Definitions
Parapneumonic Effusion
Definitions
- Parapneumonic Pleural Effusion: effusion which occurs in association with bacterial pneumonia, lung abscess, or bronchiectasis (although an infected pleural effusion may rarely develop without an adjacent pneumonia)
- Uncomplicated Parapneumonic Effusion: occurs with movement of lung interstitial fluid and neutrophils across the visceral pleural into the pleural space
- Exudate with pH >7.2
- Complicated Parapneumonic Effusion: occurs when there is bacterial invasion of the pleural space, neutrophil influx, and pleural space acidosis (due to anaerobic utilization of glucose by the neutrophils and bacteria)
- Exudate with pH <7.2
- Higher Incidence of Complicated Parapneumonic Effusion in HIV/AIDS (see Human Immunodeficiency Virus, [[Human Immunodeficiency Virus]])
- Uncomplicated Parapneumonic Effusion: occurs with movement of lung interstitial fluid and neutrophils across the visceral pleural into the pleural space
Empyema
Definitions
- Vianna Definition of Empyema (JAMA, 1971) [MEDLINE]: positive pleural fluid culture or WBC >15,000/mm3 and protein >3.0 g/dL
- Weese Definition of Empyema (Arch Intern Med, 1973) [MEDLINE]: >500 WBC/mm3, protein >2.5 g/dL, or specific gravity >1.018
- Modern Definition: presence of pus in the pleural space and/or positive Gram stain of pleural fluid
- Positive Pleural Fluid Cultures are Not Required for the Diagnosis of Empyema, Since Pleural Fluid Cultures May Be Negative for Multiple Reasons
- Anaerobic Organisms are Difficult to Culture
- Insensitivity of Bacterial Culture Methods
- Pleural Fluid Sampling Often Occurs After a Patient Has Already Received Antibiotics
- Pleural Fluid Sampling Errors May Occur Due to Loculations with Aspiration of a Sterile Fluid Pocket, Adjacent to an Infected Fluid Pocket
- Positive Pleural Fluid Cultures are Not Required for the Diagnosis of Empyema, Since Pleural Fluid Cultures May Be Negative for Multiple Reasons
Epidemiology
Parapneumonic Effusion
- Prevalence of Parapneumonic Effusion: parapneumonic effusion occurs in approximately 40% of hospitalized patients with bacterial pneumonia [MEDLINE]
Risk Factors for Parapneumonic Effusion
- Delay in Receiving Medical Care
- Cholethorax (see Pleural Effusion-Cholethorax, [[Pleural Effusion-Cholethorax]])
- Inadvertent Placement of Nasogastric (NG) Tube Into Pleural Space with Enteral Tube Feeding Infusion (see Nasogastric Tube, [[Nasogastric Tube]])
- Rheumatoid Arthritis (RA) (see Rheumatoid Arthritis, [[Rheumatoid Arthritis]]): likely has increased risk of empyema
Protective Effect of Inhaled Corticosteroids Against the Development of Parapneumonic Pleural Effusion (see Corticosteroids, [[Corticosteroids]])
- Clinical Efficacy
- Spanish Study of the Effect of Prior Inhaled Corticosteroids (in Both Asthma and COPD) on the Risk of Developing Parapneumonic Effusion in Association with Pneumonia (Am J Respir Crit Care Med, 2013) [MEDLINE]
- Prior Use of Inhaled Corticosteroids Decreased the Risk of Parapneumonic Effusion in Association with Pneumonia
- Prior Use of Inhaled Corticosteroids was Associated with Higher Pleural pH, Higher Pleural Glucose, Lower Pleural Protein, and Lower Pleural LDH
- Spanish Study of the Effect of Prior Inhaled Corticosteroids (in Both Asthma and COPD) on the Risk of Developing Parapneumonic Effusion in Association with Pneumonia (Am J Respir Crit Care Med, 2013) [MEDLINE]
Empyema
- xx
Risk Factors for Empyema
- Diabetes Mellitus (DM) (see Diabetes Mellitus, [[Diabetes Mellitus]])
- Epidemiology: increases risk for Klebsiella Pneumoniae Empyema
- Influenza (see Influenza Virus, [[Influenza Virus]])
- Predominant Etiologies of Bacterial Superinfection and Empyema Following Influenza (J Infect Dis, 2008) [MEDLINE]
- Staphylococcus Aureus (see Staphylococcus Aureus, [[Staphylococcus Aureus]])
- Streptococcus Pneumoniae (see Streptococcus Pneumoniae, [[Streptococcus Pneumoniae]])
- Streptococcus Pyogenes (Group A β-Hemolytic Streptococcus) (see Streptococcus Pyogenes, [[Streptococcus Pyogenes]])
- Predominant Etiologies of Bacterial Superinfection and Empyema Following Influenza (J Infect Dis, 2008) [MEDLINE]
Etiology
- Pneumonia (see Pneumonia, [[Pneumonia]])
- Epidemiology
- Parapneumonic Effusion Occurs in 40% of Bacterial Pneumonias Cases (Am J Med, 1980) [MEDLINE]
- Pneumonia Accounts for 55% of Parapneumonic Effusion Cases
- Epidemiology
- Esophageal Perforation (see Esophageal Perforation, [[Esophageal Perforation]])
- Epidemiology: xxx
- Clinical: usually produces an infected effusion
- Rheumatoid Arthritis (RA) (see Rheumatoid Arthritis, [[Rheumatoid Arthritis]])
- Epidemiology: xxx
- Physiology: probably due to formation of bronchopleural fistula via rupture of necrotic subpleural nodules
- Sepsis (see Sepsis, [[Sepsis]])
- Epidemiology: xxx
- Physiology: xxxx
- Spontaneous Pneumothorax (see Pneumothorax, [[Pneumothorax]])
- Epidemiology: xxx
- Subdiaphragmatic Infection
- Types of Subdiaphragmatic Infection
- Abdominal Abscess (see Abdominal Abscess, [[Abdominal Abscess]])
- Pyogenic Liver Abscess (see Pyogenic Liver Abscess, [[Pyogenic Liver Abscess]])
- Types of Subdiaphragmatic Infection
- Thoracentesis (see Thoracentesis, [[Thoracentesis]])
- Epidemiology
- Physiology: xxx
- Thoracic Surgery
- Epidemiology: accounts for 21-25% of cases
- Incidence of Post-Pneumonectomy Empyema: 2-10%
- Epidemiology: accounts for 21-25% of cases
- Trauma (see Trauma-General, [[Trauma-General]])
- Epidemiology: accounts for 6% of cases
- Idiopathic Parapneumonic Effusion
- Epidemiology: accounts for 7% of cases
Microbiology
General Comments
- Animal Studies Indicate that a Mixed Pleural Space Infection with Both Aerobes and Anerobes is More Likely to Produce an Empyema than Infection with a Single Organism (J Pediatr Surg, 1994) [MEDLINE]
- Mixed Aerobic and Anaerobic Empyema was Found in 23% of Cases (Chest, 1993) [MEDLINE]: mixed microaerophilic or aerobic Streptococci with anaerobes are a common combination (as these are all components of normal oral flora)
- For These Reasons, Isolation of an Aerobic Organism Alone Does Not Eliminate the Need to Cover for Unrecovered Anaerobic Organisms
- Microbiology of Pleural Space Infection Appears to Be Changing (Respirology, 2011) [MEDLINE]
- Different Organisms Predominate in Pediatric vs Adult Cases
- Different Organisms Predominate in Community-Acquired vs Hospital-Acquired Cases
- Pneumococcal Vaccination Has Altered Streptococcus Pneumoniae Serotypes in Empyema
Organisms
- Anerobes: anaerobes are present in 36-76% of empyemas (Chest, 1993) [MEDLINE]
- Bacteroides Fragilis (see Bacteroides Fragilis, [[Bacteroides Fragilis]])
- Fusobacterium Nucleatum (see Fusobacterium Nucleatum, [[Fusobacterium Nucleatum]])
- Peptostreptococcus (see Peptostreptococcus, [[Peptostreptococcus]])
- Prevotella (see Prevotella, [[Prevotella]])
- Actinomycosis (see Actinomycosis, [[Actinomycosis]])
- Epidemiology: pleural space involvement occurs in >50% of thoracic Actinomycosis cases
- Bacillus (see Bacillus, [[Bacillus]])
- Bacillus Anthracis (see Anthrax, [[Anthrax]])
- Epidemiology: xxx
- Bacillus Cereus (see Bacillus Cereus, [[Bacillus Cereus]])
- Epidemiology: uncommon etiology of parapneumonic effusion
- Bacillus Anthracis (see Anthrax, [[Anthrax]])
- Clostridium (see Clostridium, [[Clostridium]])
- Epidemiology: uncommon etiology of parapneumonic effusion
- Enterobacteriaceae (Selected Organisms) (see Enterobacteriaceae, [[Enterobacteriaceae]])
- Citrobacter (see Citrobacter, [[Citrobacter]])
- Enterobacter (see Enterobacter, [[Enterobacter]])
- Escherichia Coli (see Escherichia Coli, [[Escherichia Coli]]): aerobic Gram-negative rod
- Klebsiella (see Klebsiella, [[Klebsiella]]): aerobic GNR
- Proteus (see Proteus, [[Proteus]])
- Salmonella (see Salmonella, [[Salmonella]])
- Serratia (see Serratia, [[Serratia]])
- Francisella Tularensis (see Tularemia, [[Tularemia]])
- Epidemiology: uncommon etiology of parapneumonic effusion
- Haemophilus (see Haemophilus, [[Haemophilus]])
- Haemophilus Influenzae (see Haemophilus Influenzae, [[Haemophilus Influenzae]])
- Haemophilus Parainfluenzae (see Haemophilus Parainfluenzae, [[Haemophilus Parainfluenzae]])
- Legionella (see Legionellosis, [[Legionellosis]])
- Listeria Monocytogenes (see Listeriosis, [[Listeriosis]])
- Epidemiology: uncommon etiology of parapneumonic effusion
- Pseudomonas (see Pseudomonas, [[Pseudomonas]])
- Staphylococcus (see Staphylococcus, [[Staphylococcus]])
- Staphylococcus Aureus (see Staphylococcus Aureus, [[Staphylococcus Aureus]])
- Methicillin-Sensitive Staphylococcus Aureus (MSSA)
- Methicillin-Resistant Staphylococcus Aureus (MRSA)
- Staphylococcus Epidermidis (see Staphylococcus Epidermidis, [[Staphylococcus Epidermidis]])
- Staphylococcus Aureus (see Staphylococcus Aureus, [[Staphylococcus Aureus]])
- Streptococcus (see Streptococcus, [[Streptococcus]])
- Streptococcus Anginosus Group (Formerly Streptococcus Milleri Group) (see Streptococcus Anginosus Group, [[Streptococcus Anginosus Group]])
- Streptococcus Pneumoniae (see Streptococcus Pneumoniae, [[Streptococcus Pneumoniae]])
- Streptococcus Pyogenes (Group A β-Hemolytic Streptococcus) (see Streptococcus Pyogenes, [[Streptococcus Pyogenes]])
- Mycobacterium Tuberculosis (see Tuberculosis, [[Tuberculosis]])
- Tuberculous Empyema is a Rare Manifestation in which Tuberculous Infection Results in a Neutrophil-Predominant Empyema: in contrast, tuberculous pleurisy is a lymphocytic-predominant effusion which occurs due an immunologic response to tuberculous proteins
Physiology
- Exudative Stage: rapid accumulation of sterile fluid (with low WBC, low LDH, normal glucose, normal pH) in pleural space (probably from interstitium in lung/possibly some originates from visceral pleural capillaries also)
- Progression can be arrested at this stage if treated with antibiotics alone
- Fibropurulent Stage: accumulation of neutrophils, bacteria, fibrin, and cellular debris in pleural space (with resultant decrease in pH and glucose/increase in LDH/formation of loculations in space)
- Organization Stage: fibroblasts grow into exudate from visceral and parietal pleura, creating an inelastic pleural peel
- Thick exudate may drain through the chest wall (empyema necessitatis) or into the lung (bronchopleural fistula)
Diagnosis
Complete Blood Count (CBC) (see Complete Blood Count, [[Complete Blood Count]])
- Leukocytosis
- Leukocytosis with Aerobic Bacterial Pneumonia
- Mean WBC in Cases without Parapneumonic Effusion: 17,100
- Mean WBC in Cases with Parapneumonic Effusion: 17,800
- Leukocytosis with Anerobic Bacterial Pneumonia and Parapneumonic Effusion
- Median WBC: 23,500
- Leukocytosis with Aerobic Bacterial Pneumonia
- Mild Anemia (see Anemia, [[Anemia]]): common in anerobic cases
Serum Procalcitonin (see Serum Procalcitonin, [[Serum Procalcitonin]])
- Rationale
- Serum Procalcitonin Has Proved Useful in Diagnosing Bacterial Pneumonia
- Clinical Efficacy
- Study of Serum Procalcitonin in Differentiating Parapneumonic Effusion from Malignant/Tuberculous Effusion (Clin Biochem, 2013) [MEDLINE]
- Serum Procalcitonin >0.18 ng/mL: 83.3% sensitivity/81.0% specificity in determining if a pleural effusion has a bacterial infectious etiology
- Serum Procalcitonin Performed Better than Pleural Fluid Procalcitonin
- Study of Serum Procalcitonin in Differentiating Parapneumonic Effusion from Malignant/Tuberculous Effusion (Clin Biochem, 2013) [MEDLINE]
- Other Considerations
- Serum Procalcitonin Does Not Have Utility in Determining the Need for Pleural Chest Tube Drainage
Pleural Fluid (see Thoracentesis, [[Thoracentesis]])
Indications for Thoracentesis in the Setting of Parapneumonic Effusion (Chest, 2000) [MEDLINE]
- Free-Flowing Pleural Fluid Which Layers >25 mm on a Lateral Decubitus Chest X-Ray or Chest CT
- Pleural Fluid Loculations
- Thickened Parietal Pleural on Intravenous Contrast-Enhanced Chest CT: this is suggestive of empyema
Technique
- Ultrasound Guidance is Standard
Appearance
- Example: empyema (purulent drainage) in pleurevac container
Odor
- Foul-Smelling Odor: indicates the presence of anaerobic infection
Pleural Fluid Cell Count and Differential
- xxx
Pleural Fluid pH
- Decreased: pleural fluid pH >7.20 is considered the recommended threshold for pleural chest tube drainage (Chest, 2000) [MEDLINE]
- Pleural Fluid pH is the Most Sensitive Indicator for Pleural Chest Tube Drainage (Am J Respir Crit Care Med, 1995) [MEDLINE]
- Technique
- Improper Processing of Pleural Fluid pH Samples Occurs in 30-50% of Labs in the US (Curr Opin Pulm Med, 2013) [MEDLINE]
- Potential Errors in pH Measurement in Pleural Fluid Samples: exposure of sample to air, delay in measurement, use of pH meter instead of a blood gas machine
- Improper Processing of Pleural Fluid pH Samples Occurs in 30-50% of Labs in the US (Curr Opin Pulm Med, 2013) [MEDLINE]
- Other Conditions May Also Present with Pleural Fluid Acidosis and/or Low Pleural Fluid Glucose (see Pleural Effusion-Glucose + pH Patterns, [[Pleural Effusion-Glucose + pH Patterns]])
Pleural Fluid Glucose
- Decreased: pleural fluid glucose <60 mg/dL is considered the threshold for pleural chest tube drainage
- Diagnostic Accuracy of Pleural Fluid Glucose for Parapneumonic Effusion is Less Sensitive than Pleural Fluid pH (Am J Respir Crit Care Med, 1995) [MEDLINE]: however, it may be useful when pleural fluid pH is not available
Pleural Fluid Total Protein
- Pleural Fluid Total Protein/Serum Total Protein Ratio >0.5
- Exudative (see Pleural Effusion-Exudate, [[Pleural Effusion-Exudate]])
Pleural Fluid Lactate Dehydrogenase (LDH)
- Pleural Fluid LDH/Serum LDH Ratio >0.6
- Exudative (see Pleural Effusion-Exudate, [[Pleural Effusion-Exudate]])
- Pleural Fluid LDH is Increased Due to the Lysis of Neutrophils
- Pleural Fluid LDH >66% of Upper Limit of Normal Range for Serum LDH
- Pleural Fluid LDH May Be >1000 IU/L in Some Cases
Serum-Pleural Albumin Gradient (SPAG)
- Serum-Pleural Albumin Gradient (SPAG) <1.2 g/dl
- If Fluid Clinically Appears to be a Transudate and SPAG >1.2, but Light’s Criteria Suggest Exudate, Pleural Fluid Can Be Assumed to Be a Transudate: due to the fact that albumin is lower molecular weight than other proteins and crosses capillary walls more easily
Pleural Fluid Cholesterol
- Pleural Fluid Cholsterol: elevated >55-60 mg/dL
- Seen in All Exudates
- Pleural Cholesterol/Serum Cholesterol Ratio: elevated
- Seen in All Exudates
Staining
- Gram-Stain: useful to identify etiologic organism
- Acid-Fast Bacteria (AFB) Stain: useful to identify etiologic organism
Pleural Fluid Culture
- Sensitivity of Pleural Fluid CUlture
- Pleural Fluid Culture is Often Negative in Empyema: since animal models demonstrate that bacteria are typically cleared rapidly from the pleural space (Ann Thoracic Surg, 1987) [MEDLINE]
- Anerobic Organisms are Difficult to Isolate by Pleural Fluid (and Blood) Culture: increased sensitivity for detection of anaerobes may be provided by molecular methods (Chest, 2011) [MEDLINE]
- Use of Blood Culture Bottles to Culture Pleural Fluid: use of blood culture bottles (in addition to standard culture) improves the sensitivity of pleural fluid culture (Thorax, 2011) [MEDLINE]
Molecular Analysis of Pleural Fluid
- PCR or Rapid Antigen Assay for Streptococcus Pneumioniae: these increase sensitivity for detection of Streptococcus Pneumioniae (Clin Infect Dis, 2006) [MEDLINE]
Chest X-Ray (see Chest X-Ray, [[Chest X-Ray]])
- Indications
- Quantification of Pleural Fluid: using upright and lateral decubitus chest x-ray to determine the extent of layering
- Detection of Pleural Fluid Loculation: may be seen on chest x-ray in some cases
Chest CT with Intravenous Contrast (see Chest Computed Tomography, [[Chest Computed Tomography]])
- Technique
- Intravenous Contrast Accentuates the Pleural Line: this aids in the differentiation of parenchymal consolidation vs a pleural collection
- Indications
- Quantification of Pleural Fluid
- Identification of Endobronchial Lesions
- Identification of Associated Pneumonia/Lung Abscess (see Pneumonia, [[Pneumonia]] and Lung Abscess, [[Lung Abscess]])
- Detection of Pleural Fluid Loculation and Localization for Potential CT-Guided Chest Tube Placement
- Example: red arrow indicates loculated posterior pleural effusion which was amenable to single CT-guided chest tube drainage
- Findings
- “Split Pleura Sign” (with Chest CT with Intravenous Contrast): thickening of the visceral and parietal pleura with >30 mm of separation of the pleural surfaces
- Pleural Fluid Loculation
- Pleural Fluid Microbubbles: presence of microbubbles within the pleural fluid collection (which presumably are introduced via a prior thoracentesis) suggest that the fluid will be more resistant to chest tube drainage (Clin Radiol, 2006) [MEDLINE]
- CT Findings Which Allow Differentiation of Empyema from Lung Abscess (see Lung Abscess, [[Lung Abscess]])
- CT Features Suggestive of Empyema
- Angles: “ball under the carpet” appearance (obtuse angles between fluid collection and chest wall)
- Shape: lenticular shape
- Internal Surface: typically smooth internal surface of fluid collection
- Displacement: displacement of lung and mediastinum, as empyema pushes adjacent structures toward contralateral side
- “Split Pleura Sign”: separation of parietal and visceral pleura
- Air-Fluid Level: may be seen in cases with an associated bronchopleural fistula (see Bronchopleural Fistula, [[Bronchopleural Fistula]])
- CT Features Suggestive of Lung Abscess (see Lung Abscess, [[Lung Abscess]])
- Angles: acute angles between fluid collection and chest wall
- Shape: typically round shape
- Internal Surface: typically thick, irregular internal surface of fluid collection
- Displacement: lack of displacement of lung and mediastinum, as abscess tends to destroy adjacent lung, rather than displace it
- Air-Fluid Level: may be seen
- CT Features Suggestive of Empyema
Thoracic Ultrasound (see Thoracic Ultrasound, [[Thoracic Ultrasound]])
- Indications
- Quantification of Pleural Fluid
- Detection of Pleural Fluid Loculation
- Example: red arrow indicates loculations within pleural effusion
Other Pleural Fluid Assays
- Pleural Fluid VEGF and IL-8 Levels
- Study of Angiogenic Cytokines in Pleural Fluid (PLoS One. 2013) [MEDLINE]
- Higher Pleural Fluid VEGF and IL-8 Levels Identified Complicated Parapneumonic Effusions
- Higher VEGF Level or Larger Effusion was Associated with Decreased Fibrinolytic Activity, Development of Pleural Fluid Loculation and Fibrosis, and Higher Risk of Medical Treatment Failure
- Study of Angiogenic Cytokines in Pleural Fluid (PLoS One. 2013) [MEDLINE]
Clinical-Light Classification Scheme for Parapneumonic Effusion/Empyema
- Class 1 (Non-Significant Parapneumonic Effusion)
- Small
- Layering Pleural Fluid <1 cm Thick on Decubitus Chest X-Ray
- Class 2 (Typical Parapneumonic Effusion)
- Layering Pleural Fluid >1 cm Thick on Decubitus Chest X-Ray
- Pleural Fluid Glucose <40
- Pleural Fluid pH >7.2
- Negative Pleural Fluid Gram Stain and Culture
- Class 3 (Borderline Complicated Parapneumonic Effusion)
- Pleural Fluid pH 7.0-7.2
- Pleural Fluid LDH >1000
- Pleural Fluid Glucose <40
- Negative Pleural Fluid Gram Stain and Culture
- Class 4 (Simple Complicated Parapneumonic Effusion)
- Pleural Fluid pH <7.0
- Pleural Fluid Glucose <40
- Positive Pleural Fluid Gram Stain and Culture
- Pleural Fluid Not Loculated or Frank Pus
- Class 5 (Complex Complicated Parapneumonic Effusion)
- Pleural Fluid pH <7.0
- Pleural Fluid Glucose <40
- Positive Pleural Fluid Gram Stain or Culture
- Multiloculated
- Class 6 (Simple Empyema)
- Frank Pus
- Single Locule or Free Flowing
- Class 7 (Complex Empyema)
- Frank Pus
- Multiple Locules
Clinical Manifestations
General Comments
- Time Course of Presentation: depends on underlying organism, immunocompetence of the host, and timing of the patient’s presentation for medical care
- Anerobic Emypema: may present after a longer time course (may be as long as weeks in duration)
- Renal/Age/Purulence/Infection Source/Dietary Factors (RAPID) Score: used to risk-stratify patients with pleural space infection at presentation
- Study of RAPID Score in Patients (from the UK MIST1 Trial) with Pleural Space Infection at Presentation with Pneumonia (Chest, 2014) [MEDLINE]
- Increased Age, Hospital-Acquired Infection, Non-Purulence Predicted Poor Outcome
- Increased RAPID Score Predicted Mortality and Increased Hospital Length of Stay
- Study of RAPID Score to Predict Long-Term Outcome in Pleural Space Infection at Presentation for Pneumonia (Ann Am Thorac Soc, 2015)
- Increased RAPID Score Predicted Mortality Rate at 3 mo and 1/3/5 yrs
- Factors Associated with High-Risk RAPID Scores: Gram-negative rod infections, heart disease, diabetes mellitus, lung disease, and increased length of stay
- Study of RAPID Score in Patients (from the UK MIST1 Trial) with Pleural Space Infection at Presentation with Pneumonia (Chest, 2014) [MEDLINE]
Pulmonary Manifestations
Symptoms Related to Underlying Pneumonia
- Cough with Sputum Production (see Cough, [[Cough]])
- Dyspnea (see Dyspnea, [[Dyspnea]])
- Fever (see Fever, [[Fever]])
- Pleuritic Chest Pain (see Chest Pain, [[Chest Pain]])
- Physical Exam Findings
- Crackles
- Egophony (E to A Changes)
- Increased Tactile Fremitus
Symptoms Related to Parapneumonic Pleural Effusion/Empyema
- Dyspnea (see Dyspnea, [[Dyspnea]])
- Empyema Necessitatis: spontaneous drainage of empyema via fistula through the chest wall
- Fever (see Fever, [[Fever]])
- Pleuritic Chest Pain (see Chest Pain, [[Chest Pain]])
- Weight Loss (seeWeight Loss, [[Weight Loss]])
- Physical Exam Findings
- Decreased Breath Sounds
- Decreased Tactile Fremitus
- Dullness to Percussion
Symptoms in Cases of Post-Pneumonectomy Empyema
- Fever (see Fever, [[Fever]])
- Shift of Mediastinum to Contralateral Side: normally, mediastinum shifts to ipsilateral side as it fills with fluid over days-weeks post-procedure
- Expectoration of Large Amounts of Pleural Fluid
- Presence of Air-Fluid Level within the Pneumonectomized Space
- Drainage of Purulent Material from Surgical Incisions
Treatment
Treatment Recommendations by Class
- Class 1: no thoracentesis required
- Class 2: antibiotics alone
- Class 3: antibiotics + serial thoracentesis
- Class 4: antibiotics + chest tube
- Class 5: chest tube + thrombolytics (rarely requires VATS pleural space drainage)
- Class 6: chest tube + VATS pleural space drainage
- Class 7: chest tube + thrombolytics (often requires thoracoscopy or decortication)
Treatment Recommendations by Category (ACCP Consensus Guidelines) (Chest, 2000) [MEDLINE]
- Category 1: very low risk of poor outcome -> drainage not recommended
- Minimal Free Flowing and <10 mm on Lateral Decubitus CXR: A0
- Pleural Fluid Gram Stain and Culture Results Unknown: Bx
- Pleural Fluid pH Unknown: Cx
- Category 2: low risk of poor outcome -> drainage not recommended
- Small-Moderate Free Flowing and <10 mm on Lateral Decubitus CXR and Less than 50% of the Hemithorax: A1
- Negative Pleural Fluid Gram Stain and Culture: B0
- Pleural Fluid pH ≥7.20: C0
- Category 3: moderate risk of poor outcome -> drainage recommended
- Large Free Flowing (≥50% of Hemithorax), Loculated Effusion, or Effusion with Thickened Parietal Pleura: A2
- Positive Pleural Fluid Gram Stain or Culture: B1
- Pleural Fluid pH <7.20
- Category 4: high risk of poor outcome -> drainage recommended
- Large Free Flowing (≥50% of Hemithorax), Loculated Effusion, or Effusion with Thickened Parietal Pleura: A2
- Pus: B2
- Pleural Fluid pH <7.20
Antibiotics
- Should Be Directed at Etiology of Underlying Pneumonia (see Pneumonia, [[Pneumonia]])
Chest Tube (Tube Thoracostomy) (see Chest Tube, [[Chest Tube]])
-
Indications: as noted above
-
Clinical Efficacy
- xxxx
Intrapleural Deoxyribonuclease (DNase) (see Dornase Alfa, [[Dornase Alfa]])
General Comments
- Rationale: DNA is the main contributor to the viscosity of empyema fluid
Administration
- DNase
- Administration (MIST2 Trial) NEJM, 2011) [MEDLINE]: 5 mg intrapleural BID x 3 days
Clinical Efficacy
- See Below
Intrapleural Thrombolytics (see Thrombolytics, [[Thrombolytics]])
Agents
- Streptokinase (see Streptokinase, [[Streptokinase]]): 250k IU
- Pre-existing Anti-SK Ab (from strep/staph infection, previous systemic or IP SK use,etc) can render SK ineffective
- Urokinase: 100k IU
- Alteplase (see Alteplase, [[Alteplase]])
- Administration (MIST2 Trial) NEJM, 2011) [MEDLINE]: 10 mg BID x 3 days
- Sterile preparation of alteplase 10 mg in 25 mL normal saline in 60 mL catheter-tip syringe
- With two chest tube clamps in place, unclamp chest tube and instill alteplase
- Flush with sterile 25 ml saline in 60 mL catheter-tip syringe
- Clamp chest tube for 2 hrs, then place chest tube back to suction
- Administration (MIST2 Trial) NEJM, 2011) [MEDLINE]: 10 mg BID x 3 days
Clinical Efficacy
- First Multicenter Intrapleural Sepsis Trial (MIST1) (NEJM, 2005) [MEDLINE]
- Intrapleural Streptokinase Did Not Improve Mortality, Rate of Surgery, or Length of Hospital Stay in Patients with Pleural Space Infection
- MIST2 Trial Comparing Intrapleural Tissue Plasminogen Activator with/without DNase in Pleural Space Infection (NEJM, 2011) [MEDLINE]: n = 210 patients (blinded 2 x 2 factorial trial)
- Intrapleural tPA + DNase Therapy: improved drainage, decreased the frequency of surgical referral, and decreased the duration of hospital stay
- Treatment with Either tPA + DNase Alone: no clinical benefit
- DNase Treatment Alone Resulted in a 3x Increase in the Number of Surgical Referrals Due to Worsening Infection
Video-Assisted Thoracoscopic Surgery (VATS) (see Video-Assisted Thoracoscopic Surgery, [[Video-Assisted Thoracoscopic Surgery]])
- Indications
- Failure of Chest Tube Drainage
- Procedures
- Pleural Space Drainage: VATS pleural drainage is the standard treatment for patients who fail chest tube drainage
- Conversion Rate to Thoracotomy: 3% (Ann Thorac Surg, 2006) [MEDLINE]
- Decortication (see Decortication, [[Decortication]]): considered when symptomatic restriction of lung expansion (due to fibrothorax) is still present >6 mo after initial event
- Pleural Space Drainage: VATS pleural drainage is the standard treatment for patients who fail chest tube drainage
Prognosis
- Study of Impact of Parapneumonic Effusion Associated with Pneumonia at Hospital Admission on Outcome (Chest, 2016) [MEDLINE]
- Presence of Pleural Effusion at Emergency Department Presentation with Pneumonia Predicts an Increasing Likelihood of Being Admitted, Longer Hospital Stay, and Increased 30-Day Mortality Rate
References
General
- Nontuberculous bacterial empyema in patients with and without underlying diseases. JAMA. 1971 Jan 4;215(1):69-75 [MEDLINE]
- Empyema of the thorax then and now. A study of 122 cases over four decades. Arch Intern Med. 1973 Apr;131(4):516-20 [MEDLINE]
- Parapneumonic effusions. Am J Med. 1980;69(4):507 [MEDLINE]
- Experimental aerobic-anaerobic thoracic empyema in the guinea pig. Ann Thorac Surg. 1987;43(3):298 [MEDLINE]
- Aerobic and anaerobic microbiology of empyema. A retrospective review in two military hospitals. Chest. 1993;103(5):1502 [MEDLINE]
- A bacteriologic basis for the evolution and severity of empyema. J Pediatr Surg. 1994;29(5):667 [MEDLINE]
- Pleural fluid chemical analysis in parapneumonic effusions. A meta-analysis. Am J Respir Crit Care Med. 1995;151(6):1700 [MEDLINE]
- Microbiological diagnosis of empyema in children: comparative evaluations by culture, polymerase chain reaction, and pneumococcal antigen detection in pleural fluids. Clin Infect Dis. 2006;42(8):1135 [MEDLINE]
- Prevalence and clinical significance of pleural microbubbles in computed tomography of thoracic empyema. Clin Radiol. 2006;61(6):513 [MEDLINE]
- Predominant role of bacterial pneumonia as a cause of death in pandemic influenza: implications for pandemic influenza preparedness. J Infect Dis. 2008;198(7):962 [MEDLINE]
- Blood culture bottle culture of pleural fluid in pleural infection. Thorax. 2011;66(8):658 [MEDLINE]
- A higher significance of anaerobes: the clone library analysis of bacterial pleurisy. Chest. 2011;139(3):600 [MEDLINE]
- Pleural infection: changing bacteriology and its implications. Respirology. 2011 May;16(4):598-603 [MEDLINE]
- Influence of previous use of inhaled corticoids on the development of pleural effusion in community-acquired pneumonia. Am J Respir Crit Care Med. 2013;187(11):1241 [MEDLINE]
- Clinical importance of angiogenic cytokines, fibrinolytic activity and effusion size in parapneumonic effusions. PLoS One. 2013;8(1):e53169. Epub 2013 Jan 7 [MEDLINE]
- Procalcitonin as a diagnostic marker in differentiating parapneumonic effusion from tuberculous pleurisy or malignant effusion. Clin Biochem. 2013;46(15):1484 [MEDLINE]
- Do we measure pleural fluid pH correctly? Curr Opin Pulm Med. 2013 Jul;19(4):357-61 [MEDLINE]
- A clinical score (RAPID) to identify those at risk for poor outcome at presentation in patients with pleural infection. Chest. 2014 Apr;145(4):848-55 [MEDLINE]
- Predicting Long-Term Outcomes in Pleural Infections. RAPID Score for Risk Stratification. Ann Am Thorac Soc. 2015 Sep;12(9):1310-6 [MEDLINE]
- Pleural Effusions at First ED Encounter Predict Worse Clinical Outcomes in Patients With Pneumonia. Chest. 2016;149(6):1509 [MEDLINE]
Treatment
- Medical and surgical treatment of parapneumonic effusions : an evidence-based guideline. Chest. 2000 Oct;118(4):1158-71 [MEDLINE]
- MIST1 Trial. U.K. Controlled trial of intrapleural streptokinase for pleural infection. N Engl J Med. 2005 Mar 3;352(9):865-74 [MEDLINE]
- Video-assisted thoracic surgery for pleural empyema. Ann Thorac Surg. 2006;81(1):309 [MEDLINE]
- Intrapleural administration of Pulmozyme for pleural empyema. Respiratory Medicine CME 2011, Vol.4(3):114–115, doi:10.1016/j.rmedc.2010.12.002
- MIST2 Trial. Intrapleural Use of Tissue Plasminogen Activator and DNase in Pleural Infection. N Engl J Med. 2011 Aug 11;365(6):518-26. doi: 10.1056/NEJMoa1012740 [MEDLINE]
- Is medical thoracoscopy efficient in the management of multiloculated and organized thoracic empyema? Respiration. 2012;84(3):219 [MEDLINE]
- Intrapleural tissue plasminogen activator and deoxyribonuclease therapy for pleural infection. J Thorac Dis. 2015 Jun;7(6):999-1008 [MEDLINE]
- New therapy of pleural empyema by deoxyribonuclease. Braz J Infect Dis. 2013 Jan-Feb;17(1):90-3. doi: 10.1016/j.bjid.2012.08.019. Epub 2013 Jan 16 [MEDLINE]