Surgical management of empyema

The effects of a physiotherapy programme on patients with a pleural effusion: a randomized controlled trial

Objective:

To investigate the effects of a physiotherapy protocol on patients with pleural effusion.

Design:

Randomized controlled trial.

Setting:

University hospital.

Participants:

A total of 104 consecutive inpatients with a medical diagnosis of pleural effusion.

Intervention:

Patients were randomly allocated to a control group receiving standard treatment (medical treatment and drainage) or an intervention group treated with physiotherapy added to standard treatment. The physiotherapy programme included deep breathing exercises, mobilizations and incentive spirometry.

Main outcome measures:

Spirometric predicted values and chest radiographs were measured before treatment and at discharge and the length of hospital stay was recorded. Assessors were blinded to the intervention.

Results:

A comparative analysis showed a significant improvement of spirometric parameters in the intervention group; pre-to-post hospitalization predicted values showed significant changes in vital capacity (73.1 ± 12.6% to 72.13 ± 13.7 %, P<0.001 ), forced expiratory volume in first second (72.13 ± 13.7% to 78.98 ± 16.9%, P<0.001) and forced expiratory flow at 25-75 % (64.8 ± 35.1% to 76.78 ± 35.3%, P=0.198) compared to the control group that showed no significant changes across treatment. The radiographic findings showed better scores on the affected side of the thorax at discharge in the physiotherapy group. Length of hospital stay was also significantly ( P=0.014) shorter in the intervention group (26.7 ± 8.8 days) compared to the control group (38.6 ± 10.7 days).

Conclusions:

A physiotherapy programme added to standard treatment improves the spirometric parameters and the radiological findings and reduces the hospital stay in patients with a pleural effusion.

Empyema thoracis: a clinical study

BACKGROUND:

Empyema thoracis is a disease that, despite centuries of study, still causes significant morbidity and mortality.

AIM:

The present study was undertaken to study the age-sex profile, symptomatology, microbiologic findings, etiology and the management and treatment outcome in a tertiary care hospital.

SETTINGS AND DESIGN:

A prospective study of empyema thoracis was conducted on 40 consecutive patients with empyema thoracis admitted to the tuberculosis and chest diseases ward of a teaching hospital.

MATERIALS AND METHODS:

The demographic data, clinical presentation, microbiological findings, etiology, the clinical course and management were recorded as per a planned pro forma and analyzed.

RESULTS:

The peak age was in the range of 21-40 years, the male-to-female ratio was 3.4:1.0 and the left pleura was more commonly affected than the right pleura. Risk factors include pulmonary tuberculosis, chronic obstructive pulmonary diseases, smoking, diabetes mellitus and pneumonia. Etiology of empyema was tubercular in 65% cases and nontubercular in 35% cases. Gram-negative organisms were cultured in 11 cases (27.5%). Two patients received antibiotics with repeated thoracentesis only, intercostal chest tube drainage was required in 38 cases (95%) and more aggressive surgery was performed on 2 patients. The average duration for which the chest tube was kept in the complete expansion cases was 22.3 days.

CONCLUSION:

It was concluded that all cases of simple empyema with thin pus and only those cases of simple empyema with thick pus where size of empyema is small should be managed by aspiration/s. Cases failed by the above method, all cases of simple empyema with thick pus and with moderate to large size of empyema and all cases of empyema with bronchopleural fistula should be managed by intercostal drainage tube connected to water seal. It was also observed that all cases of empyema complicated by bronchopleural fistula were difficult to manage and needed major surgery.

Decortication after lung transplantation

BACKGROUND

Compromise of a pulmonary allograft by restrictive or infectious pleural-space pathology may be amenable to surgical intervention; however, the role of decortication in this patient population has not yet been substantiated. To address this issue, indications and outcomes of decortication after lung transplantation were examined at our institution.

METHODS

From February 1990 to December 2006, 553 patients underwent lung transplantation; postoperative decortications were performed 27 times in 24 patients (4.3%).

RESULTS

Indications for decortication included presumed empyema (15), loculated effusion (7), hemothorax (3), and fibrothorax (2). Decortication was performed at a median of 81 days after transplantation (range, 12 days to 7.8 years). Complete lung reexpansion was achieved after 19 of 27 decortications (70%). Infection was cleared from the pleural space in 9 of 15 empyema patients (64%). Survivals at 1, 3, 6, and 12 months after decortication were 85%, 73%, 65%, and 60%, respectively. Operative mortality (30-day or in-hospital) was 23%, and median length of stay was 19 days.

CONCLUSIONS

Decortication may alleviate the compromise of a transplanted lung by restrictive or infectious pleural-space disease, but operative risk is substantial.

The management of pleural space infections

Pleural infection is responsible for significant morbidity and mortality worldwide, and its clinical management is challenging. The diagnosis of empyema and tuberculous pleurisy may be difficult, and these conditions may be confused with other causes of exudative pleural effusions. Complicated parapneumonic effusion or empyema may present with 'atypical' clinical features; delays in diagnosis are common and may contribute to the high mortality of these infections. Pleural aspiration is the key diagnostic step; pleural fluid that is purulent or that has a pH < 7.2, or organisms on Gram stain or culture, is an indication for formal intercostal drainage. In order to achieve a definitive diagnosis of tuberculous pleurisy, Mycobacterium tuberculosis must be isolated in the culture of pleural fluid, pleural tissue or sputum; demonstration of granulomas in pleural tissue is also suggestive of tuberculosis. The use of pleural fluid biochemical markers, such as adenosine deaminase, in the diagnosis of tuberculous pleurisy varies among clinicians; the diagnostic value of such markers is affected by the background prevalence of tuberculosis and the likelihood of an alternative diagnosis. Uncertainties also remain regarding the treatment of pleural infection. Treatment of complicated parapneumonic effusion and empyema involves prolonged courses of antibiotics and attention to the patient's nutritional state. The role of intrapleural fibrinolytics and the optimal timing of surgical intervention are unknown. The lack of clear predictors of clinical outcome in empyema contributes to the difficulty in treating this condition. The pharmacological treatment of tuberculous pleurisy is the same as for pulmonary tuberculosis; the precise role of steroids in the treatment of tuberculous pleurisy remains uncertain.

A new sterilization technique with balloon-tube thoracostomy for thoracic empyema

OBJECTIVE

Failure or prolongation of treatment for refractory thoracic empyema by the current chest-tube drainage technique is often due to sterilization difficulties. Insufficient sterilization prolongs hospitalization, and is often associated with life-threatening complications and/or additional invasive surgical procedures. A new chest-tube sterilization technique aimed at making it less invasive and shortening the therapy is proposed.

METHODS

Following pretreatment for complications including loculation, bronchopleural fistula, or corticated lung, a double-lumen trocar catheter was introduced at the bottom of the empyemic cavity through the lateral chest wall. Then, a Foley balloon urethra-catheter was inserted and attached just inside the anterior chest wall at the top of the cavity for the evacuation of intrathoracic air. After irrigation of the cavity with distilled water once or twice, the cavity was completely filled with a bactericidal solution which was left in place for 30-60 minutes, followed by an antibiotic solution for more than 20 hours.

RESULTS

Among the five treated post-lobectomy or pneumonectomy cases, sterilization was obtained after only one treatment in four cases and after two courses in the other. Catheterization duration from the initial treatment was 2-13 days. Neither recurrence nor treatment-related major complications were observed.

CONCLUSIONS

This balloon-tube thoracostomy technique is simple, minimally invasive and cost-effective, due to shortening of the treatment time with minimal manpower and equipment requirements. It is thus a promising therapeutic approach to thoracic empyema and has the potential for application to other intrathoracic disorders.

Successful management of empyema in a patient with a total artificial heart

A description of successful management of a patient who developed an empyema as a postoperative complication following the insertion of a CardioWest total artificial heart (TAH) as a bridge to cardiac transplantation is presented. By using traditional methods of management, the patient recovered and went on to transplant.

Morbidity and mortality after 94 extrapleural pneumonectomies for empyema

BACKGROUND

Extrapleural pneumonectomy is still indicated in some patients with empyema. We examined morbidity and mortality after this high-risk operation.

METHODS

Between 1979 and 1998, 94 (92 chronic, 2 postsurgical) patients with empyema underwent extrapleural pneumonectomy. There were 79 men and 15 women (mean age, 59 years). Eighty-eight patients had a history of tuberculosis, and 53 had undergone a therapeutic pneumothorax. The right side was operated on in 50 patients and left in 44.

RESULTS

Operative mortality was 8.5%. Fifteen major complications (1 esophageal perforation, 9 empyemas, and 5 bronchopleural fistulas) occurred in 13 patients. Eight patients required reexploration for hemorrhage. Reexploration was a risk factor for empyema. Bronchopleural fistulas occurred only on the right side. Eighty-nine percent of the 86 operative survivors were free of empyemas at 5 years. Overall 5-year survival was 83%, and survival was better in patients without than in those with empyema.

CONCLUSIONS

Extrapleural pneumonectomy for empyema has acceptable morbidity and mortality. Postoperative empyema affects prognosis. Covering a bronchial stump with muscle is recommended, especially when the operation is performed on the right side.

Improved patient outcome after surgical treatment for loculated empyema

BACKGROUND

Empyemas complicate the hospital course of many patients. Advanced stages of empyema often require surgical intervention.

METHODS

A retrospective review of 70 adult patients with empyema, hospitalized between the years of 1992 and 1997, was performed. Data on age, length of stay, comorbidities, diagnostic studies, and treatment was obtained. We compared patient outcome from patients with loculated empyemas who had surgical treatment and those who were managed nonsurgically.

RESULTS

Seventy patient records were reviewed, 37 of which were of patients with loculated empyemas. Parapneumonic empyemas comprised 60% of all cases. Chest radiographs, computed tomography scan, and thoracentesis were the most common studies performed in both groups. Thirty-three patients with the radiographic finding of a loculated empyema were treated with either surgical decortication or tube thoracostomy.

CONCLUSION

Empyemas at various stages of development require different forms of therapy; advanced empyemas treated early with decortication have a shorter duration of treatment, lower incidence of recurrence and fewer complications.

Pyogenic lung infections

Pyogenic lung infections still occur despite the availability of effective antibiotics for the treatment of patients with acute bacterial pneumonia. Our understanding of the pathogenesis and management of these conditions has steadily improved over the past few decades, although some areas remain obscure. The effect of HIV infection on the incidence of pyogenic lung infections remains largely unknown, and large studies are required to evaluate this. Burkholderia (formerly Pseudomonas) cepacia strains are now recognized as important respiratory pathogens in patients with cystic fibrosis, and the high transmissibility of some strains, combined with their inherent multiple antibiotic resistance, are continuing causes for concern.