Pleural Empyema: the Australian ExperiencePleural Empyema: the Australian Experience Sarath...
Transcript of Pleural Empyema: the Australian ExperiencePleural Empyema: the Australian Experience Sarath...
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Pleural Empyema: the Australian Experience
Sarath Ranganathan
MB ChB MRCP FRCPCH PhD
Department of Respiratory Medicine
Royal Children’s Hospital
Melbourne, Australia
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Royal Children’s Hospital Melbourne
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Royal Children’s Hospital, Sydney(Don’t go to Sydney!)
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Empyema = pus within
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Overview
• Epidemiology
• Investigations
• Microbiology
• The treatment controversy:
The Fuss about Pus!
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Secretion AbsorptionPleuralCirculation
• Pleural space contains 0.3 mL/kg of fluid
• Pleural fluid circulation- lymphatics deal with several 100 mLs of extra fluid/ 24 hrs
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Secretion AbsorptionLung infection
Inflammation
Cytokines from mesothelial cells
Inflammatory cells
Vascular permeability
Bacterial invasion
Neutrophil migrationProcoagulant state
fibrinolysis
Fluid
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Burden of empyema in Australia
Pneumonia admissions per million
Empyema admissions per million
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Guidelines
• British Thoracic Society (2005): www.brit-thoracic.org.uk
• Thoracic Society of Australia and New Zealand (2011): www.thoracic.org.au
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Investigation pathway to diagnosis
Signs of empyema: respiratory distress, prefers to lie on one side, scoliosis, decreased expansion, decreased vocal fremitus, stony dull to percussion, absent breath sounds, decreased vocal resonance, whispering petriloquy, mediastinal shift
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Physical examination in empyema
Clinical sign Sensitivity
Specificity PPV NPVDecreased expansion 0.74 0.91 0.68 0.93Decreased tactile vocal fremitus 0.82 0.86 0.59 0.95Stony dullness 0.53-0.89 0.71 0.55 0.97Absent breath sounds 0.42-0.88 0.83-0.9 0.57 0.96
Adapted from Diaz‐Guzman and Budev. Cleveland Clinic J Med 2008;75:297‐303
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Investigations
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Investigations‐Ultrasound
• Differentiate pleural fluid from solid lung
• Estimates size and position
• Demonstrates loculations and debris
• Identify abscesses
• Marks spot for drain insertion
• Very user dependent
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Septations seen on thoracic ultrasound
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Pus and Septations seen during video assisted thoracoscopic surgery (VATS)
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No routine role for chest computed tomography
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Blood Investigations
• ↑White cell count• ↑ CRP/ESR/procalcitonin
– Not good for differentiating viral/bacterial pneumonia
– Useful to monitor progress in empyema
• ↑ Platelets• Blood cultures‐minority will be positive• LDH
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Pleural Fluid Investigations
• Microbiology– Culture– Stain for AFB– Molecular studies
• Cytology– ↑ lymphocytes in malignancy and TB
• Biochemistry‐ no data for LDH, pH
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Australian Research Network in Empyema (ARNiE)
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Bacteria identified from blood and pleural fluid investigations
Strachan et al. Emerg Infect Dis 2011;17:1839‐45
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S. Pneumoniae serotypesStrachan et al. Emerg Infect Dis 2011;17:1839‐45
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S. Pneumoniae serotypes in relation to age and vacination status
Strachan et al. Emerg Infect Dis 2011;17:1839‐45
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Vaccine‐serotypes identified from pleural fluid in ARNiE compared with national surveillance data
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Pleural fluid –immunochromatogenic assay
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Utility of a bedside immunochromatographic testStrachan et al. Pediatr Pulmonol 2011;46:179‐83
PPV = 93%NPV = 84%
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Aims of treatment
– Sterilise pleural cavity– Get rid of fluid– Return to normal activity– Return to normal lung function
– Expand the lung– Early discharge
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Controversies in Management• Antibiotics
• recurrent thoracocentesis– Shoseyov et al. Chest 2002;121:836
• chest tube drainage alone– Chan et al. J Paediatr Child Health 2000;36:375
• chest drain + fibrinolytics– Thomson et al. Thorax 2002;57:343
• Video assisted thoracoscopic surgery– Sonnappa et al. Am J Respir Crit Care Med 2006;15:221‐7
• Open decortication
↑ Length of stay
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Controversies in Management• Antibiotics
• recurrent thoracocentesis– Shoseyov et al. Chest 2002;121:836
• chest tube drainage alone– Chan et al. J Paediatr Child Health 2000;36:375
• chest drain + fibrinolytics– Thomson et al. Thorax 2002;57:343
• Video assisted thoracoscopic surgery– Sonnappa et al. Am J Respir Crit Care Med 2006;15:221‐7
• Open decortication
↑ Technical skills
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Controversies in Management• Antibiotics
• recurrent thoracocentesis– Shoseyov et al. Chest 2002;121:836
• chest tube drainage alone– Chan et al. J Paediatr Child Health 2000;36:375
• chest drain + fibrinolytics– Thomson et al. Thorax 2002;57:343
• Video assisted thoracoscopic surgery– Sonnappa et al. Am J Respir Crit Care Med 2006;15:221‐7
• Open decortication
↑ Cost
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VATS decortication
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Pathway from diagnosis of empyema
Re-evaluate
Drain adequacyLung abscessBronchopleural fistulaNecrotising pneumoniaAtypical pneumoniaHost factorsWrong diagnosis
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Choosing Fibrinolytics versus VATS
Choose Fibrinolytics if:
Technical competence in chest drain insertion available
Technical skill and experience in VATS unavailable
Child where anesthesia risk too high
Choose VATS if:
Technical competence and experience in VATS available
Don’t mind paying for increased costs!
Surgeons inserts chest drains under general anesthetic anyway
Septations and loculations advanced?
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Inflammation in loculated and free‐flowing exudates
Chung et al. Chest 2005; 128:690‐697
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Conclusions from recent experience
• Empyema epidemiology is changing
• Molecular surveillance is important
• Extending vaccine coverage is indicated
• Management depends on local expertise
• Refer for specialist help sooner improves treatment outcomes
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Acknowledgements
• Professor Adam Jaffe
• Ms. Roxanne Strachan
• ARNie
• Mr Michael Nightingale
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