronchopleural fistula)
2-Clinical signs of fluid in the pleural space
Differential diagnosis
Pleural involvement occurs in up to 5% of patients with
rheumatoid arthritis.
Pleural malignancy
Chylothorax and pseudochylous effusion
Pulmonary embolism
Esophageal rupture
Bacteriology
Aerobic organisms are the most frequent organisms
identified from infected pleural fluid.
These are most commonly Gram-positive organisms
from Streptococcal species, followed by Staphylococcus
aureus.
Gram-negative empyema is more frequent in patients
with underlying diseases, especially those with diabetes
and alcoholism.
Staphylococcus aureus and Gram-negative enteric
bacteria such as Klebsiella pneumonia have a particular
propensity to cause pleural infection.
Bacteriological data.
Streptococcus pneumoniae: 15-20%
Increased resistance
Staphylococcus:15-30%
Streptococcus spp
Gram Negative: 20-50%
Klebsiella, Enterobacter, Pseudomonas, Hemophilus,
[Link]
Anaerobes:
Fusobacterium, Bacteroides fragilis
Diagnostic
X-ray
Pleura USG
Fast, safe&effective in confirming the presence of pleural fluid
and estimating its volume, can differentiate between pleural
fluid and thickening ,guiding thoracosintesis (dx and therapy)
CT Scan
should be obtained when pleural space infection is
suspected
Bronchoscopy
particularly recommended where there is a mass or volume
loss on imaging
Goal of Treatment
Evacuation of Pus
Expansion of Lung
Eliminate of ongoing infection
Non Surgery Therapy
Antibiotics
Intrapleural fibrinolytics
Intrapleural fibrinolytics
1949 Tillet and Sherry: partial purified streptococcal fibrinolysin
Highly purified streptokinase: 250000IU
Urokinase: 100000IU
It form a complex with plasminogen that converts additional circulating
plasminogen to plasmin. Plasmin lyses fresh fibrin clot and digests
prothrobin and fibrinogen.
Improvement in the chest radiograph and greater volume pleural
drainage, not outcome of mortality, surgical frequency, or hospital stay.
Tube drainage with streptokinase and early surgical intervention showed
reduced length of hospitalization
Potential side effect: hemorrhage, pleuritic pain and fever
What Surgery can do ?
The goals of surgery for empyema are:
to debride the pleural cavity and
to achieve lung re-expansion
Debridement of the pleural cavity comprises drainage of
all fluid, breaking of all loculations and removal of all the
pleural exudate.
Decortication entails thorough removal of the restrictive
cortex of fibrous and infected tissue overlying the visceral
pleura to allow the lung to re-expand
Surgical management of empyema
(AATS)
Best surgical approach to manage stage
II empyema?
Class IIa:VATS should be the first line approach in all patients
with stage II acute empyema (LOE B)
Surgical management of empyema
(EACTS)
VATS benefit
Benefits of a minimally invasive approach including:
reduction in operative time
postoperative pain,
duration of chest tube
length of hospital stay
Greater satisfaction with postoperative wound appearance
an earlier return to work
