Management Of Empyema Thoracis Research Articles

Thoracoscopic management of empyema thoracis

Appropriate management of empyema thoracis is dependent upon a secure diagnosis of the etiology of empyema and the phase of development. Minimal access surgery using video-assisted thoracoscopy (VATS) is one of many useful techniques in treating empyema. Complex empyema requires adjunctive treatment in addition to VATS.

Less is best? The impact of urokinase as the first line management of empyema thoracis

To assess the impact of intrapleural urokinase and small tube thoracostomy on the management of childhood empyema thoracis. The study population included 38 children presenting consecutively to a regional surgical unit with empyema thoracis from January 2001 to December 2003. Children with malignancy, immunodeficiency and complex intercurrent illness were excluded. Primary outcome variables were the need for second intervention and duration of stay, with other variables including duration of antibiotics, serial CRP and amelioration of pyrexia. Interventions were: tube thoracostomy (16-20 Fr) alone (n=2), tube thoracostomy (6-10 Fr)+urokinase (n=17), thoracoscopy (tube: 20-24 Fr) (n=9), thoracotomy (tube: 16-24 Fr) (n=10). There were no differences in age, weight or length of prodromal symptoms, between treatment groups. There were no differences in primary outcome variables, although no child undergoing thoracotomy required further intervention. The duration of intravenous antibiotics was similar in all groups. Amelioration of pyrexia was more rapid in children undergoing thoracotomy. There were no differences seen with regard to decline in CRP level. Small tube thoracostomy and intrapleural urokinase had a similar outcome to more invasive therapies such as thoracotomy or thoracoscopy thereby supporting the evidence base for urokinase and tube drainage as first line intervention.

Outcome of Pediatric Empyema Thoracis Managed by Tube Thoracostomy

The proper management of empyema thoracis in children continues to be a source of debate. This study assessed the clinical profile and outcome of patients managed by tube thoracostomy. Chart review was performed in 31 patients managed from January 1989 to December 2003. Outcome measures were duration and outcome of thoracostomy, number of days to radiologic lung re-expansion, length of hospitalization, and microbiologic flora involved. The mean age was 9 years (male/female, 2:1) and the most commonly affected group were those aged 1 year and below. Staphylococcus aureus was the most frequent infecting organism. A few (6%) achieved lung re-expansion 1 week postoperatively, but 64% did not achieve full lung re-expansion even after 3 weeks. Most (71%) of the thoracostomies were converted to open drainage. Half (52%) of the patients were hospitalized for at least 5 weeks. There were 3 recurrences and 3 deaths, 2 of which were most likely associated with empyema. Empyema managed by tube thoracostomy alone showed evidence of delayed lung re-expansion, prolonged drainage and hospitalization, and unfavorable outcome.

Comparison of closed-tube thoracostomy and open thoracotomy procedures in the management of thoracic empyema in childhood: Karaman I, Erdogan D, Karaman A, et al. Eur J Pediatr Surg 2004 (August);14:250-254

Comparison of closed-tube thoracostomy and open thoracotomy procedures in the management of thoracic empyema in childhood: Karaman I, Erdogan D, Karaman A, et al. Eur J Pediatr Surg 2004 (August);14:250-254

Video-assisted thoracoscopic decortication for management of postpneumonic pleural empyema

Background Video-assisted thoracoscopic surgery (VATS) for decortication or debridement in the management of empyema thoracis has increased the available treatment options but requires validation. We present and evaluate our technique and experience with thoracoscopic management of pleural empyema, irrespective of chronicity. Methods From May 1, 2000, to April 30, 2002, VATS debridement and decortication in 70 consecutive patients presenting with pleural space infections was performed with endoscopic shaver system. A retrospective review was performed and the effect of this technique on perioperative outcome was assessed. Results The VATS evacuation of infected pleural fluid and decortication was successfully performed in 65 of 70 patients. The mean duration of preoperative symptoms before referral was 23 ± 1.8 days. The mean duration of hospitalization before transfer was 13.5 ± 1.5 days. Blood loss was 330 ± 200 mL. Intercostal drainage was required for 5 ± 3 days. The postoperative hospital stay was 5 ± 0.7 days. There were no operative mortalities. Conclusions Video-assisted thoracoscopic decortication with endoshaver system is a simple and effective method in the management of the fibropurulent or organic pleural empyema.

Empyema thoracis.

Parapneumonic effusion and empyema thoracis remains a significant source of morbidity in children, though the overall incidence of empyema thoracis has decreased in the past two decades. These conditions pose a dilemma regarding evaluation and treatment for the treating physician. This article discusses the practical strategies in the management of empyema thoracis in children.

Management of thoracic empyema in childhood: does the pleural thickening matter?

Aims: To determine the clinical course and long term outcome of empyema treated without decortication. Methods: Fourteen consecutive admissions to one hospital were studied; radiological resolution and lung function were...

Efficacy of Pigtail Catheter Drainage in Patients with Thoracic Empyema or Complicated Parapneumonic Effusion

Background : The management of thoracic empyema and complicated parapneumonic effusion requires adequate antibiotics use and prompt drainage of infected pleural space. Tube thoracostomy for loculated empyema has low success rate and is also an invasive procedure with potential morbidity. Complications include hemothorax, perforation of intra-abdominal or intra-thoracic organs, diaphragmatic laceration, empyema, pulmonary edema, and Horner's syndrome. Given the potential morbidity of traditional chest tube insertion, use of the image-guided pigtail catheter drainage(PCD) of empyema has been employed. We retrospectively analyzed the medical records of patients with empyema or complicated parapneumonic effusion to determine the efficacy of percutaneous pigtail catheter drainage. Materials and Methods : 45 patients with complicated parapneumonic effusions or empyema were treated at Gil medical center from January 1998 to June, 1999. All were initially given PCD procedure and the following data were collected: clinical symptoms at the time of diagnosis, alcohol and smoking

Management of thoracic empyema in children.

The effectiveness of fibrinolytic treatment has been shown in cases of thoracic empyema in adults. In pediatric patients experience is, however, very limited. The aim of this study was to determine the success and complication rates of fibrinolytic treatment in thoracic empyema in children. A series of 25 consecutive children who had loculated pleural empyemas that did not respond to tube thoracostomy and antibiotics is presented. Their ages ranged from 1 to 12 years (mean 4.2). There were 19 boys and 6 girls, and all epyemas were postpneumonic. The fibrinolytic agent used was urokinase in 17 and streptokinase in 8. The mean duration of fibrinolytic treatment was 4.3 days (range 2 to 8) and the mean duration of chest-tube drainage was 8.9 days (range 7 to 13). In 20 patients the fluid output from the chest tube increased significantly after instillation of the fibrinolytic agent, and these patients showed almost complete resolution of the effusion on chest radiograph and ultrasound examinations (80%). Only 5 patients developed complications: bronchopleural fistula and pleural thickening in 3, and recurrent effusion, multiloculation, and pleural thickening in other 2 which were managed by surgical intervention (20%). Our study suggests that intrapleural fibrinolytic treatment is an effective and safe adjunctive therapy in children with thoracic empyema and can obviate a thoracotomy in most cases.

Evolving experience in the management of empyema thoracis

The optimal management of paediatric empyema thoracis remains controversial. The objective of the study was to analyse evolving experience in clinical presentation, management, outcome and factors contributing to adverse morbidity in thoracic empyema. Forty‐seven patients presenting to a paediatric surgical centre were studied in three consecutive 6‐y periods during 1980‐97 to compare any change in the pattern of disease influencing diagnosis and management. Patients were categorized into two treatment groups: (i) conservative management (antibiotics and/or tube thoracostomy), (ii) thoracotomy. The median duration of illness prior to hospital admission was 10 d (range 1‐42 d). Ultrasound was increasingly utilized in the diagnosis and staging of empyema and played an important role in directing definitive management. The presence of loculated pleural fluid determined the need for thoracotomy. Sixteen of 20 patients (80%) who were initially treated with thoracocentesis or tube thoracostomy eventually needed thoracotomy. There was a positive shift in management towards early thoracotomy resulting in prompt symptomatic recovery. Significant complications were noted in seven children who had delayed thoracotomy. These included recurrent empyema with lung abscess (n= 2), scoliosis (n= 2), restrictive lung disease (n= 1), bronchopleural fistula (n= 1) and sympathetic pericardial effusion (n= 1). An unfavourable experience with delayed thoracotomy during the study period has led us to adopt a more aggressive early operative approach to empyema thoracis. The decision to undertake thoracotomy has been influenced by the ultrasound findings of organized loculated pleural fluid. Delayed surgery was associated with adverse outcome.Whilst fibrinolytics and thoracoscopy may provide attractive options for early empyema, thoracotomy can hasten patient recovery regardless of the stage of disease. Prospective randomized trials are required to assess the ideal therapy for childhood empyema.

Evolving experience in the management of empyema thoracis.

The optimal management of paediatric empyema thoracis remains controversial. The objective of the study was to analyse evolving experience in clinical presentation, management, outcome and factors contributing to adverse morbidity in thoracic empyema. Forty-seven patients presenting to a paediatric surgical centre were studied in three consecutive 6-y periods during 1980-97 to compare any change in the pattern of disease influencing diagnosis and management. Patients were categorized into two treatment groups: (i) conservative management (antibiotics and/or tube thoracostomy), (ii) thoracotomy. The median duration of illness prior to hospital admission was 10 d (range 1-42 d). Ultrasound was increasingly utilized in the diagnosis and staging of empyema and played an important role in directing definitive management. The presence of loculated pleural fluid determined the need for thoracotomy. Sixteen of 20 patients (80%) who were initially treated with thoracocentesis or tube thoracostomy eventually needed thoracotomy. There was a positive shift in management towards early thoracotomy resulting in prompt symptomatic recovery. Significant complications were noted in seven children who had delayed thoracotomy. These included recurrent empyema with lung abscess (n = 2), scoliosis (n = 2), restrictive lung disease (n = 1), bronchopleural fistula (n = 1) and sympathetic pericardial effusion (n = 1). An unfavourable experience with delayed thoracotomy during the study period has led us to adopt a more aggressive early operative approach to empyema thoracis. The decision to undertake thoracotomy has been influenced by the ultrasound findings of organized loculated pleural fluid. Delayed surgery was associated with adverse outcome. Whilst fibrinolytics and thoracoscopy may provide attractive options for early empyema, thoracotomy can hasten patient recovery regardless of the stage of disease. Prospective randomized trials are required to assess the ideal therapy for childhood empyema.

Management of thoracic empyema in childhood

A total of 160 cases of thoracic empyema admitted to our clinic between September 1988 and March 1994 have been analyzed retrospectively. There were 83 males and 77 females whose ages ranged from 25 days to 13 years. Cough (82%), fever (81%), and dyspnea (70%) were the most common presenting symptoms followed by chest pain, abdominal pain, and cyanosis. The preadmission history was often long (average 14 days). Following admission antibiotic therapy was initiated by parenteral administration of sulbactam-ampicillin, amikacin or netilmicin, and ornidazole or clindamycin and modified with vancomycin or piperracillin on the basis of culture and sensitivity reports. Fifty-four of 156 aerobic and 2 of 28 anaerobic cultures were positive.Staphylococcus aureus was the most common (57%) micro-organism isolated followed byPseudomonas aeroginosa andStreptococcus pneumoniae. In addition, 5 of 11Haemophilus influenzae latex-agglutination tests were positive. Two patients with pneumatocele formation received antibiotics as the only therapy. In the remaining patients, in addition to antibiotics treatment modalities included tube drainage (n = 111), decortication (n = 39), decortication with lobectomy or segmentectomy (n = 6), and pneumonectomy (n = 2). The overall mortality was 5%. Our results show that appropriate antibiotics and tube drainage provided effective control of childhood thoracic empyema, although in patients with serious respiratory distress and poor response to tube drainage, operative intervention is required.

Thoracoscopic debridement and pleural irrigation in the management of empyema thoracis

As a sequel to a paper reporting good results obtained in 12 patients with empyema thoracis treated by thoracoscopic debridement and irrigation in our department, subsequent experience with a further 18 patients is reported. Drainage of pus and irrigation resulted in resolution of pyrexia with improvement in general condition in all patients. Overall, complete resolution was obtained by this technique alone in 60% ( 18 / 30 ). Of the 12 patients in whom complete resolution was not obtained, secondary surgical measures resulted in resolution of empyema in 8. Four patients died; all were elderly and severely debilitated, 3 with advanced malignancy. Their deaths were not related to the technique, which was well tolerated in all cases. Thoracoscopic debridement and irrigation used routinely as a first-line measure in empyema thoracis is a safe and relatively atraumatic procedure, does not exclude the use of any subsequent surgical measure, and provides valuable time to improve the condition of debilitated patients so that they may tolerate more aggressive surgical procedures.

Interventional Radiology of the Pleural Space: Management of Thoracic Empyema with Image-Guided Catheter Drainage

Interventional Radiology of the Pleural Space: Management of Thoracic Empyema with Image-Guided Catheter Drainage

Management of Empyema thoracis in children—a study of 65 cases

Sixty-five cases of pleural empyema (50 boys and 15 girls) were seen between January 1983 and June 1986. Fifty-three of these 65 children were below 10 years of age. Pulmonary infection was the commonest underlying cause. Cough with or without expectoration (98%) and fever (95%) were the commonest symptoms followed by breathlessness (85%) and chest pain (83%). Staphylococcus aureus was isolated from pus and blood in 61% and 18% of cases, respectively, while pseudomonas was grown in 8% and 3%. Most of the children (88%) were treated with antibiotics and tube thoracostomy drainage. Decortication was needed in 12% of cases. There were four deaths in this study. The overall success rate was 94%.

The Management of Empyema Thoracis by Thoracoscopy and Irrigation

A technique of irrigation for the management of empyema is described. Initial thoracoscopy under general anesthesia enabled full debridement and division of loculi within the empyema cavity under direct vision. Irrigation with two tubes was instituted until three consecutive cultures of irrigation fluid became sterile; then the chest drains were removed. The results in 12 patients are presented. Using this method, irrigation was required for an average of 14 days and chest drains were removed after an average of 20 days. Patients remained in the hospital for an average of 4.8 weeks. Tuberculous empyema was not found to be a contraindication to the irrigation technique.

Improved survival in management of empyema thoracis

Empyema thoracis following pneumonia, trauma, and surgical procedures continues to be a source of major morbidity and mortality. We retrospectively reviewed the hospital records of 100 patients treated for empyema thoracis at San Francisco General Hospital during the past 10 years. The causes of empyema in these patients were as follows: pneumonia 44%, trauma 24%, surgical and invasive procedures 15%, lung abscess 11%, and hematogenous spread 6%. Ten patients in this series died of sepsis from necrotizing pneumonia or overwhelming injuries caused by trauma. Streptococcus (31%), Staphylococcus (21%), and Bacteroides (15%) were the organisms most commonly isolated. Bacterial isolates were single in 55%, multiple 42%, and absent in 3%. The type of organism did not correlate with severity of disease or eventual requirement for thoracotomy, pleural débridement, or Eloesser procedure. Successful methods of treatment included aspiration in 9%, tube thoracostomy in 63%, pleural débridement and drainage in 7%, and an Eloesser procedure in 11%. Because our patients were often debilitated from chronic alcoholism, drug addiction, and major trauma, conservative management was initially tried. In most patients empyema resolved with tube thoracostomy. Pleural débridement should be reserved for patients with special problems such as multiple loculation or purulence inaccessible to percutaneous tube placement. the Eloesser procedure is indicated in patients who have an infected residual pleural space that persists despite adequate tube drainage.