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CHAPTER 58

Parapneumonic Empyema

JosephS. McLaughlin and Mark J. Krasna

Pleuraleffusion is a common accompaniment of the inflam- weeks, and the organized collagen on the pleural surface is
mationof bacterial pneumonia. These "uncomplicated effu- termed a "peel." The effusion at this point is grossly puru-
sions"arenonpurulent, have a negative Gram's stain result lent, and at least 75% of the volume is sediment on standing.
forbacteria,have negative results by culture, and are gener- Chronicity is characterized by dense fibrosis, contraction
allyfreeflowing.Light (1985, 1991, 2002) and associates and trapping of the lung, atelectasis, and prolonged pulmo-
(1972,1980),using biochemical parameters, noted a pH nary infection and reduction of the size of the hemithorax.
greaterthan 7.30, a normal glucose level, and a lactic acid Fibrothorax with invasion of the chest wall and narrowing of
dehydrogenase(LDH) concentration less than 1,000 lUlL. the intercostal spaces may be thought of as the end stage of
Mostparapneumonic effusions resolve with appropriate an- this process.
tibiotictreatment and resolution of the pulmonary infection. Complications of the empyema process may take place
Thoracicempyema occurs when bacteria invade the nor- early or late. Necrosis of the visceral pleural surface, as
mallysterile pleural space. The process was described by noted by Hankins and associates (1978), may result in bron-
IAndrews and colleagues, reporting for the American Tho- chopleural fistula heralded by sudden expectoration of, at
.cicSociety (ATS) in 1962, as a continuum of three stages times, copious amounts of purulent sputum. Marks and
'able58-1). Eickhoff (1970) noted that the necrosis of the parietal pleura
Stage1 is characterizedby the presence of an exudative and the chest wall and skin results in empyema necessitatis.
from increased permeability of the inflamed and
.fusion These conditions are usually seen in patients treated with an-
:wollenpleuralsurfaces. This stage corresponds to the un- tibiotics for pneumonia who have unrecognized empyema.
omplicatedparapneumonic effusion of Light and col- Often, these patients have persistent, low-grade fever until
gues(1980) and is initially sterile. Fibrin is deposited and the empyema drains through the chest wall or into the lung.
Ilymorphonuclearleukocytes are present in small num- Rarely, osteomyelitis of the ribs or spine may occur. Inva-
rs.Withbacterial invasion, the process blends into the fi- sion of the mediastinum with pulmonary esophageal fistula
opurulentstage 2, true empyema or Light's "complicated" and pericarditis have also been reported. Metastatic spread
:!euraleffusion.Initially, the fluid is still relatively clear and is unusual, but ScheId (1998) has suggested that up to 12%
ow,but the white blood cell count is greater than 500 of brain abscesses are from pleuropulmonary disease, in-
,lispermicroliter, the specific gravity is greater than 1.018, cluding empyema.
dtheprotein level is greater than 2.5 gldL. The pH is less
hn7.2and the LDH levels reach 1,000 lUlL. Although fi-
depositsand early angioblastic and fibroblastic prolifer-
on are seen in later phases of the exudative stage, these COMMUNITY-ACQUIRED PNEUMONIA
essesaccelerate and heavy fibrin deposition takes place
bothpleuralsurfaces,particularly the parietal pleura. The According to the American Thoracic Society (2001),
)Jsionbecomes purulent, with a white cell count above community-acquired pneumonia (CAP) is the sixth most
000cellsper IJL.Biochemically, the pH decreases to lev- common cause of death in the United States and is the most
below7.0, the glucose decreases to less than 50 mgldL, common infectious cause of death. There are approximately
theLDH increases to greater than 1,000 lUlL. Stage 3 5.6 million cases of CAP in the United States each year, 1.1
. asearly as 1 week after infection with collagen orga- million requiring hospitalization. The outpatient mortality
tion anddepositionon both pleural surfaces and entrap- rate ranges from 1% to 5%, and the overall mortality rate is
Iofthe underlying lung. This process is mature in 3 to 4 12%. Guidelines for the evaluation and treatment of CAP

819
820 XI. THE PLEURA

Table 58-1. American Thoracic Society group II (outpatients with comorbidity) have congestive
Classification of Empyema heart failure or COPD, but no risk factors for DRSP or
Stage 1. Exudative with swelling of the pleural membranes Gram-negative bacteria (including residing in a nursing care
Stage 2. Fibrinopurulent with heavy fibrin deposits facility). Streptococcus pneumoniae remains the most likely
Stage 3. Organization with ingrowth of fibroblasts and deposition
of collagen pathogen, but DRSP is a consideration in this group and
modifies the antibiotic therapy. The mortality rate in group11
From Andrews NC, et al: Management of nontuberculous is less than 5%, but according to Fine and associates (1996,
empyema: a statement of the subcommittee on surgery. Am Rev
Respir Dis 85:935, 1962.With permission. 1997), as many as 20% of patients treated initially as outpa-
tients will require hospitalization. Group III patients are ad-
mitted to the hospital due to severe pneumonia. They are
divided into two groups: those with cardiopulmonary disease
or modifying factors (including residing in a nursing care fa-
using an "evidence-based" approach have been published cility) and those with no cardiopulmonary disease and no
by the American Thoracic Society (1995, 2001), Mandell modifying factors. Modifying factors and cardiopulmonary
and associates (2000) for the Canadian Infectious Diseases disease increase the mortality rate significantly. Group lirA
Society and the Canadian Thoracic Society, Bartlett and his patients suffer mortality rates ranging from 5% to 25%.
associates (2000) for the Infectious Diseases Society of Group IV patients have severe pneumonia defined by the
America, and the British Thoracic Society (1993). All of study group as those admitted to an ICU. They are divided
these official statements modify past practices and recom- further into patients with no risk for Pseudomonas aerugi-
mendations significantly. nosa infection and those with risk for Pseudomonas aerugi-
As noted by Bartlett and associates (2000), up to 50% of the nosa infection. Patients with severe CAP have a mortality
pathogens responsible for CAP are never identified despite rate of up to 50% (Tables 58-2 through 58-5).
careful and extensive testing. There is no single test that can
identify all potential pathogens, and all diagnostic tests have
their limitations. Sputum Gram's stains and cultures are often
unable to identify Streptococcus pneumoniae and frequently HOSPITAL-ACQUIRED PNEUMONIA
encountered pathogens such as Mycoplasma pneumoniae,
Chlamydia pneumoniae, and Legionella species and respira- The Official Statement of the American ThoracicSociety
tory viruses.These may be detected at a later time by serologic (1995) noted that hospital-acquired pneumonia (HAP)is a
testing. Furthermore, "atypical" infections can occur and in- major cause of death within the hospital setting. It is gener-
volve either more than one bacterial species or a bacterial ally defined as pneumonia occurring 48 hours after admis-
pathogen and a virus. Thus, an empiric approach to the initial sion and excludes pneumonia existing prior to hospital
treatment of community-acquired infection is recommended, admission. It is thought to occur at a rate of 5 to 10 cases
based on the patient's status as defined by Bartlett and Mundy per 1,000 hospital admissions with increases of 6 to 20 times
(1995): (a) outpatientswith no history of cardiopulmonarydis- that rate among patients who are mechanically ventilated.
ease and no modifying factors; (b) outpatients with cardiopul- Craven and Driks (1987), Craven and associates (1991),
monary disease [congestiveheart failureor chronic obstructive
pulmonary disease (COPD)] or other modifying factors such
as risk factors for drug-resistant Streptococcus pneumoniae
(DRSP) or Gram-negativebacteria; (c) inpatientsnot admitted
to the intensivecare unit (ICU) who (i) have cardiopulmonary Table 58-2. Community-Acquired Pneumonia:
Group 1. Outpatients, No Cardiopulmonary Disease,
disease and/or other modifying factors (includingresiding in a No Modifying Factors
nursing care facility) or who (ii) have no cardiopulmonarydis-
Organisms Therapy
ease and no other modifying factors; and (d) ICU-admittedpa-
tients with either risk or no risk for Pseudomonas aeruginosa. Streptococcus pneumoniae Advanced-generation macrolide:
Mycoplasma pneumoniae azithromycin, cIarithromycin,
Antibiotic therapy is based on the probable bacterial etiology
Chlamydia pneumoniae or doxycycline
of pneumonia in the four groups. Parenthetically,appropriate (alone or as mixed
efforts should be made to identify the agent or agents involved infection)
and specific antibiotictherapy directed to their eradication. Haemophilus injluenzae
Patients in group I (outpatients) are most commonly in- Respiratory viruses
Miscellaneous
fected with Streptococcus pneumoniae, Mycoplasma pneu-
Legionella species
moniae, Chlamydia pneumoniae, and respiratory viruses. Mycobacterium tuberculosis
Less common are Legionella species and Haemophilus in- Endemic fungi
fluenzae (in cigarette smokers). The mortality rate of this
From American Thoracic Society: Guidelines for the management
group is less than 1% to 5%. Roughly 50% to 90% of these of adults with community-acquired pneumonia. Am J Respir Crit
patients have no identifiable etiologic agents. Patients in Care Med 163:1732, 2001. With permission.
58. PARAPNEUMONIC EMPYEMA 821
Table58-3. Community-Acquired Pneumonia: many of these patients have other life-threatening conditions,
Group 2. Outpatient, with Cardiopulmonary Disease and approximately two thirds of all deaths of patients with
and/or other Modifying Factors HAP can be attributed to these other conditions. The attribut-
Organisms Therapy able mortality rate can be higher if bacteremia is present or if
pneumoniae
Streptococcus j3-lactam(oralcefpodoxime, the etiologic agent is Pseudomonas aeruginosa or Acineto-
(includingDRSP) cefuroxime, high-dose bacter species.
Mycoplasma pneumoniae amoxicillin;or amoxicillin! Craven (1991), Rouby (1992), Bartlett (1986), and
Chlamydia pneumoniae clavulanate;or parenteral
Mixedinfection (bacteriaplus ceftriaxonefollowedby oral Prod'hom (1994) and their associates as well as Schleup-
atypicalpathogenor virus) cefpodoxime) ner and Cobb (1992) found that the bacteria most fre-
Haemophilus influenzae plus quently associated with HAP are enteric Gram-negative
EntericGram-negatives Macrolideor doxycycline bacteria and Staphylococcus aureus. Accumulated data
Respiratoryviruses or
suggest that the etiology is polymicrobial in up to half of
Miscellaneous Antipneumococcal fluoro-
Moraxellacatarrhalis, quinolone (used alone) mechanically ventilated patients. The role of viruses has
Legionellaspecies,aspiration yet to be defined. As with CAP, initial diagnosis and treat-
, (anaerobes),Mycobacterium ment of HAP is based on an empirically based review of
tuberculosis,
endemicfungi numerous studies to determine the cause of the pneumonia
i:DRSP,drug-resistant Streptococcus pneumoniae. and its treatment. It is recognized that these studies have
dapted from American Thoracic Society: Guidelines for the the basic shortcoming of being unable to identify the etio-
managementof adults with community-acquired pneumonia. Am logic agents initially in a significant number of patients.
RespirCrit Care Med 163: 1735, 200 I. With permission.
Accordingly, patients have been categorized by the ATS
into mild-to-moderate pneumonia and severe pneumonia.
These groups are further characterized based on the pres-
Drossand associates (1980), Gross and Van Antwerpen ence or absence of risk factors and the time [early 5
1983),and Fagon and associates (1989) all found that pneu- days) or late (>5 days)] of onset of the pneumonia (Table
oniais the second most common nosocomial infection in 58-6). This "cookbook" approach to therapy must be sup-
e UnitedStates and has the highest mortality and morbidity plemented by appropriate bacteriologic studies and di-
'ates.The crude mortality rate approaches 70%. However, rected treatment based on these studies.

Table 58-4. Community-Acquired Pneumonia: Group 3.


Inpatients Not in Intensive Care Unit
Organisms Therapy
Cardiopulmonarydisease and/or modifying factors
(including being from a nursing home)
Streptococcuspneumoniae (including DRSP) Intravenous j3-lactam(cefotaxime,
Haemophilus influenzae ceftriaxone, ampicillin!
Mycoplasmapneumoniae sulbactam, high-dose ampicillin)
Chlamydiapneumoniae plus
Mixed infection (bacteria plus atypical pathogen) Intravenous or oral macrolide or
Enteric Gram-negatives doxycycline
Aspiration(anaerobes) or
Viruses Intravenous antipneumococcal
Legionellaspecies fluoroquinolone alone
Miscellaneous
Mycobacterium tuberculosis, endemic fungi,
Pneumocystis carinii
No cardiopulmonary disease, no modifying factors
S.pneumoniae Intravenous azithromycin alone if
H. influenzae macrolide allergic or intolerant:
M. pneumoniae doxycycline and a j3-lactam
C.pneumoniae or
Mixed infection (bacteria plus atypical pathogen) Monotherapy with an antipneumococcal
Viruses Fluoroquinolone
Legionellaspecies
Miscellaneous
M. tuberculosis, endemic fungi, P. carinii
DRSP, drug-resistant Streptococcus pneumoniae.
Adapted from American Thoracic Society: Guidelines for the management of adults with commu-
nity-acquired pneumonia. Am J Respir Crit Care Med 163: 1736, 2001. With permission.
822 XI. THE PLEURA

Table 58-5. Community-Acquired Pneumonia: Group 4. ICU-Admitted Patients


Organisms Therapy
No risks for Pseudomonas aeruginosa
Streptococcus pneumoniae (including DRSP) Intravenous ~-lactam (cefotaxime,
Legionella species ceftriaxone)
Haemophilus injluenzae plus either
Enteric Gram-negative bacilli Intravenous macrolide (azithromycin)
Staphylococcus aureus or
Mycoplasma pneumoniae Intravenous fluoroquinolone
Respiratory viruses
Miscellaneous
Chlamydia pneumoniae, Mycobacterium
tuberculosis, endemic fungi
Risks for Pseudomonas aeruginosa
All of the above pathogens plus Selected intravenous antipseudomonal ~-
p. aeruginosa lactam (cefepime, imipenem, meropenem,
piperacillinltazobactam) plus
intravenous antipseudomonal quinolone
(ciprofloxacin)
or
Selected intravenous antipseudomonal ~-
lactam (cefepime, imipenem, meropenem,
piperacillinltazobactam) plus
intravenous aminoglycoside
plus either
intravenous macrolide (azithromycin)
or intravenous nonpseudomonal
fluoroquinolone
DRSP, drug-resistant Streptococcus pneumoniae; ICU, intensive care unit.
Adapted from American Thoracic Society: Guidelines for the management of adults with
community-acquired pneumonia. Am J Respir Crit Care Med 163: 1736, 2001. With permission.

BACTERIOLOGY cording to Ehler (1941), Streptococcus and Pneumococcu,


were the most frequent organisms. After the introduction 0..
The bacterial etiology of empyema has changed over antibiotics, the incidence of empyema from these organ
the years. Before the development of antibiotics, 10% of isms was markedly reduced, as was the mortality rate.
patients who survived pneumonia developed empyema. Ac- Staphylococcus became much more prevalent, and in the;
1950s and 1960s, Ravitch and Fein (1961) found that this
organism produced 90% of empyema in children under 2
Table 58-6. Modifying Factors that Increase the Risk for years of age. In more recent times, as pointed out by Varkey
Infection with Specific Pathogens and associates (1981) and Bergeron (1990), penicillin-resis-
Penicillin-resistant and drug-resistant pneumococci tant Staphylococcus, Gram-negative bacteria, and anaerobic
Age >65 years organisms have been the predominant microbes. Bartlett
~-Iactam therapy within the past 3 months and colleagues (1974a) reported that 76% of empyema pa-
Alcoholism
tients had positive culture results for either anaerobes ex-
Immune-suppressive illness (including therapy with
corticosteroids) clusively (35%) or anaerobes in combination with aerobes
Multiple medical comorbidities (41 %). Anaerobic bacteria are normal flora of the mouth,
Exposure to a child in a day-care center intestine, and female genital tract. They are difficult to cul-
Enteric Gram-negatives ture, being extremely oxygen sensitive. Multiple organ-
Residence in a nursing home
isms, 50 in the series of Sullivan and colleagues (1973), are
Underlying cardiopulmonary disease
Multiple medical comorbidities frequently cultured, but the most common is Peptostrepto-
Recent antibiotic therapy coccus. Similar findings were recorded by Ali and Unruh
Pseudomonas aeruginosa (1990).
Structural lung disease (bronchiectasis) Brook and Frazier (1993) independently studied 197pa-
Corticosteroid therapy (>I0 mg of prednisone per day)
tients with culture-positive empyema from two military
Broad-spectrum antibiotic therapy for> 7 days in the past
month hospitals. Aerobic organisms were isolated in 127 patients
Malnutrition (64%), mixed aerobic and anaerobic organisms in 45 pa-
Adapted from American Thoracic Society: Guidelines for the tients (23%), and anaerobic organisms in 25 patients (13%).
management of adults with community-acquired pneumonia. Am The predominant aerobic or facultative bacterial isolates
J Respir Crit Care Med 163:1737, 2001. With permission. were Streptococcus pneumoniae (70), Staphylococcusau-
58. PARAPNEUMONICEMPYEMA 823
reus (58), Escherichiacoli (17), Klebsiellapneumoniae Table 58-7. Etiology of Pneumonia
(16), and Haemophilus influenzae (12). The predominant Agent Incidence (%)0
anaerobeswere anaerobic cocci (36), pigmented Prevotella
Community-acquired pneumonia
and Porphyromonas (24), Bacteroides fragilis (22), and Streptococcus pneumoniae 60-75
fusobacterium species (20). Most patients from whom Haemophilus influenzaeb 5-10
S.pneumoniae and H. influenzae were cultured had pneu- Staphylococcus aureus <5
monia.Most patients from whom S. aureus were recovered Mycoplasma pneumoniae 1-10
Legionella pneumophila 1-5
had pneumonia, aspiration pneumonia, or lung abscesses. 1-5
Chlamydia pneumoniae
Recoveryof anaerobic bacteria was associated with the di- Streptococcus pyogenesc <1
agnosis of aspiration pneumonia and lung, dental, and Unknown 35
oropharyngealabscesses. Hospital-acquired pneumonia
Lemenseand associates (1995) at the Medical University Aerobic Gram negative 45+
Klebsiella pneumoniae
of SouthCarolina studied, retrospectively, 43 patients with Escherichia coli
empyema.Twenty-four of the 43 patients (56%) had para- Pseudomonas aeruginosad
pneumonicempyema, and 19 patients had empyema from a S. aureus <10
varietyof causes including gunshot wounds, thoracotomy, lncidence varies with series.
and esophageal rupture. Most nonparapneumonic empy- bEmpyema complicates 10% of H. influenzae pneumonias in chil-
emashad positive cultures (84%), whereas only 11 of 24 dren, but is rare in adults.
patientswith parapneumonic empyema (46%) had positive cEmpyema in 30% or greater. Incidence may be much higher in
children.
cultureson Gram's stain. Alfageme and associates (1993)
dMost common cause of pneumonia in intensive care unit, with
notedincreasing numbers of patients with Staphylococcus significant potential for empyema.
empyema,particularly in alcoholics.
Thepropensity for developing empyema varies consider-
ablywiththe type of bacteria producing the primary pneu-
monia,the setting in which the infection is acquired, and The clinician should be aware that the incidence of pleuritic
the alteration in these produced by antibiotic therapy ad- chest pain and leukocytosis are similar whether or not
ministeredfor primary pneumonia or for concurrent condi- pleural effusion is present.
tions. For example, as reported by Bartlett (1974a) and Empyema from aerobic bacterial pneumonia usually pre-
Fang(1990) and their colleagues, Light (1990), and John- sents as an acute febrile illness with chest pain, sputum pro-
sonandFinegold (1994), S. pneumoniae is responsible for duction, and leukocytosis. Anaerobic pleural infection is
60%to 75% of CAPs, but only 2% of patients with pneu- more indolent and, in Bartlett's (1974a) series, averaged 10
mococcalpneumonia develop empyema (Tables 58-7 and days before presentation. The majority of these patients
58-8).I3-hemolyticStreptococcus accounts for 1% to 2% of have a history of alcoholism or unconsciousness, frequently
CAPs,but up to 10% of adults and 50% of children develop have lost weight and have mild anemia. Hospital-acquired
empyema.In hospital settings, Staphylococcus and aerobic, infection and immunosuppression may alter this course.
Gram-negativebacteria are the most common agents pro- Physical examination reveals a toxic, anxious patient
ducingpneumonia. Both have significant potential to pro- with tachycardia and tachypnea. Restricted and guarded
duce empyema. chest wall excursion may be present. Percussion of the
chest wall may elicit pain and dullness over the empyema

CLINICALFEATURES
Table 58-8. Incidence of Empyema According
Empyemamay be heralded by an exacerbation or recur- to Bacteria-Causing Pneumonia
renceof the septic course of pneumonia or may present as a Incidence of
continuationof symptoms and manifestations of the pri- Organism Effusion (%) Empyema (%)
marypneumonic process. Antibiotics have blunted and Aerobic
changedthe clinical picture, and there may be only subtle Gram positive
progressionfrom the symptoms and signs of pneumonia to Streptococcus 50 <5
thoseof empyema. The most common presenting symp- pneumoniae
Staphylococcus 70 80
toms of empyema according to Varkey and associates
aureus (children)
(1981)are shortnessof breath (82%), fever (81%),cough Staphylococcus 40 20
(70%),and chest pain (67%), all of which are common to aureus (adults)
pneumonia.The presentation of these symptoms in a pa- Gram negative
tientwithfebrile respiratory illness or the accentuation or Escherichia coli 50 90
Pseudomonas 50 90
prolongationof these symptoms in a patient with pneumo- Anaerobic 35 90
niashouldalert the clinician to the possibility of empyema.
824 XI. THE PLEURA

area. With chronicity, the patient may develop clubbing of density and the presence of loculations can be determined,
the fingers, contraction of the chest wall, inanition, and other the latter being an important factor in treatment planning.
signs of chronic illness. CT-guided thoracocentesis is a highly accurate and safe
technique that is used routinely.
DIAGNOSIS
Sonography
Traditional Radiographic Evaluation
Alternately, sonography of the chest may be used. Sonog-
The presence of a significant pleural effusion in associa-
raphy can demonstrate pleural fluid collections, loculations,
tion with a lower respiratory illness is typical, but this clini-
and parenchyma involvement and may be used to guide tho-
cal picture may also be seen with pulmonary embolism,
racocentesis. The choice of this technique is institutionally
acute pancreatitis, Dressler's syndrome, tuberculosis, and
dependent.
other conditions. Light and associates (1980) have suggested
that bilateral decubitus chest radiographs be obtained. With
the involved side down, the distance between the inside of
the chest wall and the outside of the lung should not exceed MANAGEMENT
10 mm. If this distance exceeds 10 mm, thoracentesis
should be performed. Effective management of empyema requires (a) control
When seen by the surgeon, many empyemas are advanced of infection and sepsis by appropriate antibiotic therapy,(b)
and empyemic collections are loculated. Because the poste- evacuation of pus from the pleural space, and (c) oblitera-
rior lateral diaphragmatic angle is the most dependent posi- tion of the empyema cavity. Once the diagnosis is estab-
tion of the thorax, most empyemas are found in this area. The lished, treatment must proceed with all possible haste. In
inverted D or pregnant lady sign, as coined by LeRoux and Bartlett's (1974b) series of 43 patients with anaerobic
Dodds (1964), on the lateral view is classic (Fig. 58-1). The empyemas, five patients (12%) died. He attributed all five
differentiation of lung abscess with effusion from empyema deaths to a delay in appropriate drainage. In Ashbaugh's se-
and bronchopleural fistula may also be suggested by "plain" ries (1991), delay in instituting drainage increased the mor-
radiographic examination (Fig. 58-2). Friedman and Helle- tality rate from 3.4% to 16%.
kant (1977) noted that the air fluid levels oflung abscess are Colice and colleagues (2000) published the American
usually of the same dimensions in posterior/anterior and lat- College of Chest Physicians' Consensus Statement of the
eral views, whereas empyema air fluid levels are rarely the Treatment of Parapneumonic Effusions. The study group
same in these views. examined 789 citations from a Medline search. Twenty-
four articles were identified for full review by the panel.
Meta-analysis was performed and recommendations pre-
Computed Tomography sented, primarily addressing techniques of drainage. How-
ever, it should be noted that, as with all meta-analyses, it
Computed tomographic (CT) scanning is now used uni- has the significant shortcoming of incomplete comparative
versally to identify underlying parenchymal disease and to analysis despite extensive data. Drainage tube size could
distinguish empyema from lung abscess (Fig. 58-3). Fluid not be compared, and specific antibiotic therapy was not

Fig. 58-1. A. Posteroanterior radiograph


of patient with encapsulated pleural effu-
sion. B. Inverted D or pregnant lady sign
B on lateral view is classic, if not typical. of
encapsulated empyema.
EMPYEMA 825
58. PARAPNEUMONIC

6,L

Fig. 58.2. A, B. Chest radiographs reveal fluid-filled cavities.


Thediameters of the cavities are essentially equal in anteroposte-
riorand lateral views. This symmetry is typical of lung abscesses
andfluid-filledcysts (arrows) within the lung. C, D. Chest radio-
graphsreveal a normal study result, then pneumonia two weeks
later. (Continues) o
826 XI. THE PLEURA

E
F

G H
Fig. 58-2. (Continued) E, F. This study reveals an asymmetric air fluid space typical of bronchopleural fistula
and empyema. G, H. A decubitus study confirms the large empyema and the computed tomography scan con-
firms the large air- and fluid-filled space outside the lung.

addressed. Thus, the following, while drawing from these ready been treated with antibiotics and, according to LeMense
data, is a compilation of these data plus other studies and and colleagues (1995), approximately 50% of cultures with
the authors' experiences. parapneumonic empyema will be negative. The yield is
higher with empyema secondary to HAP. Despite these facts,
aerobic and anaerobic cultures of the blood and empyema
Antibiotic Therapy fluid should be obtained. If the cultures become positive, an-
tibiotic therapy should be guided by these results. Initial an-
Appropriate antibiotics should be administered promptly. tibiotic therapy is usually based upon empiric guidelines for
Many patients, when fIrst seen by the surgeon, will have al- the treatment of CAP or HAP.
58. PARAPNEUMONICEMPYEMA 827

Fig. 58-3. Patient with acute lower respiratory illness. A. Patient


upright radiograph reveals density in right lower lung field. B.
Computed tomography scan reveals large empyema collection
A with atelectatic lobe and consolidation.

Thoracentesis stains, cultures, and glucose and LDH determinations were


recommended. Of these, only culture and pH determinations
The appearance of the fluid provides a first and major are of practical value. A pH of less than 7.1 indicates an
sourceof information concerning diagnosis and treatment. empyema, and positive cultures may serve as a late guide for
Straw-colored,clear, or slightly cloudy fluid is found in ster- antibiotic therapy. Radiographic examination should be re-
ile "parapneumonic"effusions. This condition corresponds peated in 24 hours to ascertain the status of the effusion. If
toearlystage 1 of the ATS classification and the "uncompli- the volume has increased or if the patient's status has not im-
cated"effusion of Light (1980), the "benign" effusion of proved, a closed chest tube thoracostomy is indicated. If tho-
Potts(1976),and the "low pH" pleural effusion of Van Way racentesis demonstrates cloudy or purulent fluid, or if the
(1988)and their associates. Twenty to 70% of these will effusion is greater than one half of the hemithorax (even if
clearwithappropriate treatment of the primary pneumonia. free flowing), fibrin loculations are probably present and
The problem and dilemma is that benign-appearing fluid closed chest tube drainage is required. The presence of obvi-
mayheraldan impending "frank" empyema. Therefore, the ous pus also indicates the need for closed chest tube
fluidmustbe examined by Gram's stain, cultured for aero- drainage. It is noted that, in meta-analysis, the mortality rate
bicandanaerobicbacteria, and tested for antibiotic sensitiv- of patients treated primarily by thoracentesis is 10%and 46%
ity.Biochemicalchanges (Le., low pH, low glucose, and of patients require additional procedures.
highLDH) indicate and precede positive culture and, ac-
cordingto Light (1991) and others, can serve as a guide to
therapy.Cloudyor frankly purulent fluid is diagnostic. Aer- Chest Thbe Drainage
obicpushas little or no offensiveodor.Anaerobicpus is
usuallyfoul smelling. Closed chest tube drainage is the usual first step in the
Needleaspiration of the fluid collection should be per- treatment of acute empyema. However, this approach may
formedwith an 18-gauge needle under local anesthesia and take a number of forms. Traditionally, a No. 36F or larger
radiographicor sonographic guidance. If the fluid appears tube was placed in the most dependent area of the empyema
benign,is not loculated, and can be removed totally or nearly cavity as determined by previous thoracentesis and radio-
so, thoracentesismay be all that is necessary to control graphic examination. Underwater seal drainage with moder-
thediseaseprocess. Traditionally, leukocyte counts, Gram's ate suction (-20 cm Hz0) is applied to drain the purulent
828 XI. THE PLEURA

Table 58.9. Surgical Treatment of Empyema: Proportion of Deaths


with 95% Confidence Interval (CI) in Individual Cohorts and Pooled
by Primary Management Approach
Death
Procedure No. at Risk No. Died Proportion (%) 95% CI, %
No drainage 61 4 6.6 1.8, 16
Therapeutic 175 18 10.3 6.2, 15.8
thoracentesis
Tube thoracostomy 408 36 8.8 6.3, 12.0
Fibrinolytics 94 4 4.3 1.2, 10.5
VPlTS 42 2 4.8 0.6,16.2
Surgery 159 3 1.9 0.6,16.2
VPlTS,video-assisted thoracic surgery.
Pldapted from CoHce GL, et al: Medical and surgical treatment of parapneumonic effusions. Chest
118:1158,2000. With permission.

fluid and to obliterate the space. In meta-analysis, Colice and of drainage was 6.3 days. The mean number of urokinasein-
colleagues (2000) found that such treatment is associated stallations was five. The mean total dose of urokinase used
with a 9% mortality rate and that secondary intervention, in- per case was 466,000 units. No complications were encoun-
cluding the use of additional chest tubes, is necessary in 40% tered.
of patients (Tables 58-9 and 58-10). During the past decade, Bouros and associates (1997) compared streptokinase
image-guided drainage with much smaller tubes (12-16F) in and urokinase in a double-blind study of 50 consecutivepa-
association with the use of fibrinolytic agents has superseded tients with either complicated pleural effusion or frank
traditional chest tube drainage. Meta-analysis indicates a empyema who had inadequate drainage through the chest
lower (4.3%) mortality rate with secondary intervention tube 70 mL per 24 hours). Clinical and radiologic im-
being required in approximately 15% of patients. Numerous provement was noted in all but two patients (8%) in each
studies have compared the efficiency of fibrolytic agents, no- group who required surgical intervention. The mean vol-
tably streptokinase and urokinase. Urokinase, although much ume of drainage was significantly increased (urokinase,
more expensive and although temporarily recalled from the 420 mL per 24 hours; streptokinase, 380 mL per 24 hours).
marketplace because of viral contamination, appears to be The mean number of installations was six in both groups
the most efficacious, primarily due to its lack of systemic ef- and the mean lengths of stay were approximately 11 days.
fect. Both agents are efficient in breaking down fibrin locula- Two patients in the streptokinase group suffered high fever.
tions and increasing fluid drainage. Moulton (1989) and Lee The total cost for drug therapy was approximately twice as
(1991) and their associates reported success rates of 90%. much in the urokinase group. The researchers concluded
Moulton and colleagues (1995) subsequently updated their that fibrinolytic therapy is a valuable adjunct to chest tube
series and reported successful drainage in 111 of 118 cases drainage and that, despite the cost, urokinase may be desir-
(94%). Two patients died of sepsis with incomplete drainage. able because of local and systemic reactions to streptoki-
Five patients underwent decortication (three recovered and nase. These reactions included fever, chills, and chest pain.
two died postoperatively). Fifty-three patients (45%) re- In Laisaar and colleagues' (1996) series, enzymatic treat-
quired placement of more than one drain. The mean duration ment was effective in 72% of patients, but 28% required

Table 58-10. Surgical Treatment of Empyema: Proportion of Patients


Needing a Second Intervention with 95% CI in Individual Cohorts and Pooled by
Primary Management Approach
No at No. with Second Intervention
Procedure Risk Second Intervention Proportion (%) 95% CI, %
No drainage 61 30 49.2 36.1,62.3
Therapeutic 175 81 46.3 38.7,54.0
thoracentesis
Tube thoracostomy 434 175 40.3 35.7,45.1
Fibrinolytics 94 14 14.9 8.4,23.7
VPlTS 42 o 0.0 0.0, 8.4
Surgery 159 17 10.7 6.3, 16.6
VPlTS,video-assisted thoracoscopic surgery.
Pldapted from CoHce GL, et al: Medical and surgical treatment of parapneumonic effusions. Chest
118:1158,2000. With permission.
58. PARAPNEUMONICEMPYEMA 829
further treatment such as decortication or lung resection. Commission, demonstrated that open drainage was an effec-
Chin and Um (1997), in a controlled study of 52 patients tive treatment for empyema. They demonstrated that open
(29 treated with drainage only and 23 treated with drainage drainage must not be performed during the acute phase of the
plus streptokinase daily), noted increased drainage in the disease since an open pneumothorax was produced with re-
streptokinasegroup, but no difference in hospital stay dura- duced ventilation, hypoxia, and death. Once the lung is fixed
tion, mortality, or need for decortication. to the chest wall and ventilation is assured, open drainage is
The technique is simple. A 12 to 16 F chest tube is placed safe. In times past, this was heralded by increased sediment
in the effusion guided by CT, ultrasonography, or fluo- in the fluid drained by thoracocentesis from the empyema
roscopy.For moderate-sized unilocular collections, a single cavity. When the sediment reached 75%, open drainage was
drain is usually all that is necessary. If collections are large said to be safe.
or if multiple loculations are present, more than one drain At the present time, open drainage through a thoracos-
may be placed. Following drain placement, all fluid is aspi- tomy tube may be performed in situations where the lung
rated. Follow-up imaging is then performed to determine has not expanded completely, a space exists, and circum-
the final position of the drains and the location and amount stances dictate that no further therapy is indicated. Once the
of any remaining pleural fluid. If significant loculations re- space has become stable (usually 2-3 weeks following chest
main, additional drains should be placed. The drains are tube insertion), there are no gross up and down movements
then attached to -20 cm water suction via a closed under- of the water column, and pneumothorax fails to occur when
waterseal system. The drains are irrigated daily with sterile the chest is open to atmospheric pressure, the chest tube is
salineto maintain patency. The decision to proceed with fi- cut off a few centimeters from the skin and anchored in
brinolyticagents is based primarily on the amount of fluid place with a safety pin and tape. The tube may be withdrawn
remainingafter catheter placement. If all fluid was drained a few centimeters per week as space is obliterated and gran-
during the first 2 days following drain placement and the ulation tissue fills the tract and drainage decreases.
lung has expanded, no fibrinolytic agents are recom- Eloesser (1935) was able to maintain patency of the open
mended.If significant amounts of fluid remain, fibrinolyt- drainage tract achieved by rib resection with a modified skin
ics are injected through the drains into the pleural cavity flap technique. According to Ali and colleagues (1996), this
(assumingthat no bronchopleural fistula is present). Gener- is a useful procedure in those instances where a large space
ally, 100,000 units of urokinase or 250,000 units of strep- exists and prolonged drainage is anticipated.
tokinaseare dissolved -in 250 mL of normal saline solution.
Followinginstallation of 75 to 100 mL of the fibrinolytic
solution,the catheters are clamped and the patient is in- Video-Assisted Thoracoscopic Decortication
structedto intermittently change position from supine to
eachdecubitus position in order to facilitate mixing of the As evidenced by Angelillo Mackinlay (1996) and Landre-
solutionwith the pleural fluid. After 1 to 4 hours, the cathe- neau (1996) and their colleagues as well as one of us (M.K.)
tersare unclamped and as much fluid as possible aspirated. (1998) and both authors (1996) and their associates, video-
The net amount of fluid is recorded. The procedure should assisted thoracic surgery (VATS) has become the primary
be repeated after 1 to 2 hours of suction drainage. Three modality for treating complicated empyema after initial
separateirrigations daily are recommended. Three criteria therapy (with or without chest tube drainage) in many insti-
areusedto determine when to remove the chest tubes. Clin- tutions. VATS allows adhesiolysis and debridement with
icalimprovement with resolution of fever and leukocytosis better exposure than minithoracotomy. Decortication for
is desirable.However, if the pleural space is considered ad- lung expansion prior to fibrosis can be accomplished with
equatelydrained and an alternate source of fever is apparent equal facility. Although chest tube drainage combined with
(i.e.,persistent pneumonia), it is not considered absolutely enzymatic debridement is effective, VATStherapy results in
necessarythat the white blood cell count be normal and the a higher (90%) success rate, shorter hospital stay, and less
patientafebrile. The second criterion is that almost all of the cost. Wait and co-workers (1997) concluded that it can rou-
pleural fluid was drained as determined by radiographic tinely salvage patients in whom chest tube drainage with en-
evaluation.If any fluid remains and the clinical response is zymatic debridement was not successful.
incomplete,the drainage process should be continued. The The VATSprocedure is described in Chapter 18. A dual-
thirdcriterionis that there should be no more than 20 mL of lumen endotracheal tube is inserted for single-lung ventila-
netdrainoutput over a 24-hour period. tion. Its position is confirmed by bronchoscopy. Blood
pressure, central venous pressure, arterial oxygen saturation
(Sa02), and end tidal C02 are monitored continuously. The
OpenDrainage patient is placed in the lateral decubitus position. A two- or
three-port triangular approach is used with the ports later
Open drainage was the classic method of draining serving as chest tube drainage sites. The empyema cavity is
empyemacavities prior to the antibiotic era. Historically, entered, loculations broken up, adhesions lysed with endo-
Grahamand Bell (1918), when reporting to the Empyema shears and cautery, fibrin and purulent material removed
830 XI. THE PLEURA

mechanically and by suction, and the chest cavity irrigated uncommon occurrence following appropriate treatment. In
with copious amounts of saline. The lung surface is wiped the past, such spaces were treated by some form of thora-
clean and the lung reexpanded. Morbidity is low and chest coplasty. This generally took the form of a modified Shede
tubes can usually be removed sequentially beginning in 3 to procedure. Ribs were resected over the cavity, the parietal
4 days depending on the virulence of the infection, the pres- pleura was removed, and the muscle bundles were allowedto
ence of a bronchopleural fistula, and the state of the patient. fall against the visceral pleura. The procedure was effective,
If complete reexpansion is not achieved, the remaining, de- but mutilating. Hankins and associates (1978) concludedthat
pendent chest tube can be cut off and converted to an muscle translocation into the cavity with occasional rib re-
empyema tube. section is the more desirable and effective procedure.
VATS is highly effective in the treatment of parapneu-
monic empyema. The combined mortality rate in Angelillo
Mackinlay's (1996) and Wait's (1997) and their associates' TREATMENT OF EMPYEMA IN CHILDREN
series is 4.8% and, most important, no additional proce-
dures were necessary. Empyema in infants and children is usually associated
with pneumonia. Its incidence has diminished greatly in re-
sponse to-the successful treatment of pneumonia with an-
Thoracotomy, Minithoracotomy, and Decortication tibiotics. In addition, its bacterial etiology has changed
concomitantly with the evolution of microbial resistance.
Although VATShas the advantages of greater patient tol- Nearly two decades ago, Foglia and Randolph (1987) found
erance, open thoracotomy with debridement and decortica- that the most frequent causes of empyema were Haemo-
tion is an effective means of dealing with empyema. Most phi/us injluenzae, ~-hemolytic streptococci, Streptococcus
studies of this technique predate the widespread use of pneumoniae, and anaerobes. At present, Hardie and co-
VATS. Van Way and associates (1988) reported on 22 pa- workers (1996) have found that Streptococcus pneumoniae,
tients in which debridement and decortication were per- often penicillin and erythromycin resistant, is the most
formed and in which drainage was established through common organism. Gustafson and associates (1990) found
limited thoracotomy. The process resolved completely in all that anaerobic bacteria produce effusions that loculate
and there were no deaths in this series. Miller (1990) de- quickly and are difficult to drain, whereas staphylococcal
scribed 52 patients treated with open thoracotomy. Good re- effusions are most commonly unilocular and relatively eas-
sults were obtained in 50 patients, and there were no ier to drain.
operative deaths. MandaI and associates (1998) treated 179 The clinical scenario has changed as well, with empyema
consecutive adult patients with primary empyema. Ninety seen more often in older children as opposed to infants.
underwent closed thoracostomy, with a cure rate of 62% Hardie and colleagues' (1996) study of CAP complicated
and a mortality rate of 11%. Twenty-four of these required a by empyema, revealed that 40% of empyemas were due to
second procedure. Seventy-six patients underwent decorti- Streptococcus pneumoniae, 15% of which were resistant to
cation as either a primary or secondary procedure, with a penicillin, and 44% of cultures were negative. None of the
cure rate of 88% and a mortality rate of 1.3%. Thus, 42% of empyemas were associated with Staphylococcus aureus or
these patients required decortication. In a meta-analysis of Haemophi/us injluenzae. Only one empyema was caused
159 patients undergoing surgical procedures, the mortality by group A Streptococcus. Miller (1990) noted that the cul-
rate was 1.9% and 11% of the patients required at least one ture-negative status of these children is now a common
additional intervention. finding because of pretreatment with antibiotics in the com-
munity setting.
Campbell and Nataro (1999) noted that host defenses are
Empyemectomy weakened in the nutrient-rich purulent space due to (a) lack
of phagocytic surface for optimal white cell function, (b)
Empyectomy is rarely performed. It requires an ex- low levels of opsonins and complement, and (c) conditions
trapleural dissection of the parietal pleura and tedious dis- of acidosis, hypoglycemia, and hypoxia. Furthermore,
section of the sac from the lung. Just as in decortication of a Bryant and Salmon (1996) found that many antibiotics do
chronically collapsed and trapped lung, lung damage requir- not work optimally in pleural empyema despite efficient
ing undesirable and unnecessary resection is often the result. penetration into the pleural space.
Fever is the most common presenting symptom in child-
hood empyema. Fever, cough, and dyspnea are present in
CHRONIC EMPYEMA 75% of children on admission. Decreased breath sounds,
tactile and vocal fremitus, and tachypnea and tachycardia
Chronicity refers to a state of continued infection associ- are often present according to Middlekamp (1964) and
ated with both fibrosis and a pleural space that is often com- McLaughlin (1984) and their associates and Chonmaitree
promised by bronchopleural fistulae. Fortunately, this is an and Powell (1983). Other symptoms are grunting respira-

~--
58. PARAPNEUMONIC EMPYEMA 831

tion, intercostal retraction, and lethargy. The polymorphic because of late skeletal deformities. We do not believe that
leukocytecount is virtually always elevated. Chonmaitree the use of enzymatic debridement is indicated in infants and
andPowell (1983) noted pulmonary lobar infiltrate in 52% small children. However, Rosen and associates (1993) and
of patients with empyema, segmental infiltrate in 33%, and Komecki and Sivan (1997) reported success with adjuvant
bilateral patchy infiltrate in 14%. Foglia and Randolph use of enzymatic debridement. A controlled trail is needed to
(1987)found that CT scanning is extremely useful in clari- define the use of enzymatic debridement in children.
fyingthe extent of parenchymal lung and pleural involve-
ment.However,Donnelly and Klosterman (1997), in studies
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