Management Of Pleural Empyema Research Articles

Role of Video-Assisted Thoracoscopic Surgery in the Management of Pleural Empyema

Background: Video-assisted thoracoscopic surgery (VATS) has revolutionized surgical management of patients with empyema. Thoracoscopic management of empyema includes VATS debridement and decortication. VATS debridement has been employed by many centres as the primary treatment option for early-stage empyema. Objective: To evaluate the outcome of VATS over open thoracotomy. Methods: This cross-sectional study was conducted in the department of Thoracic Surgery of Combined Military Hospital Dhaka from 01 January 2017 to 30 May 2018 among 30 patients (20 patients underwent VATS and 10 patients underwent open decortication/OD). The results were viewed with respect to baseline characteristics, preoperative management, operative and postoperative course. Results: Operative time and median in-hospital length of stay were shorter for the VATS group: 128 vs 140 minutes (p < .001), and 14 vs 11 days (p .03), respectively. The median postoperative length of stay was 12 days for the VATS group vs15 days for the OD group (p < .001). Complications after Video Assisted Thoracic Surgery is less like prolonged air leakage, infection and atelectasis. Conclusions: VATS decortications for empyema thoracis, complex effusion, haemothorax yields better results than open decortications. Patients treated with VATS have less postoperative complications. VATS debridement and decortication is safe and effective treatment in the management of empyema thoracis. JAFMC Bangladesh. Vol 18, No 1 (June) 2022: 19-22

Management of pleural empyema in a 12-year-old obese patient with COVID-19: a pediatric case report

BackgroundWith the ongoing coronavirus disease (COVID-19) pandemic, along with the development of new mutations of the virus and an increase in the number of cases among pediatrics, physicians should be aware and alerted on the atypical presentations of the disease, especially in less expected individuals.Case presentationHere we present a 12-year-old obese boy (BMI = 37.5 kg/m2) who presented with empyema, which was following SARS-CoV-2 infection. The patient had no history of fever. Due to the onset of dyspnea, a chest tube was inserted for him which was later altered to a pleural drainage needle catheter.ConclusionOur case is the first report of COVID-19 presenting as empyema among pediatrics. Pleural empyema should be considered as a rare complication of COVID-19. Since there is still no guideline in the management of empyema in the context of COVID-19, delay in diagnosis and intervention may cause morbidity and mortality in children.

Epidemiology of pleural empyema in English hospitals and the impact of influenza.

Pleural empyema represents a significant healthcare burden due to extended hospital admissions and potential requirement for surgical intervention. This study aimed to assess changes in incidence and management of pleural empyema in England over the past 10 years and the potential impact of influenza on rates.Hospital Episode Statistics data were used to identify patients admitted to English hospitals with pleural empyema between 2008 and 2018. Linear regression was used to analyse the relationship between empyema rates and influenza incidence recorded by Public Health England. The relationship between influenza and empyema was further explored using serological data from a prospective cohort study of patients presenting with pleural empyema.Between April 2008 and March 2018 there were 55 530 patients admitted with pleural empyema. There was male predominance (67% versus 33%), which increased with age. Cases have increased significantly from 4447 in 2008 to 7268 in 2017. Peaks of incidence correlated moderately with rates of laboratory-confirmed influenza in children and young adults (r=0.30). For nine of the 10 years studied, the highest annual point incidence of influenza coincided with the highest admission rate for empyema (with a 2-week lag). In a cohort study of patients presenting to a single UK hospital with pleural empyema/infection, 24% (17 out of 72) had serological evidence of recent influenza infection, compared to 7% in seasonally matched controls with simple parapneumonic or cardiogenic effusions (p<0.001).Rates of empyema admissions in England have increased steadily with a seasonal variation that is temporally related to influenza incidence. Patient-level serological data from a prospective study support the hypothesis that influenza may play a pathogenic role in empyema development.

Albumin and leukocyte: pre-operative factors for advanced management in pleural empyema?

Background: Surgical intervention such as video-assisted thoracoscopic surgery (VATS) has shown the benefit of reducing morbidity and mortality in the management of pleural empyema. The objective of the study was to investigate preoperative factors that could predict the need for VATS rather than chest tube thoracostomy.Methods: This is retrospective observational study of consecutive patients diagnosed with pleural empyema admitted to the Dr. Zainoel Abidin Hospital, Banda Aceh in period of 2015 to 2017. The demographic, clinical dan laboratory data of the patients were evaluated from hospital medical records.Results: A total of 48 consecutive patients were identified. The mean age of the patients was 34.3 ± 20.4 years; and 31 (64.6%) were male. Twenty-six patients underwent VATS decortication and twenty-two patients underwent chest tube thoracostomy. Patient demographics were similar between VATS decortication and chest tube thoracostomy group. The significant preoperative factors associated with the VATS were serum albumin level and leukocytes (p &lt;0.05). The mean serum albumin level was 2.81 ± 0.44 g/dL for the VATS decortication group vs 3.06 ± 0.41 g/dL for the chest tube thoracostomy group (p = 0.047). In addition, serum leukocyte level was higher in VATS decortication group compared to chest tube thoracostomy group (21,600 mm-3 vs 12,900 mm-3; p = 0.024).Conclusion: We demonstrate that a low serum albumin level or an elevated leukocyte level may represent as preoperative factors in which surgical treatment may be required in the management of pleural empyema.

Pleural Empyema in Children: Diagnosis and Management in a Pediatric Department in Development Country

Pleural empyema is a serious complication of pneumonia, its morbidity and mortality is important in developing country where hospital resources are limited. Different treatment strategies continue to generate controversy. We reported our experience in diagnosis and management of pleural empyema in children in a pediatric department in a development country.The early adequate surgical treatment in children with pleural empyema results in low morbidity, shorter hospital stay and good long-term outcome.

Video-Assisted Thoracoscopic Surgery: Is It a Safe Procedure for Pleural Empyema? Aceh Experiences

Purpose: Video-assisted thoracoscopic surgery (VATS) has been used widely in the management of pleural empyema with the benefit of reducing morbidity and mortality. This study aimed to evaluate the efficacy of VATS over chest tube thoracostomy in the management of pleural empyema with respect to postoperative length of hospital stay (LOS) and chest tube duration.

Predictors of conversion from thoracoscopic to open surgery in management of postpneumonic empyema

BackgroundVideo-assisted thoracoscopic surgery (VATS) has an important role in management of pleural empyema. The objective of this study was to assess the predictors for conversion from VATS to open thoracotomy in an assumed stage II postpneumonic empyema. MethodsThis prospective randomized study included 120 patients admitted to cardio-thoracic surgery department, Benha University, between 2011 and 2016. All cases were enrolled for thoracoscopic debridement for an assumed stage II postpneumonic empyema. If stage III empyema was diagnosed during thoracoscopy, conversion to thoracotomy became indicated. Predictors for conversion to thoracotomy were assessed in a univariate, a bivariate correlation and a multivariate analysis using several variables like age, sex, associated comorbidities, duration of symptoms, pleural fluid analysis, and pleural thickness measured by CT scan. ResultsOut of 120 patients, thoracoscopic management was successful in 82 (68%) patients, while conversion to thoracotomy was done in 38 (32%) patients. Conversion to thoracotomy was higher in patients with long duration of symptoms (p < 0.001) with cutoff value at 18.1 days, increased pleural thickness (p < 0.001) with cutoff value at 3.95 mm, increased LDH with cutoff value at 1854 IU/L, and Gram-negative infection of pleural fluid (p < 0.001). Multivariate analysis identified that the duration of symptoms, gram-negative bacteria, LDH and pleural thickness were the significant predictors for conversion from VATS to thoracotomy. ConclusionPredictive factors for conversion to thoracotomy in an assumed stage II postpneumonic empyema include long duration, Gram-negative bacterial infection, increased LDH, and increased pleural thickness.

Massive pleural empyema in infancy

Pleural empyema is an emergency clinical condition characterised by presence of purulent organisms within the pleural fluid. It is associated with significant morbidity and consumption of scarce resources. It is a rare clinical condition but constitute a serious thoracic emergency despite advances in management. Imaging plays an important role in the diagnosis and management of pleural empyema. We present an 11 month old infant with a month history of fever, cough, shortness of breath and weight loss. Clinical diagnosis of bronchopneumonia with pleural effusion was made. Chest radiograph revealed right opaque hemithorax with central mediastinum. Computed tomography (CT) of the chest showed extensive right pleural effusion with compression of viable lung tissue. Ultrasound guided thoracocentesis drained about one litre of pus. Intravenous antibiotics were also administered. Repeat chest radiograph a week after the drainage showed marked reduction in the size of the previously noted opaque right hemithorax with remarkable improvement of the clinical condition.

An integrated care pathway for optimizing the investigation and management of pediatric pleural empyema

There are no reports of the use of an integrated care pathway (ICP) to facilitate the management of pleural empyema in children. Our aim is to assess pleural empyema management in our institute, to establish an ICP and to review the impact of this on the patient journey. Data were collected about management strategies, pain control and length of hospital stay from children admitted in 2000 with a diagnosis of pleural empyema. An integrated care pathway was developed to facilitate change in practice and provide greater consistency in management. This incorporated the use of intrapleural urokinase and guidelines on pain control. This was followed by data collection in 2004 to review the impact of the integrated care pathway. The 2000 review revealed that the majority of children (eight of 13) underwent a primary surgical intervention. Urokinase was not used. The median length of stay was 11.5 days (range 4–49 days). Implementation of the pathway led to a reduction in the number of children who underwent surgery (one of 18) with no adverse impact on clinical outcome. Median length of stay was 9 days (range 2–28 days). Children had a smoother patient journey, with prompter investigation and intervention. Children on the pathway had smaller chest drains inserted, received urokinase and had a clearly recorded analgesia strategy. Pleural empyema in childhood requires multi-disciplinary management. The implementation of an integrated care pathway is a valuable tool for managing a condition that requires multi-disciplinary input.

Modern Management of Empyema Thoracis

Empyema thoracis is a centuries-old disease, with the first documented description being recorded in Egypt more than 5000 years ago. However, despite medical and technical progress, pleural infections remain a major healthcare problem, with incidences rising in children and adults and with significant mortality in adults. More than 65,000 patients suffer from a pleural infection (complicated parapneumonic pleural effusion [PPE] or empyema) each year in the UK and the USA. The hospitalization rates for empyema increased in the USA from 3.04 per 100,000 persons in 1996 to 5.98 per 100,000 persons in 2008. Therefore, efforts to achieve significant improvements in the diagnosis as well therapy of empyema thoracis must continue. Randomized trials with a focus on empyema thoracis are very rare, and thus, evidence-based medicine in this field is also correspondingly rare. The main objectives of most trials have been the evaluation of the efficacy or safety of intrapleural lyses and the importance of videoassisted thoracic surgery (VATS) in patients with complex complicated PPE and empyema. The aim of this article is to provide insights into the modern management of pleural empyema over nearly the past 10 years. Completed and ongoing trials are discussed.

Neonatal pleural empyema in an extremely low birth weight infant

Pleural empyema is rarely seen in the newborn period. Here we report the first case of exclusive and successful conservative management of pleural empyema in an extremely low birth weight infant. Chest drainage or percutaneous aspiration was not feasible. Noninvasive treatment might represent an acceptable option in premature infants.

Toracoscopia no tratamento do empiema pleural em pacientes pediátricos

To evaluate the results of thoracoscopy for the treatment of pleural empyema in pediatric patients. A retrospective study of 117 patients who underwent mediastinoscopy or video-assisted thoracoscopy for pleural empyema treatment. General anesthesia and single-lumen oral intubation were used. Surgery was indicated when there was pleural effusion and no clinical and radiological response to clinical treatment (antibiotics, physiotherapy and thoracocentesis) or severe sepsis, together with loculated pleural effusion (confirmed through ultrasound or computed tomography of the chest). Between February of 1983 and July of 2006, 117 thoracoscopies were performed in patients ranging in age from 5 months to 17 years (mean, 4 years). Mean time for thoracic drainage was 9 days (range, 2-33 days), and mean period of hospitalization was 16.4 days (range, 4 to 49 days). One patient (0.8%) died after surgery, and persistent fistula was observed in 33 patients (28%). In 7 cases (6%), open thoracotomy with pulmonary decortication was performed due to the disposition of the empyema. Management of pleural empyema in this age bracket is still controversial, and surgical indication is often delayed, particularly when there are multiple loculations or severe sepsis. Early thoracoscopy yields a better clinical outcome for pediatric patients with pleural empyema, with apparent decreased morbidity and mortality, earlier chest tube removal, earlier hospital discharge and improved response to antibiotic therapy.

Videoassisted decortication for pleural empyema – alternative to conventional treatment? Indication, technique, results

Objectives: With evolving experience video-assisted thoracoscopic surgery (VATS) was introduced in the management of pleural empyema (VATS-decortication). It remains still under discussion, what patients (pts) are suitable for and what are the limitations of VATS-decortication.

Evolving Experience in the Management of Pleural Empyema: Eroglu E, Tekant G, Erdogan E, et al. Eur J Surg 2004 (April);14:75-78

Evolving Experience in the Management of Pleural Empyema: Eroglu E, Tekant G, Erdogan E, et al. Eur J Surg 2004 (April);14:75-78

Evolving experience in the management of pleural empyema.

The objective of this study was to determine treatment strategies for children admitted with pleural empyema. We reviewed the medical records of 93 consecutive patients with pleural empyema who presented in the last three years. Mean age was 3.8 years (range 3.5 months to 14 years) and the male to female ratio was 52 : 41. The left side was involved in 51 (54.8 %) cases and there was only one case with bilateral effusion. After the chest X-ray and analysis of pus obtained by thoracocentesis, the initial treatment modality was chest tube drainage in 81 (87 %) patients. Children required chest tube drainage for an average of 11.9 +/- 4.8 days. Out of the 81 children, 6 needed thoracotomy due to organized pleural fluid and another 4, who developed loculated pleural effusions, were treated with intrapleural urokinase (UK) administration. Twelve children, who had a delayed presentation with organized loculated pleural fluid and pleural thickening, underwent decortication and one, who was found to have a foreign body, found during surgery, needed an upper lobe resection. Medical management with adequate chest tube drainage and appropriate antibiotics has resulted in full resolution in the majority of patients with empyema. In cases of loculated pleural effusions identified at the early stages of the chest tube drainage, intrapleural UK administration was found to be a safe and efficient treatment modality. Thoracotomy should be reserved for late and organized empyema cases.

Surgical Treatment of Pleural Empyema: Changing Priorities

The surgical management of pleural empyema and post-traumatic clotted haemothorax is described. The study included 15 cases of post-thoracotomy empyema, 23 of empyema of other aetiology and five of post-traumatic haemothorax. Chest-tube drainage was the first measure in most cases. Post-pneumonectomy empyema was treated with partial thoracoplasty plus omentoplasty (8 cases) or plus myoplasty (1 case). Empyema after lobectomy or bilobectomy (4 cases) or after failed decortication (1 case) was managed with thoracoplasty or, in cases of concomitant wound infection, with open-window thoracostomy followed by thoracoplasty. Empyema after subclavian artery reconstruction (1 case) was cleared by removal of a previously unrecognized foreign body. For early empyema of other aetiology or haemothorax (10 cases in total), treatment comprised debridement by video-assisted thoracoscopic surgery (VATS). VATS was also used to establish suitable pleural drainage prior to elective thoracotomy (2 cases). Decortication and partial parietal pleurectomy were performed for organizing-stage empyema (16 cases). Three of the 15 patients with post-thoracotomy empyema died perioperatively, one died two months postoperatively and one had recurrence of bronchopleural fistula during follow-up. One patient with VATS debridement subsequently required thoracotomy and lobectomy for lung abscess. All the others with VATS or decortication recovered without complications. During follow-up there was no mortality or recurrence of empyema.

The diagnosis and management of pleural empyema

The diagnosis and management of pleural infection continues to improve steadily. Recent advances include: newer, smaller, and more comfortable chest drainage catheters; improved pleural pus drainage with the aid of intrapleural fibrinolytics; and improved surgical procedures including thoracoscopic surgery. The optimal size of chest drainage tube remains a matter of debate, with no large data sets available to clarify the optimal tube size. In contrast, there are now small controlled trials of sound basic methodology which suggest a therapeutic role for both fibrinolytics and thoracoscopy. Studies large enough to establish clearly the efficacy and safety of these approaches are now at the planning and recruitment stage.

Is open decortication superior to fibrinolytic therapy as a first line treatment in the management of pleural empyema?

Objective:To confirm that either Fibrinolytic therapy or open decortication which of the two is an effective First line treatment of pleural empyema.Methods:This prospective comparative study was conducted in the department of surgery Sheikh Zayed Medical College and Hospital, Rahim Yaar Khan. Seventy eight (78) patients were included in this study. There were two groups of patients; Group I (n=35) patients treated with fibrinolytic therapy, Group II (n=43) patients treated with open decortication. Data was entered and analyzed in SPSS v16. Student’s t-test was used for comparison of quantitative variables. Chi-square and Fisher’s Exact test were used for comparison of qualitative variables. P-value ≤ 0.05 was taken as significant difference.Results:There was no significant difference in base baseline characteristics of patients of Group I and II. Incidence of comorbidities was also same between the groups. Most of the patients in Group I and II were in empyema stage III. Fluid cultures was positive in 33 (94.3%) patients in group I and 39 (90.7%) patients in group II. 30 (85.7%) was successfully treated using fibrinolytic therapy but this therapy failed in five (14.3%) patients, two of these patients expired within the hospital. There was only one (2.3%) treatment failure in open decortication Group that patient expired within the hospital (p-value 0.04). Overall duration of hospitalization was significantly high in fibrinolytic group, this was 17.6± 1.95 days versus 12.09± 2.18 days in open decortication group (p-value<0.0001). There was no significant difference regarding operative mortality within the two groups.Conclusion:Open Drainage is associated with better outcomes as compared to fibrinolytic therapy when used as a First line treatment of empyema.