EMPYEMA THORACIS

the role of VATS

Empyema Thoracis
 Defined as “pus in the
chest”
 Ancient disease
 Hippocrates credited with
first description of natural
history and treatment
 Most common precursor
is bacterial pneumonia
and subsequent
parapneumonic effusion

Hippocrates of Kos 460-370 B.C.

 Empyema
 Aetiology
 Empyema is always secondary to infection in a neighboring
structure, usually the lung;
 1-Bacterial pneumonia &tuberculosis.
 2-Over 40% of patients with community-acquired pneumonia
develop an associated pleural effusion
 And 15% of them develop secondary bacterial infection and
empyema.
 3-Infection of haemothorax,& rapture of subphrenic abscess.
 4-Delay in the diagnosis and instigation of appropriate therapy.
 The Stages of Empyema
 Stage I - “Exudative”
 sterile pleural fluid develops secondary to inflammation
without fusion of the pleura
 Stage II - “Fibrinopurulent”
 a fibrinous peel develops on both pleural surfaces
limiting lung expansion
 Stage III - “Organizing”
 in-growth of capillaries & fibroblasts into the fibrinous
peel
 Clinical features
Systemic features ;
1-Pyrexia,usually high and remittent
2-Rigors,sweating,malaise and weight loss
3-Polymorphonuclear leucocytosis, high (C-Reactive Protein)
CRP.
 Local feature ;
 1-Pleural pain; breathlessness; cough and sputum usually
because of underlying lung disease; copious purulent sputum if
empyema rupture into a bronchus (bronchopleural fistula)
 2-Clinical signs of fluid in the pleural space
 Differential diagnosis
 Pleural involvement occurs in up to 5% of patients with
rheumatoid arthritis.
 Pleural malignancy
 Chylothorax and pseudochylous effusion
 Pulmonary embolism
 Esophageal rupture
 Bacteriology
 Aerobic organisms are the most frequent organisms
identified from infected pleural fluid.
 These are most commonly Gram-positive organisms
from Streptococcal species, followed by Staphylococcus
aureus.
 Gram-negative empyema is more frequent in patients
with underlying diseases, especially those with diabetes
and alcoholism.
 Staphylococcus aureus and Gram-negative enteric
bacteria such as Klebsiella pneumonia have a particular
propensity to cause pleural infection.
 Bacteriological data.
 Streptococcus pneumoniae: 15-20%
Increased resistance

 Staphylococcus:15-30%
 Streptococcus spp
 Gram Negative: 20-50%
Klebsiella, Enterobacter, Pseudomonas, Hemophilus,
E.Coli
 Anaerobes:
Fusobacterium, Bacteroides fragilis
 Diagnostic
 X-ray
 Pleura USG
 Fast, safe&effective in confirming the presence of pleural fluid
and estimating its volume, can differentiate between pleural
fluid and thickening ,guiding thoracosintesis (dx and therapy)
 CT Scan
 should be obtained when pleural space infection is
suspected
 Bronchoscopy
 particularly recommended where there is a mass or volume
loss on imaging
Goal of Treatment
 Evacuation of Pus
 Expansion of Lung
 Eliminate of ongoing infection
Non Surgery Therapy
 Antibiotics
 Intrapleural fibrinolytics
 Intrapleural fibrinolytics
 1949 Tillet and Sherry: partial purified streptococcal fibrinolysin
 Highly purified streptokinase: 250000IU
 Urokinase: 100000IU
 It form a complex with plasminogen that converts additional circulating
plasminogen to plasmin. Plasmin lyses fresh fibrin clot and digests
prothrobin and fibrinogen.
 Improvement in the chest radiograph and greater volume pleural
drainage, not outcome of mortality, surgical frequency, or hospital stay.
 Tube drainage with streptokinase and early surgical intervention showed
reduced length of hospitalization
 Potential side effect: hemorrhage, pleuritic pain and fever
What Surgery can do ?
 The goals of surgery for empyema are:
 to debride the pleural cavity and
 to achieve lung re-expansion
 Debridement of the pleural cavity comprises drainage of
all fluid, breaking of all loculations and removal of all the
pleural exudate.
 Decortication entails thorough removal of the restrictive
cortex of fibrous and infected tissue overlying the visceral
pleura to allow the lung to re-expand
Surgical management of empyema
(AATS)
Best surgical approach to manage stage
II empyema?
 Class IIa:VATS should be the first line approach in all patients
with stage II acute empyema (LOE B)
Surgical management of empyema
(EACTS)
 VATS benefit
 Benefits of a minimally invasive approach including:
 reduction in operative time
 postoperative pain,
 duration of chest tube
 length of hospital stay
 Greater satisfaction with postoperative wound appearance
 an earlier return to work