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Ind. J. Tub.

1998, 45, 155

EMPYEMA THORACIS-STUDY OF PRESENT DAY CLINICAL & ETIOLOGICAL PROFILE AND MANAGEMENT TECHNIQUES
M.V. Vardhan, S.C. Tewari, B.N.B.M. Prasad and S.K. Nikumb* Summitry : Present study was undertaken on 50 cases admitted to a tertiary respiratory disease centre over 2 years. The main objectives were (1) to study the clinical profile of empyema thoracis (2) detailed investjgations to estab|ish the etiology (3) to analyse efficacy or othewise of varjous therapeutic modalities. Investigations included detailed clinical, radiological and sonographic studies and CT scan, wherever necessary. Overall, 28% cases required thoracic surgical intervention to obviate symptoms and restore deranged functional status. INTRODUCTION Pleural empyema, by definition, is pus in the pleural space, but how many white blood cells need to be present in pleural fluid to make it pus has been controversial. Weese defined it as a fluid with a specific gravity greater than 1018, a white blood cell count greater than 500/Cmm, or a protein level greater than 2.5g%. Vianna defined empyema as a pleural fluid with positive bacterial cultures or white blood cell count greater than 15,000/Cmm and a protein level above 3g%. Because many pleural effusions may meet these criteria, the most favoured definition is that of thick, purulent appearing pleural fluid. Pleural empyema is a serious complication of infection adjacent to or within the chest that rarely resolves without appropriate medical therapy and drainage procedure. Host defenses are seriously compromised by the anatomy and physiology of an infected pleural space, and subtleties of presentation may delay recognition and appropriate management. Empyema is usually a complication of pneumonia but may arise from infections at other sites. In our country, tubercular empyema continues to be, an important cause. Presentation and microbial etiology can be modified by local trauma, surgery or by underlying conditions such as malignancy, collagen vascular disease, immunodeficiency disorders, and adjacent infection involving the oropharynx, oesophagus, mediastinum, or subdiaphragmatic tissues. Despite the availability of potent antibiotics, bacterial pneumonia is still an important cause of morbidity and mortality Twenty percent of these patients suffering from bacterial pneumonia require hospitalization, and as many as 40% of them have an accompanying pleural effusion. The morbidity and mortality rates in cases of pneumonia with associated pleural effusion are higher than in patients with pneumonia alone. Most of there effusions resolve spontaneously with no specific therapy directed towards them, but about 10% require an active intervention for their resolution. Delay in instituting specific therapy leads to much of the morbidity which is substantial. Recent advances in imaging and instrumentation have facilitated the recognition and management of bacterial empyema. Intensive work in this field has improved the understanding of its pathophysiology and clinical presentation. Use of thromobolytic agents (urokinase and streptokinase), in conjunction with precise and timely placement of drainage catheters has made it possible to reduce the risk of pleural fibrosis and lung entrapment, thus avoiding thoracotomy. Similarly, video-assisted thoracoscopic techniques also provide an effective, less invasive means of assessing and managing the infected pleural space without conventional thoracotomy. Empyema thoracis continues to pose problems regarding its ctiological diagnosis and management. The extensive use of antimicrobials has reduced the incidence of empyema thoracis and perhaps modified its etiological pattern. Previously, many cases were presumed to be of tubercular etiology, but with improved diagnostic facilities, more and more cases of empyema of non tubercular etiology are being diagnosed. Overall, empyema thoracis is a

* Department of Respiratory Medicine, Military Hospital (Cardiothoracic Centre), Armed Forces Medical College, Pune Correspondence : Major Vasu Vardhan, Department of Respiratory Medicine, Military Hospital (Cardiothoracic Centre, A F M C Pune)

M.V. VARDHAN ET AL. 156 morbid and difficult condition to eradicate. The study due to the fear of clogging the mortality rate reported varies from 10% to 50%. machine with thick purulent material. The key to successful management is eradication of Instead, Elicos digital pH meter was infection, obliteration of pleural space and closure used along with microcombi nation of broncho-pleural fistula (when present). The electrode. Specimens for pH were choice of surgical procedure in the management of collected in a heparinised 10ml thoracic empyema when resorted to remains disposable syringe and were transported controversial. to the laboratory immediately where, if not analysed immediately, were stored AIMS OF STUDY on ice. (c) LDH : Pleural fluid LDH is also an im1. To study the clinical profile of empyema portant parameter determining the need thoracis. for drainage therapy. The samples were 2. To attempt to establish the underlying analysed using a AUTOPAK cometiology. mercial kit which gives quantitative de3. To analyse in detail, efficacy or otherwise of termination for lactate dehydrogenase. various modalities of therapy used. It operates using a method according to the recommendations of the ScandinaMATERIAL AND METHODS vian Committee on Enzymes (SCE). (d) Glucose: It is another important criteria Fifty cases of empyema thoracis admitted to a which determines the need for drainage tertiary referral respiratory centre were included in of an empyema. the present study. These cases were studied over a (e) Other parameters such as specific period of two years. Detailed particulars of the gravity, protein, ADA (adenosine patients included in the study were recorded. deaminase) and cytology were Elaborate history of presenting illness was taken determined. with special attention to history of r-anthem, (f) Bacteriological investigations carried immunosuppressive drugs, smoking, alcoholism, out were lower respiratory tract infection, chest trauma, Staining - gram stain, ZN stain and diabetes mellitus and recent instrumentation. All fungal stain. patients were subjected to general and systemic Cultures - pyogenic, mycobacterial, physical examination. Treatment received by these fungal and anaerobic. patients was carefully recorded. Patients were 4. Radiology - Xray chest PA and lateral view subjected to the following investigations. 5. Ultrasonography chest for confirming 1. Haemogram, ESR presence of fluid or loculations. It was also used to guide the site for cutaneous entry 2. Sputum for gram stain, ZN stain, fungal into the empyema space. Sonography of stain and cultures (pyogenic, mycobacterial abdomen was also performed where and fungal) indicated. 3. Pleural fluid analysis 6. Fiberoptic bronchoscopy, where necessary. (a) Appearance : Was considered as an 7. Pulmonary function tests important criteria for deciding the mode of drainage therapy. Overtly purulent 8. Pleural biopsy whereever it was feasible. fluids were drained using pleural 9. CT scan thorax where necessary. catheter/chest tube depending on The following drainage procedures were viscosity and presence of loculations. (b) pH: It is an important parameter which employed for the present study. (a) Conventional chest tube drainage with guides the need for a drainage. Ideally, underwater seal was used for patients with it is determined by ABO machine but thick pus and/or bronchopleural fistula. Size the same was not used in the present

EMPYEMA THORACIS

157

of the tubes used varied from 28 Fr to 34 Fr. (b) Pleural catheter drainage was performed for patients with thin pus and/or loculated empyema using catheters varying from 7 Fr to 10 Fr size. Catheters were introduced using direct trocar or modified Seldinger technique depending on the size of the catheter which is being introudced. (c) Repeated pleurocentesis. (d) Open drainage. The total duration of drainage and the amount drained off daily was recorded. Patients were followed up for a period of six months to one year and were assessed clinically, radiologically and functionally.
Table 1. Age Distribution Age group (years) 0-10 11-20 21-30 31-40 41-50 51-60 61-70 Total 50 Number of cases 4 9 15 16 3 1 2 100 Percentage 8 18 30 32 6 2 4

Table 3. Symptons
Symptoms Fever Cough Expectoration Chest pain Dyspnoea Haemoptysis Pain abdomen Urticaria Altered sensorium Weight loss/Weakness Extrathoracic sepsis Shock Number 38 29 26 33 14 5 2 1 3 10 3 3 Percentage 76 58 52 66 28 10 4 2 6 20 6 6

In the present study, commonest symptoms were fever in 38 (76%), cough 29 (58%), expectoration 26 (52%), chest pain 33 (66%), dyspnoea 14 (28%), and weight loss in 10 (20%).
Table 4. Underlying conditions associated -with Condition Number Percent age 1 . Primary Pulmonary Infection (a) Bacterial non tubercular pneumonia (b) Pleuropulmonary tuberculosis (c) Pulmonary tuberculosis with BPF (d) Pulmonary tuberculosis with transient air leak 2. Post surgical 3. Pleuropulmonary hydatid disease 4. Contiguous spread (a) Amoebic liver abscess (b) Potts spine 5. Latrogenic Pleurocentesis/Chest tube 6. Septicemia 7. Oesophageal perforation 8. Secondary spontaneous pneumothorax without persistent air leak 9. Others (Bronchial Carcinoid) Total 50 8 8 9 3 3 3 2 2 6 3 1 1 1 100 16 16 18 6 6 6 4 4 12 6 2 2 2

Majority of cases of empyema occurred in the age group 21 to 40 years comprising 31 (62%) of cases.
Table 2. Underlying risk factors for developing thoracic sepsis History of Smoking Alcohol Consumption Diabetes Mellitus Tuberculosis Exanthem Gastro-intestinal instrumentation Total Number 14 23 2 3 2 1 45 2 90 Percentage 28 46 4 6 4

Table 4 depicts the various underlying

M.V. VARDHAN ET AL. 158 conditions which lead to the development of in both these cases as expected, sugar and pH were empyema thoracis. 28 cases (56%) were detected to low. In contrast, 22 (44%) cases had glucose levels have associated pulmonary infection. Out of these 8 39 mg% and all had pH values 7.22 but it was (16%) had bacterial pneumonia and presented with not true vice versa e.g. 43 (86%) cases had pH acute onset of respiratory symptoms and fever with 7.22 but only 22 out of them had correspondingly chills. low ( 39 mg%) glucose levels. Hence in only 2 cases all the three parameters correlated. Two Correlation of Pleural Fouid pH, Glucose and LDH parameters (pH and glucose) correlated expectedly in 22 cases. Inspite of overt purulence in all cases, the above Table 5. Organisms in Gram stain/ZN stain/F stain three parameters of purulence had following and/or culture on initial presentation correlations: 1. LDH : 2 (4%) cases had values > 1000 U/L Stain Culture Number Number positive and positive and and in both these cases the pleural fluid Percentage percentage sugar ( 39 mg%) and pH ( 7.17) were found to be low. Gram stain 12 (24%) Pyogenic culture 12 (24%) 2. Glucose : 22 (44%) had glucose values 39 ZN stain 6(12%) 4 (8%) Mycobacterial culture mg% and out of these 2 had LDH values > 1000 U/L while all of them had pH values

7.22. 3. pH : 43 (86%) cases had pH < 7.22 but out of these, only 2 had LDH values > 1000 U/L and 22 had glucose values 39 mg%. Overall 2 cases had LDH values > 1000 U/L and

Fungal stain 3 (6%) Total 21(42%)

Fungal culture

3 (6%) 19(38%)

Only 21 (42%) patients had pleural pus which was positive for organisms on Gram/ZN/fungal

Etiology

Table 5. Etiological diagnosis, Pharmacotherapy, Drainage/Surgical procedures employed in 50 cases Other theChest Pleural Repeated Surgical PharmacoNo. of therapeutic tube catheter pleurocen- procedure therapy cases intervention tesis 22 ATT 14 5 3 Decortication 6 BPF closure 1 Lobectomy tDecortication 1 Open drainage 1 Pleural irrigation with Streptomycin and Povidine Iodine Streptokinase 1 Chloromycetin pleural irrigation 2 Parenteral and pleural Amphotericm Albendazole Decortication 2 Feeding gastrostomy 5 monectom 14 (+ 3)

Tuberculosis

Non tubercular Pneumonia Post Surgical

8 3

Antibiotics 4-6 weeks IV Amphotericin 1/Pleural Amphotericin 2/ Antibiotics Antibiotics/ Albendazole Antibiotics/Flagyl/ Chloroquine ATT/Antibiotics

1 3

7 5-singel 2-double -

BPF closure and decortication 1 2 Cyst excision lung 1, liver 1

Pleuropulmonary 3 hydatid disease Amoebic liver abscess Latrogenic Septicemia Oesophageal perforation Obstructive pneumonia Total 2

7 P. taps 5 Tube 2 Antibiotics 3 Antibiotics 1 1 50 Antibiotics

1 1 Laparotomy 1 1 4 3 -

1 1 Pleuropneu24 21

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159

stain. Out of 50 cases, 24 (48%) were managed with conventional tube thoracostomy, 21 (42%) with pleural catheter drainage and 5 (10%) with repeated pleurocentesis. Fourteen (28%) cases required thoracic surgical intervention - 9 (18%) decortication, 2 (4%) BPF closure with decortication, 1 (2%) pulmonary hydatid cyst excision (with decortication, 1 (2%) open drainage and 1 (2%) pleuropneumonectomy. One (2%) case underwent exploratory laparotomy for ruptured amoebic liver abscess to tackle the abdominal sepsis and 1(2%) case of oesophagel perforation required feeding gastrostomy to control pleural sepsis. Advantages of percutaneous catheter drainage The advantages noted were : 1. Easy to introduce 2. Minimal tissue trauma 3. Great patient acceptability due to absence of conventional underwater seal 4. Could be placed over posterior thoracic wall 5. No local/skin complications 6. No postural/mobility restrictions imposed on the patient by this procedure Overall, of 50 patients, 14 (28%) required thoracic surgical intervention. Out of 24 cases managed with tube thoracostomy 37.5% required surgical intervention as compared to 10% in

catheter group and 60% in pleurocentesis group Patients managed with conventional tube drainage, 9 had BPF which necessitated prolonged drainage and 2 required BPF closure with decortication. One case required open drainage due to bilateral extensive disease and persistent BPF with entrapped diseased lung. Due to prolonged air leak/and or pyothorax there was significant functional impairment in 14 cases and surgery was performed to restore compromised functional status
CONCLUSIONS
1.

Common conditions which were found to be associated with empycma thoracis were : primary pulmonary infections in 56% [40% tubercular and 16% non tubercular], iatrogenic causes 14%, extrathoracic sepsis/contiguous spread 14%. In the present study most reliable parameters of suppuration were overtly purulent fluid in all cases (100%), pH 7.22 in 86% cases, pleural fluid glucose levels 39 mg% in 44% cases.
Bacteriological diagnosis could established in only 21 (42%) cases. be

2.

3. 4.

Optimal therapy for empyema thoracis requires institution of appropriate pharmacotherapy and adquate drainage.

Table 7. Cases requiring thoracic surgical interventions Drainage group Total number of cases alloted to each drainage group 24 Surgery performed and number * Decortication 4 * BPF closure with decortication 2 * Hydatid cyst excision with decortication 1 * Pleuropneumonectomy 1
Pleural catheter drainage

Total number of surgical interventions in each group

Percentage

Tube thoracostomy

375

21 5 50

* Open drainage 1 * Decortication 2 * Decortication 3

2 3 14(28.0%)

100
600

Repeated pleurocentesis Total

160 5.

M.V. VARDHAN ET AL..

Percutaneous catheter drainage was found to be a viable alternative to tube thoracostomy provided there was no associated BPF and the pus was not too thick. Overall, 14 (28%) required thoracic surgical intervention to obviate symptoms [pain and breathlessness] and attempt to restore the functional status. In tube thoracostomy group 37.5%, catheter group 10%, and repeated pleurocentesis group 60% required surgical intervention.

2.

3. 4.

6.

5. 6. 7.

REFERENCES
1. Light R.W. Parapneumonic effusions and empyema. In : Light R.W. Pleural diseases, 3rd ed. Baltimore : Williams and Wilpins, 1995,129,153.

Finland M, Barnes M.W. Duration of hospitalization for acute bacterial empyema at Boston City Hospital during 12 selected years from 1935 to 1972. JInfect Dis. 1978,138, 520. Boland O.W., Lee M.J. Silverman S. Mueller P.R., Interventional radiology of pleural space. Clinical Radiology 1995, 50,205. Lahorra J.M. Haaga J.R., Stellats T., Flanigan T., Graham R. Safety of intracavitatory urokinase with percutaneous abscess drainage. AJR 1993, 160, 171. Gupta S.K., Jai Kishan, Satpaul Singh. Review of one hundred cases of Empyema Thoracis. Indian J Chest Dis and All Sci 1989, 31,15. Silverman S.G., Mueller P.R., Saini S. Thoracic empyema : Management with image guided catheter drainage. Radiology 1988,169, 5. Richar E., Bryant, Christopher J Salmon, Pleural empyema. Clinical Infectious Disease 1996, 22, 747.

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