Thoracic Empyema—Back to Basics
1988; Elsevier BV; Volume: 93; Issue: 5 Linguagem: Inglês
10.1378/chest.93.5.901
ISSN1931-3543
Autores Tópico(s)Ultrasound in Clinical Applications
ResumoThoracic empyema generally refers to a pyogenic infection of the pleural cavity, and its successful resolution, as with other “space” problems, depends upon apposition of the visceral and parietal pleura. It is widely accepted that drainage of the infected pleural space is an important part of the treatment of empyema. However, with the proliferation of “easy to insert” trocar-bearing chest tubes and CT-guided needle aspiration of virtually every body crevice, basic principles of management of empyema are being forgotten, and therapy may be far from ideal. Infected pleural fluid per se does not constitute an empyema, and similarly all infected pleural fluid does not require surgical drainage. A number of recent publications have stressed the need for chest tube drainage of pleural fluid with a low pH and glucose level, a high lactic dehydrogenase level, the presence of bacteria on Gram stain, or a positive culture, as though these are indications of empyema.1Good JT Taryle DA Maulitz RM Kaplan RL Sahn SA. The diagnostic value of pleural fluid pH.Chest. 1980; 78: 55-59Abstract Full Text Full Text PDF PubMed Scopus (85) Google Scholar, 2Potts DE Levin DC Sahn SA. Pleural fluid pH in parapneumonic effusions.Chest. 1976; 7: 328-331Abstract Full Text Full Text PDF Scopus (115) Google Scholar, 3Potts DE Tarylc DA Sahn SA. The glucose-pH relationship in parapneumonic effusions.Arch Intern Med. 1978; 138: 1378-1380Crossref PubMed Scopus (64) Google Scholar, 4Light RW Girard WM Jenkinson SG George RB. Parapneumonic effusions.Am J Med. 1980; 69: 507-512Abstract Full Text PDF PubMed Scopus (422) Google Scholar, 5Houston MC. Pleural fluid pH: Diagnostic, therapeutic, and prognostic value.Am J Surg. 1987; 154: 333-337Abstract Full Text PDF PubMed Scopus (27) Google Scholar Lets get back to basics!The initial diagnostic step in a patient with a radiographic pleural effusion and suspected empyema is a thoracocentesis (not a CT scan) to obtain a sample of the fluid for analysis. And the most important piece of information regarding the need for surgical drainage is the character of the fluid, not its cell count, protein level, specific gravity, pH, LDH, Gram-stain result, or culture report. Parapneumonic effusions, for example, frequently contain bacteria, but if thin and serosanguinous, often respond to appropriate antibiotic therapy and repeat thoracocentesis which allows expansion of the lung and obliteration of the infected pleural space. On the other hand, thick viscous pus in the pleural cavity simply cannot be aspirated adequately with a thoracocentesis needle, and when encountered, requires formal surgical drainage.Drainage of pus is not new to the profession, but far too often, little if any attempt is made to define the size, shape and exact location of the empyema cavity, so that ideal dependent drainage can be instituted. In this regard, a chest CT scan is unnecessary and not nearly so helpful as an empyemagram, a study of which many physicians now caring for chest infections have never even heard! When frank pus is obtained at thoracocentesis, the reflex to insert a chest tube should be resisted. Rather, while the Gram-stain and culture and routine physical and chemical studies of the pleural fluid are being performed, the patient should be transported to the radiology department. The thoracocentesis should be repeated, 30 to 60 ml of pus aspirated, and leaving the needle in the empyema cavity, an equal amount of oily propyliodone (Dionosil) or 3–5 ml of iodized oil (Lipiodol) instilled. Upright PA, lateral, and decubitus films will demonstrate the contrast material in the most dependent portions of the empyema cavity and provide precise localization for drainage. One does not tap a keg at the top of the barrel, and likewise, knowledge of the location of the lower-most portion of the empyema is vital for optimal drainage. And the final issue is: “What is optimal drainage?”In our recent experience with 70 adult patients with thoracic empyemas (37 percent associated with primary bronchopulmonary infections, 33 percent postoperative, 10 percent from an intra-abdominal source, and 10 percent iatrogenic), when used as the initial mode of drainage, repeat thoracocentesis was successful in only 36 percent and closed tube thoracostomy in only 35 percent, while rib resection provided cure or control in 91 percent of the patients.6Lemmer JH Botham MJ Orringer MB. Modern management of adult thoracic empyema.J Thorac Cardiovasc Surg. 1985; 90: 849-855Abstract Full Text PDF PubMed Google Scholar The etiology of the empyema clearly influences the outcome of initial chest tube therapy, as 67 percent of our parapneumonic empyemas were treated successfully with closed chest tube thoracostomy in contrast to only 12 percent of postoperative empyemas so treated. All five of the empyema-caused deaths occurred in patients who underwent chest tube drainage as the most invasive treatment modality. Thick pus in the chest, as in every other location, is most effectively treated by open, dependent drainage. While some recent reports have found closed tube thoracostomy to be effective in 62–80 percent of empyemas, 7Benfield GFA. Recent trends in empyema thoracis.Br J Dis Chest. 1981; 75: 358-366Abstract Full Text PDF PubMed Scopus (29) Google Scholar, 8Schacter EN Kreisman H Putnam C. Diagnostic problems in suppurative lung disease.Arch Intern Med. 1976; 136: 167-171Crossref PubMed Scopus (14) Google Scholar in our experience, rib resection generally permits more adequate disruption of intrathoracic loculations and accurate placement of a dependent, large bore, single end-hole drainage tube.Thoracic empyema is a serious clinical problem which is associated with definite mortality ranging from 8 to 33 percent.7Benfield GFA. Recent trends in empyema thoracis.Br J Dis Chest. 1981; 75: 358-366Abstract Full Text PDF PubMed Scopus (29) Google Scholar, 8Schacter EN Kreisman H Putnam C. Diagnostic problems in suppurative lung disease.Arch Intern Med. 1976; 136: 167-171Crossref PubMed Scopus (14) Google Scholar, 9LeBlanc KA Tucker WY. Empyema of the thorax.Surg Gynecol Obstet. 1984; 158: 66-70PubMed Google Scholar, 10Varkey B Rose HD Kutty CPK Politis J. Empyema thoracis during a ten-year period.Arch Intern Med. 1981; 141: 1771-1776Crossref PubMed Scopus (101) Google Scholar, 11Jess P Brynitz S Moller AE Mortality in thoracic empyema.Scand J Cardiovasc Surg. 1984; 18: 85-87Crossref Scopus (33) Google Scholar The proper management of thick pus in the chest requires precise localization and aggressive, adequate, open dependent drainage. Closed tube thoracostomy drainage is often unsuccessful, and early rib resection is a safer, more efficient approach, particularly in postoperative empyemas and those occurring in immunosuppressed patients. Infected pleural fluid per se does not constitute the need for a chest tube, and if the patient truly has an empyema, formal open surgical drainage is as appropriate as it is for abscesses in other parts of the body. Thoracic empyema generally refers to a pyogenic infection of the pleural cavity, and its successful resolution, as with other “space” problems, depends upon apposition of the visceral and parietal pleura. It is widely accepted that drainage of the infected pleural space is an important part of the treatment of empyema. However, with the proliferation of “easy to insert” trocar-bearing chest tubes and CT-guided needle aspiration of virtually every body crevice, basic principles of management of empyema are being forgotten, and therapy may be far from ideal. Infected pleural fluid per se does not constitute an empyema, and similarly all infected pleural fluid does not require surgical drainage. A number of recent publications have stressed the need for chest tube drainage of pleural fluid with a low pH and glucose level, a high lactic dehydrogenase level, the presence of bacteria on Gram stain, or a positive culture, as though these are indications of empyema.1Good JT Taryle DA Maulitz RM Kaplan RL Sahn SA. The diagnostic value of pleural fluid pH.Chest. 1980; 78: 55-59Abstract Full Text Full Text PDF PubMed Scopus (85) Google Scholar, 2Potts DE Levin DC Sahn SA. Pleural fluid pH in parapneumonic effusions.Chest. 1976; 7: 328-331Abstract Full Text Full Text PDF Scopus (115) Google Scholar, 3Potts DE Tarylc DA Sahn SA. The glucose-pH relationship in parapneumonic effusions.Arch Intern Med. 1978; 138: 1378-1380Crossref PubMed Scopus (64) Google Scholar, 4Light RW Girard WM Jenkinson SG George RB. Parapneumonic effusions.Am J Med. 1980; 69: 507-512Abstract Full Text PDF PubMed Scopus (422) Google Scholar, 5Houston MC. Pleural fluid pH: Diagnostic, therapeutic, and prognostic value.Am J Surg. 1987; 154: 333-337Abstract Full Text PDF PubMed Scopus (27) Google Scholar Lets get back to basics! The initial diagnostic step in a patient with a radiographic pleural effusion and suspected empyema is a thoracocentesis (not a CT scan) to obtain a sample of the fluid for analysis. And the most important piece of information regarding the need for surgical drainage is the character of the fluid, not its cell count, protein level, specific gravity, pH, LDH, Gram-stain result, or culture report. Parapneumonic effusions, for example, frequently contain bacteria, but if thin and serosanguinous, often respond to appropriate antibiotic therapy and repeat thoracocentesis which allows expansion of the lung and obliteration of the infected pleural space. On the other hand, thick viscous pus in the pleural cavity simply cannot be aspirated adequately with a thoracocentesis needle, and when encountered, requires formal surgical drainage. Drainage of pus is not new to the profession, but far too often, little if any attempt is made to define the size, shape and exact location of the empyema cavity, so that ideal dependent drainage can be instituted. In this regard, a chest CT scan is unnecessary and not nearly so helpful as an empyemagram, a study of which many physicians now caring for chest infections have never even heard! When frank pus is obtained at thoracocentesis, the reflex to insert a chest tube should be resisted. Rather, while the Gram-stain and culture and routine physical and chemical studies of the pleural fluid are being performed, the patient should be transported to the radiology department. The thoracocentesis should be repeated, 30 to 60 ml of pus aspirated, and leaving the needle in the empyema cavity, an equal amount of oily propyliodone (Dionosil) or 3–5 ml of iodized oil (Lipiodol) instilled. Upright PA, lateral, and decubitus films will demonstrate the contrast material in the most dependent portions of the empyema cavity and provide precise localization for drainage. One does not tap a keg at the top of the barrel, and likewise, knowledge of the location of the lower-most portion of the empyema is vital for optimal drainage. And the final issue is: “What is optimal drainage?” In our recent experience with 70 adult patients with thoracic empyemas (37 percent associated with primary bronchopulmonary infections, 33 percent postoperative, 10 percent from an intra-abdominal source, and 10 percent iatrogenic), when used as the initial mode of drainage, repeat thoracocentesis was successful in only 36 percent and closed tube thoracostomy in only 35 percent, while rib resection provided cure or control in 91 percent of the patients.6Lemmer JH Botham MJ Orringer MB. Modern management of adult thoracic empyema.J Thorac Cardiovasc Surg. 1985; 90: 849-855Abstract Full Text PDF PubMed Google Scholar The etiology of the empyema clearly influences the outcome of initial chest tube therapy, as 67 percent of our parapneumonic empyemas were treated successfully with closed chest tube thoracostomy in contrast to only 12 percent of postoperative empyemas so treated. All five of the empyema-caused deaths occurred in patients who underwent chest tube drainage as the most invasive treatment modality. Thick pus in the chest, as in every other location, is most effectively treated by open, dependent drainage. While some recent reports have found closed tube thoracostomy to be effective in 62–80 percent of empyemas, 7Benfield GFA. Recent trends in empyema thoracis.Br J Dis Chest. 1981; 75: 358-366Abstract Full Text PDF PubMed Scopus (29) Google Scholar, 8Schacter EN Kreisman H Putnam C. Diagnostic problems in suppurative lung disease.Arch Intern Med. 1976; 136: 167-171Crossref PubMed Scopus (14) Google Scholar in our experience, rib resection generally permits more adequate disruption of intrathoracic loculations and accurate placement of a dependent, large bore, single end-hole drainage tube. Thoracic empyema is a serious clinical problem which is associated with definite mortality ranging from 8 to 33 percent.7Benfield GFA. Recent trends in empyema thoracis.Br J Dis Chest. 1981; 75: 358-366Abstract Full Text PDF PubMed Scopus (29) Google Scholar, 8Schacter EN Kreisman H Putnam C. Diagnostic problems in suppurative lung disease.Arch Intern Med. 1976; 136: 167-171Crossref PubMed Scopus (14) Google Scholar, 9LeBlanc KA Tucker WY. Empyema of the thorax.Surg Gynecol Obstet. 1984; 158: 66-70PubMed Google Scholar, 10Varkey B Rose HD Kutty CPK Politis J. Empyema thoracis during a ten-year period.Arch Intern Med. 1981; 141: 1771-1776Crossref PubMed Scopus (101) Google Scholar, 11Jess P Brynitz S Moller AE Mortality in thoracic empyema.Scand J Cardiovasc Surg. 1984; 18: 85-87Crossref Scopus (33) Google Scholar The proper management of thick pus in the chest requires precise localization and aggressive, adequate, open dependent drainage. Closed tube thoracostomy drainage is often unsuccessful, and early rib resection is a safer, more efficient approach, particularly in postoperative empyemas and those occurring in immunosuppressed patients. Infected pleural fluid per se does not constitute the need for a chest tube, and if the patient truly has an empyema, formal open surgical drainage is as appropriate as it is for abscesses in other parts of the body.
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