EMPYEMA GUIDELINES

Dr.PREETHAM KUMAR REDDY

CONSULTANT PEDIATRICIAN &
INTENSIVIST
RAINBOW CHILDRENS HOSPITAL
 Empyema
Pus and fluid from infected tissue in the
pleural cavity.
Also called empyema thoracis, or empyema
of the chest.
Empyema has a number of causes but is
most frequently a complication of pneumonia.
Thoracic Empyema
Thoracic Empyema-- Stage 1

Exudative effusion.
Increased permeability of the
inflammatory and swollen pleural
surface.
Corresponds to the uncomplicated
parapneumonic effusion.
Sterile, fibrin and PMN may present.
Uncomplicated Effusion

Nonpurulent.
-ve Grams stain -ve culture.
Free flowing
pH 7.3
normal glucose level
LDH <1000 IU/L.
Most resolve with appropriate antibiotics
treatment and resolution of the pulmonary
infection.
Progress from stage 1 to 2 may occur
quickly, often within 2448 h .
Thoracic Empyema-- Stage 2
Fibropurulent / true empyema / complicated
pleural effusion.
Initial-- fluid is clear :
WBC > 500 cell/L
Protein> 2.5 g/dL
pH< 7.2,
LDH< 1000 IU/L, fibrin deposits.
Angioblastic and fibroblastic proliferation,
heavy fibrin deposition on both pleura,
particularly the parietal pleura.
 Later
fluid purulent
WBC 15000,
ph <7.0,
glucose < 50 mg/dL
LDH > 1000 IU/L.
Thoracic Empyema-- Stage 3

1 week after infection-- collagen organization,

entrapment of the underlying lung.
3-4 week-- mature, turns into a peel.
peel prevents entry of anti-microbial drugs in
the pleural space and contributes to drug
resistance.
Thickened pleural peel restricts lung
movement and leads to trapped lung and
fibrothorax
Etiology

Pneumococcal infection remains the

most common isolated cause in
developed countries, with
Staphylococcus aureus the
predominant pathogen in the
developing world.
Jaffe et al. Pediatr Pulmonol. 2005; 40:148-156.
US prevalence

After prevnar (1999-2000 vs 2001-2002)

1) Patients admitted with empyema (per 10
000 admissions) decreased from 23 to 12.6
2) Prevalence of S pneumoniae has
decreased from 66% to 27%
3) S aureus has become the most common
pathogen isolated (18% vs 60%), with 78% of
those being methicillin resistant.
Schultz et al.Pediatrics. 2004 Jun;113(6):1735-40
265 children with empyema admitted to
the PGIMER, 198998

Culture positivity had decreased significantly

(48% v 75%) over the years.
Staphylococcus aureus commonest (77%)
aetiological agent;
Streptococcus pneumoniae cases seen
during the winter and spring season.
Gram negative rods grew in 11%.
Community acquired MRSA in 3 patients
Baranwal et al .Arch Dis Child. 2003 November; 88(11): 10091014.
Diagnostic Evaluation

Radiographic Studies
PA and decubitus x-ray
First step in diagnosis
Fluid layer is seen on dependent
side
USG

Very useful tool for diagnosis, guidance of thoraco-

centesis, or pleural catheter placement.
Sonography can distinguish solid from liquid pleural
abnormalities with 92% accuracy compared to 68%
accuracy with chest X-ray. When both are combined,
accuracy rises to 98%
USG shows limiting membranes suggesting the
presence of loculated collections even when they are
invisible by CT scan.
CT scan

Chest CT Scan
Defines effusion
consolidation
abscess
necrosis
adhesions
Guides interventions
Is CT Scan necessary

Unnecessary for most cases of

pediatric empyema
Has a role in complicated cases
Initial failure to aspirate pleural fluid
failing medical management and
particularly in immunocompromised
children where a CT scan could reveal
other serious clinical problems.
Goal of treatment

1. Control of infection
2. Drainage of pus
3. Expansion of lungs
Stage 1/exudative stage

Free-flowing serous effusion pH>7.20, Sugar >60

mg/dL, LDH >3 times the upper limit of normal
Management with
Antibiotics
Drainage if effusion is significant
Give consideration to early active treatment as
conservative treatment results in prolonged
duration of illness and hospital stay.
Empirical antibiotics

Anti Staph antibiotic + Cephalosporin +

Aminoglycoside
Suspected anaerobic infection
Clindamycin should be added
Antibiotics

Parenteral therapy to be continued for 48-72

hours after abatement of fever and then oral
therapy can be used to complete the course.
Antibiotic to be continued until
patient is afebrile,
WBC count is normal,
radiograph shows considerable clearing
Duration of oral therapy is 1- 4 weeks.
Drainage Options

Simple thoracocentesis
Necessary for analyzing pleural fluid & to
direct antibiotic therapy
Chest tube placement
Indicated for all large transudative effusions
& the early exudative phase of
parapneumonic pneumonias
Repeated thoracocentesis is rarely
successful
Empyema drainage

CT or USG guided drainage if

empyema collection is small
Chest tube must be kept inside till
drainage is less than 30-50 ml per day
and cavity size is less than 50 ml in
size
The addition of fibrinolytic therapy may
improve drainage during the
fibrinopurulent stage
Who what where

Chest drains should be inserted by

adequately trained personnel to reduce
the risk of complications.
Small bore percutaneous drains should
be inserted at the optimum site
suggested by chest ultrasound
The drain should be removed once
there is clinical resolution or drainage is
< 50 ml.
Safe triangle for insertion of chest
drains
Stage 2/fibronopurulent stage

Uncomplicated<7.20, Sugar <60 mg/

dL, LDH >3 times the upper limit of
normal
Antibiotics
Chest tube
Drainage
Consider fibrinolytics
Complicated
pH <7.00,Sugar <60 mg/dL, LDH>3 times
the upper limit
Antibiotics
Chest tube drainage, consider
fibrinolytics or
VATS
Fibrinolytics

There is no evidence that any of the

three fibrinolytics are more effective
than the others, only urokinase studied
in a RCT in children so is
recommended.
tPA is used in US
Thompson et al Thorax 2002;57:343-347;
Stage 3/organizing stage
Fibrinous peel, lung entrapment

Antibiotics
VATS
if unsuccessful decortication
Ampofo et al. Pediatr Infect Dis J. 2007 May ; 26(5): 445446 .
Indications for Surgical
Treatment

Gates et al (2004) in a retrospective

review found that 80% of children with
empyema did not require surgical
intervention
Lack of clinical & radiological response
to medical treatment
Complex empyema with significant lung
pathology
Systematic Review of Optimal
Treatment (Gates et al, 2004)

44 studies describing treatment of empyema in

1369 infants & children (retrospective
reviews)
4 treatment strategies: chest tube drainage,
chest tube + fibrinolytics,
open thoracotomy + decortication &
VATS
LOS was the only statistically significant
difference between 4 strategies
VATS LOS = 10.5 days vs. CT 16.4 days or
fibrinolytic 18.9 days
Thank You