pleural empyema management benoit guery maladies infectieuses philippe ramon service d’endoscopie...
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Pleural EmpyemaManagement
Benoit Guery Maladies Infectieuses
Philippe RamonService d’endoscopie Respiratoire
CHRU Lille
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Empyema formation
Exudative stage fibrinous material forms on both pleural surfaces. As more fibrin is deposited
Fibrinopurulent stage may last several weeks pleural surfaces may be joined by fibrinous septae
which cause the fluid to become loculated Organisational stage
Proliferation of fibroblasts on the pleural surfaces, which form an inelastic covering preventing adequate lung expansion (fibrothorax).
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Goals of the treatment
Treat the infection
Drain the purulent effusion adequately and
completely
Re-expand the lung to fill the pleural space
Eliminate complications and avoid chronicity
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The infection
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Bacteriological data
Pleural Ponction : Exsudate Direct analysis, Gram stain Aerobic and anaerobic cultures (Bactec) If possible before antibiotic treatment
Results Mono or polymicrobial ( 4-30%) Variations between series Variations between underlying conditions
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Wait et al, Chest 1997 Cheng et al, Chest 2005
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Maskell et al, NEJM 2005
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Bacteriological data. Streptococcus pneumoniae: 15-20%
Increased resistance
Staphylococcus:15-30% Streptococcus spp Gram Negative: 20-50%
Klebsiella, Enterobacter, Pseudomonas, Hemophilus, E.Coli
Anaerobes: Fusobacterium, Bacteroides fragilis
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Microbiological diagnosis techniques
Le Monnier et al, Clin Inf Dis 2006
3 methods- Standard culture - PCA: Pneumococcal capsular antigen - 16S rDNA PCR confirmed by pneumolysin PCR
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Microbiological diagnosis techniques
Latex antigen detectionSe: 90%Sp: 95%
Le Monnier et al, Clin Inf Dis 2006
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Antibiotic treatment As soon as the bacteriologic sample
are recovered Pneumonia
Amoxicillin, 3GC or 3GC +/- MetronidazoleAmox-clavulanic acid
Dosage of the molecule
NosocomialTazobactam or Imipenem+/- Aminoglycoside or Quinolone
Not Pneumococcus directed molecules
Adapted to the laboratory results
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Adequate drainage
Available techniques
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Primary treatment options
Antibiotics alone; Recurrent thoracocentesis Insertion of chest drain alone or in
combination with fibrinolytics VATS. Open decortication
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Thoracocenthesis
Big caliber needle Mostly diagnosis technique Therapeutically used if the liquid remains
fluid Theoretically allows pleural lavage
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Chest Tube As soon as the liquid is thick
Localizationfree: axillaryloculated: Chest imaging using
ultrasonography and/or computed tomography
Size: 20 à 24
Bedside
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Pleural Lavage
Isotonic saline +/- Noxyflex (noxytioline)
Modalités3 way stopcockDirectly through the CT: 250 to 500 ml Cautiously if suspicion of broncho-pleural fistula
Timing:Immediately after CT placement+++Once a day until the liquid is clear
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NOXYFLEX (noxytioline)
Local disinfectant (formaldéhyde) 2,5 g diluted in a least 100ml isotonic
saline Maximum: 5g/day Incompatible with iodine
polyvidone,chlorhexidin, chlorine solution, lactic acid
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Fibrinolytics
Urokinase: 100 000 or 300 000 IU conditioning
Streptokinase: 250000 IU conditioning250.000 IU in 10-20 ml isotonic salineDon’t evacuate before 24 to 48 heuresConstantly associated with fever (38-39°C)Then evacuate
Pleural lavageclamp 4h ( Chest 1996)
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Video-assisted thoracic surgery
Collection<10 cm: unusualVisual control of the CT position
5 mm introducer, 4 mm optical
Collection>10 cm10 mm introducerTwo or three ports are made in the chestOne port is utilised for the camera and the others for
grasping instrumentsFree fluid is evacuated and loculations drained under
thoracoscopic visualisation. Fibrinous adhesions are separated and the pleural debris
removed from the pleural lining using endoscopic grasping forceps or by extensive irrigation and suction.
Following the procedure, one or two chest drains are then placed in the portholes.
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Local antibiotics
Usually Rifampin or Colimycin Still debated Do not replace systemic treatment
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Physiotherapy
Key to a correct evolution After CT removal Often and for a long time….. Decrease surgery Decrease long term pain and functionnal
limitations
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Therapeutic choices
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Guidelines to predict which patients with non-purulent parapneumonic effusions warrant
chest tube drainage 240 patients with PPE
85 uncomplicated PPE 67 complicated PPE 88 empyema
Porcel et al, Respir Med 2006
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BTS and ACCP criteria
BTS: non purulent PPE is complicated if any of the following pH<7.2 LDH> 1000 IU/L Glucose <40mg/dL Positive culture
ACCP: Positive culture pH<7.2 Glucose <60mg/dL Effusion>half of the
hemithorax
Porcel et al, Respir Med 2006
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Porcel et al, Respir Med 2006
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Compare Chest Tube + Streptokinase (n=9) vs VATS (n=11)
B score on the Cochrane analysis with methodological concerns: Small number Patient selection Unclear allocation and
outcome assessor blinding
But: VATS is superior to CT for large loculated pleural empyemas Duration CT LOS
Wait et al, Chest 1997 Cochrane 2005
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Prospective study between 1997 and 2004
2 groups I: video-assisted
thoracoscopy (chest tube, fibrin debrided)
II: chest tube without VAT
Surgical decortication Group I: 17.1% Group II: 37.1%
LOS Group I: 8.3 days Group II: 12.8 days
Bilgin et al, ANZ J Surg 2006
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Hypothesis: Urokinase is effective through the lysis and not the volume effect
Randomized double blind study UK (15 patients) for 3
days, 100 000 IU in 100 ml NS
Control (16 patients), 100 ml NS for 3 days
Complete drainage UK: 13/15 (86%) NS: 4/16 (25%)
Bouros et al, AJRCCM 1999
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Cochrane analysis 2007
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Cochrane analysis 2007
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Cochrane analysis 2007
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Cochrane analysis 2007
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Cochrane analysis 2007
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Cochrane analysis 2007
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Prospective study from 2001 to 2004 Cause: bacterial pneumonia 2 groups:
A: CT (70) B: CT + SK (57)
Misthos et al, Eur J Car Thor Surg 2005
Multivariate analysis: the use of fibrinolysisis the only independent factor associatedwith a favorable outcome
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452 patients with pleural infection Sk 250 000 IU twice daily
for 3 days Placebo
No difference in mortality, rate of surgery, radiographic outcomes, LOS
Serious adverse events more common with Sk (chest pain, allergy, fever)
Maskell et al, NEJM 2005
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Meta-analysis with 5 properly randomized trials comparing fibrinolytic agents to placebo
575 patients
Tokuda et al, Chest 2006
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Only one study analyzed… no differences observed on the parameters
Cochrane analysis 2007
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Fibrinolytics vs VATS
60 children matched No difference
LOS after interventionFailure rateRadiologic outcome at 6 month
Treatment cost with UK ($6 914)< VATS ($10 146)
Sonnappa et al, AJRCCM 2006
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Case report 1
50 yo Left Pneumococcus empyema Admitted on the 4th day D2 streptase instillation D3 VATS+2 CT CT removal on D8 Discharged on D12
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Case report 2
76 yo March 96: Pneumonia April 96 : Left lung effusion No fever, CRP 29, fibrinogen 7g/l Exsudate, LDH 7200, glucose 0,24g/l
cytology PMN, negative direct examination
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VATS (25/4/96): loculatedRemoved debris and liquid (600ml)Posterior CT n°24
Pleural lavage (Noxyflex) CT removal on 2/5/96
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Indications
Hamm et al, ERJ 1997
Thoracocentesis
Clear liquid Not clear or purulent effusion
pH>7.20 pH<7.20
No intervention Reccurent thoracocentesis
Not loculated Loculated
Drainage Pleural lavage
DrainagePleural lavageFibrinolytics
FailureVATSSurgery
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IndicationsThoracocentesis
Clear liquid Not clear or purulent effusion
pH>7.20 pH<7.20
No intervention
Not loculated Loculated
Drainage Pleural lavage
Fibrinolytics 24-48h
DrainageFibrinolyticsPleural lavage
VATSDrainagePleural lavage
FailureVATSSurgery
FailureSurgery
Reccurent thoracocentesis