Surgical management of thoracic empyema

The etiology and bacteriology of healthcare-associated empyema are quite different from those of community-acquired empyema

OBJECTS

Changes in patients' background and life environment could contribute to increase healthcare-associated (HCA) empyema. There are no guidelines and statements for HCA empyema.

METHODS

We retrospectively reviewed all patients with empyema who were admitted to the Aichi Medical University Hospital, Japan between 2008 and 2015. We evaluated patients' characteristics, microbial profiles, treatment and outcomes, and analyzed prognostic factors for 90-day mortality.

RESULTS

A total of 48 patients were enrolled in this study. They were categorized into community-acquired (CA) empyema (16 patients) and healthcare-associated (HCA) empyema (32 patients). HCA empyema patients had higher Charlson comorbidity index (CCI) scores, and poorer performance status (PS) than CA empyema patients. Potentially-drug resistant (PDR) pathogens were seen more frequently in HCA empyema than in CA empyema. Compared with survival and death groups, the death group showed higher CCI scores and poorer PSs than the survival group. The death group had more malignancy than the survival group. PDR pathogens were detected more frequently in the death group than in the survival group. Multivariate analysis showed that emergence of PDR pathogens and malignancies were independent poor prognostic factors for 90-days mortality among empyema.

CONCLUSION

The etiology and bacteriology of HCA empyema are quite different from those of CA empyema. Especially, the mortality of HCA empyema was higher than the one of CA empyema. Emergence of PDR pathogens in the pleural fluid detected by culture, pulmonary disease and malignancies were independent poor prognostic factors among CA and HCA empyema by multivariate logistic regression analysis.

Pneumonia and empyema: causal, casual or unknown

Parapneumonic effusions complicating pneumonia are associated with increased morbidity and mortality. Along with increased mortality, complicated parapneumonic effusion and empyema often necessitate prolonged treatment, longer hospital stay and interventions. Parapneumonic effusions arise from inflammation in the lungs and pleural space from direct invasion of bacteria, cascade of inflammatory events and bacteriologic virulence features. Patient factors and comorbidities also contribute to the pathophysiology of parapneumonic effusion development. The evolution of parapneumonic effusion can be divided into three progressive stages: (I) exudative stage; (II) fibrinopurulent stage; and (III) organizing stage with pleural peel formation. These stages can help categorize effusions into groups in order to evaluate the risk of a complicated course requiring intervention. We recommend that clinical data be evaluated and a stepwise approach be taken in management of these patients. This review article discusses current understanding of the development and relationship of parapneumonic effusions with pneumonia.

Managing the nonsurgical candidate with an empyema related to community-acquired lobar pneumonia

This case study reviews the medical management for a 76-year-old patient with a cardiac history and recurrent admissions for a persistent pneumonia. Computed tomography showed evidence of an empyema in the right middle and lower lobes of his lung. The standard treatment for an empyema is a thoracotomy and long-term antibiotics. However, the patient's cardiac history disqualified surgery as an option. Therefore the management plan was composed of antibiotics and treatment of his symptoms. The patient's symptoms improved after a week of levofloxacin (Levaquin), prednisone, bilevel positive airway pressure mask as required, and oxygen. He was discharged with home care, oxygen, Levaquin, tapering doses of prednisone, and previous medications. At a 6-week follow-up examination, the patient was asymptomatic and had marked improvement noted on chest radiograph. The advanced practice nurse played an important role in this patient's recovery by conducting patient education and coordinating follow-up after his release.

Prediction of Pulmonary Parenchymal Reexpansion by Computed Tomography after Pleural Decortication

Twenty-six patients underwent pleural decortication for chronic empyema. All had a computed tomgraphy scan of the chest showing no marked parenchymal destruction. Multiple subpleural linear densities perpendicular to the pleura were seen to various degrees and the sum of the areas of these densities was evaluated for each patient. The thickness of visceral and parietal pleura, nodularity of the empyema wall, presence of calcification, and homogeneity of the inner content of the empyema were assessed. The degree of lung reexpansion was quantified from the ratio of the aerated areas of the affected and unaffected lungs on postoperative chest radiography. Successful lung reexpansion was achieved in 23 patients. The 3 patients in whom lung reexpansion failed required a subsequent pneumonectomy. The thickness of extrapleural fat and the sum of the areas of subpleural linear densities were significantly higher in these 3 patients. In the successful decortication group, the degree of lung reexpansion correlated with the sum of subpleural linear densities and with a noted homogeneity of the inner content of the empyema. Computed tomography appeared to be useful in determining the appropriate surgical method of treating chronic empyema.