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PubMed1989

[Therapy of parenchyma and bronchus fistula in chronic pleural empyema and the remaining empyema cavity].

The peripheral bronchial fistula, which is not visible by direct endoscopic examination, is closed by endoscopic application of fibrin glue. Sometimes only conservative therapy with irrigation of the pleural space is sufficient and effective. The postlobectomy fistula of the bronchus stump is treated by preoperative puncture and irrigation of the pleural space, followed by a corrective reamputation of the stump of the bronchus or a sleeve resection with end-to-end anastomosis. The post-pneumonectomy fistula has to be corrected by preoperative irrigation of the pleural space and a corrective second amputation by an extrapleural transmediastinal procedure. Sometimes it is necessary to use an opposite posterior access. An alternative is to cover the stump by an intercostal muscle flap without directly closing the fistula by suture. The remaining pleural space must be obliterated by using an additive pedunculated muscle flap of the thoracic wall.

Bronchial Fistula↗
PubMed1989

Contained thoracic empyema presenting as an anterior chest wall abscess: empyema necessitatis revisited.

Protean manifestation of pulmonary and pleural space infections can be expected in drug addicts. Because of the need to establish strict environmental protection for staff and patients, even simple drainage procedures should be performed in the operating room. Without testing, these patients should be considered as potential carriers of the AIDS virus. If a subcutaneous abscess is found to extend into the pleural space, drainage and full lung expansion are attempted through a limited rib resection. If this is unsuccessful, a full thoracotomy should be done to meet these surgical objectives.

Adult↗
PubMed2003

Experimental pneumococcal pleural empyema model: the effect of moxifloxacin.

OBJECTIVES: Pleural empyema is a serious complication of pneumonia, the optimal therapy of which is still unknown. The objective of this study was to evaluate the use of moxifloxacin in this condition. METHODS: Pleural empyema was induced in rabbits by intrapleural administration of Pasteurella multocida (10(5-6) cfu) or turpentine (0.3 mL) followed 3 h later by instillation of Streptococcus pneumoniae (ATCC 49619) (10(6) cfu) into the pleural cavity. The MICs of moxifloxacin for S. pneumoniae and P. multocida were 0.4 and 0.05 mg/L, respectively. Starting 30 h following S. pneumoniae challenge intramuscular moxifloxacin 12.5 and 25 mg/kg was administered x 4 (every 12 h). Pleural empyema fluid samples were obtained for bacterial count at 12 h intervals following the first three moxifloxacin administrations. Moxifloxacin levels in pleural empyema and serum samples were obtained at 0, 30, 60, 120, 240, 360 and 480 min and 12 h after the 4th dose and determined by bioassay. RESULTS: In control animals, S. pneumoniae (and P. multocida) persisted in the pleural empyema. S. pneumoniae also persisted in the pleural empyema fluid when moxifloxacin was administered at 12.5 mg/kg (x4 administrations). Mean serum and pleural empyema peak moxifloxacin levels (following the 25 mg/kg dose) were 7.6 (+/-3.2) and 4.8 (+/-2.5) mg/L, respectively. Pleural empyema peak moxifloxacin concentration lagged 1 h after serum moxifloxacin. Serum and pleural empyema half-lives were approximately 1.5 and approximately 6 h, respectively. Serum AUC(1-12) was 29.4 (+/-6.8) mg.h/L and serum area under the inhibitory concentration curve (AUIC) was 73.5 mg.h/L. Pleural empyema AUC(1-12) was 34.3 (+/-11.7) mg/L and pleural empyema AUIC was 85.8 mg.h/L. S. pneumoniae was eradicated from pleural empyema following a single dose of moxifloxacin 25 mg/kg in 52% of the animals and in 96% following four doses. Moxifloxacin was also effective in eradication of P. multocida. The rate of pleural empyema sterilization was related to moxifloxacin serum AUIC (r = 0.82) as well as serum peak moxifloxacin level (r = 0.84), but not to pleural empyema AUIC (r = 0.19) or pleural empyema peak levels. The results were similar for both methods of induction of pleural empyema. CONCLUSIONS: Moxifloxacin appears to penetrate well into experimental pleural empyema and effectively sterilize it from S. pneumoniae. Sterilization of S. pneumoniae is related to serum AUIC rather than to moxifloxacin pharmacokinetics in pleural empyema.

Animals↗
PubMed2006

[Contemporary approach to treatment of the posttraumatic empyema of the thorax].

INTRODUCTION: Empyema of the thorax is a serious morbidity and mortality causative factor in the postoperative period in severe blunt and penetrating thoracic injuries. The posttraumatic empyema of the thorax results, primarily, from secondary infections of the haemothorax. Current therapeutic management of the posttraumatic empyema of the thorax depends on the disease stage. AIM: A retrospektive analysis of the treatment procedures in patients with posttraumatic empyemas of the thorax. MATERIAL, METHODS, RESULTS: A study group included 118 patients with empyemas of the thorax, who were operated during the period from 1996 - June 2005. The commonest type of the empyema was a parapneumonic empyema, present in 86 (73%) subjects. 15 (13%) patients were operated for posttraumatic empyemas of the thorax. In 13 (11%) patients the empyema followed elective intrathoracic procedures (lung or oesophagus resection). In 4 (3%) cases the empyema resulted from intraabdominal inflammatory disorders. The cause of the posttraumatic empyema of the thorax was a secondary infection following repetitive drainages for the pneumothorax in three patients, infection of the retinated haemothorax in two patients and infection of the pleural exudate from a subphrenic absces following a stab injury of the abdomen in one patient. Another patient developed empyema as a complication of the oesophagus perforation by a foreign body. 8 injured patients with ventilation pneumonias developed parapneumonic empyemas. The patients were indicated for surgeries. Videothoracoscopic procedures (VTS, VATS) proved successful in 4 injured patients with empyemas, stage II. Thoracotomy with decortication was conducted in the remaining 11 injured patients (in 3 of them as a VTS conversion). The postoperative course following the decortication in the injured group with the posttraumatic empyema was complicated by a protracted air leak with a partial pneumothorax in two subjects and by a relaps of the pleural exudate in one operated subject. CONCLUSION: 1. Open thoracotomy with empyemectomy and decortication is a standard treatment method in the thoracic empyema, grade III. 2. The videothoracoscopic procedures (VTS, VATS) are indicated in early forms of the grade II of the disorder. 3. The quality and the result of the therapy depend on the following: the management of the focus of the infection, as well as a sufficient lung expansion while the residual pleural cavity is being minimized and also the management of the air leak from the lung.

Empyema, Pleural↗
PubMed2003

Subdural Empyema.

Subdural empyema represents loculated infection between the outermost layer of the meninges, the dura, and the arachnoid. The empyema may develop intracranially or in the spinal canal. Intracranial subdural empyema is most frequently a complication of sinusitis or, less frequently, otitis or neurosurgical procedures. Spinal subdural empyema is rare and may result from hematogenous infection or spread of infection from osteomyelitis. The most common organisms in intracranial subdural empyema are anaerobic and microaerophilic streptococci, in particular those of the Streptococcus milleri group (S. milleri and Streptococcus anginosus). Staphylococcus aureus is present in a minority of cases, and multiple additional organisms, including Gram-negative organisms, such as Escherichia coli, and anaerobic organisms, such as Bacteroides, may be present. Pseudomonas aeruginosa or Staphylococcus epidermidis may be present in cases related to neurosurgical procedures, and Salmonella species have been detected in patients with advanced AIDS; multiple organisms may be present simultaneously. Spinal subdural empyemas are almost invariably caused by streptococci or by S. aureus. Subdural empyema--whether it occurs in the skull or the spinal canal--may cause rapid compression of the brain or spinal cord, and represents an extreme medical and neurosurgical emergency. The diagnostic procedure of choice for intracranial and spinal subdural empyema is MRI with gadolinium enhancement. Computed tomography scan may miss intracranial subdural empyemas detectable by MRI. Conversely, occasion spinal subdural empyemas may be detected by CT myelography where MRI is negative. Treatment in virtually all cases of intracranial or spinal subdural empyema requires prompt surgical drainage and antibiotic therapy. Pus from the empyema should always be sent for anaerobic, as well as aerobic, culture. Because intracranial subdural empyemas may contain multiple organisms, provisional antibiotic therapy of intracranial subdural empyema, where the organism is unknown, should be directed against S. aureus, microaerophilic and anaerobic streptococci, and Gram-negative organisms. Antibiotics should include 1) nafcillin, oxacillin, or vancomycin; plus 2) a third generation cephalosporin; plus 3) metronidazole. Provisional antibiotic therapy of spinal subdural empyemas should be directed against S. aureus and streptococci, and should include nafcillin, oxacillin, or vancomycin. Morbidity and mortality in intracranial and spinal subdural empyema relate directly to the delay in institution of therapy. Both conditions should, thus, be treated with great urgency.

Journal Article↗
PubMed2006

Clinical characteristics and outcomes of empyema thoracis in 117 patients: a comparative analysis of tuberculous vs. non-tuberculous aetiologies.

BACKGROUND: Empyema thoracis remains a major problem in developing countries. Clinical outcomes in tuberculous empyema are generally believed to be worse than in non-tuberculous aetiologies because of the presence of concomitant fibrocavitary parenchymal disease, frequent bronchopleural fistulae and poor general condition of patients. We performed a prospective study over a 2-year period with the objective of comparing the clinical characteristics and outcomes of patients with tuberculous vs. non-tuberculous empyema. METHODS: Prospective study of all cases of non-surgical thoracic empyema seen at a tertiary care centre in North India over a 2-year period. A comparative analysis of clinical characteristics, treatment modalities and outcomes of patients with tuberculous vs. non-tuberculous empyema was carried out. Factors associated with poor outcomes were analysed using multivariate logistic regression. RESULTS: One hundred and seventeen cases of empyema were seen in the study period of which 95 had non-tuberculous and 41 had tuberculous empyema. Malnutrition and bronchopleural fistulae (BPF) were more common and duration of symptoms longer in the tuberculous empyema group. Time to resolution of fever, duration of pleural drainage and pleural thickening >2 cm were significantly greater as well. Eight (10.5%) patients with non-tuberculous empyema and four (9.8%) with tuberculous empyema succumbed. Presence of a BPF was significantly associated with poor outcomes on multivariate logistic regression analysis. CONCLUSIONS: Tuberculous empyema remains a common cause of thoracic empyema in India though it ranked second amongst all causes of empyema after community acquired lung infections in this study. Tuberculous empyema is associated with longer duration of symptoms, greater duration of pleural drainage and more residual pleural fibrosis.

Adolescent↗
PubMed1997

CT appearance of parapneumonic effusions in children: findings are not specific for empyema.

OBJECTIVE: Although definitive differentiation of empyema from transudative parapneumonic effusion is based on the analysis of pleural fluid, certain CT findings have been described as highly suggestive of empyema. This study compares the CT findings of parapneumonic effusions with the results of thoracentesis, thoracoscopy, or both to determine whether these CT findings can reliably differentiate empyemas from transudative parapneumonic effusions in children. MATERIALS AND METHODS: CT scans obtained to evaluate pleural or parenchymal complications of pneumonia were reviewed. Parapneumonic effusions were evaluated for the CT findings of pleural enhancement; parietal pleural thickening; thickening, increased attenuation, or both of the extrapleural subcostal fat: and edema of the extracostal chest wall. Each parapneumonic effusion was assigned a CT score on the basis of these CT findings. Individual CT findings and the CT score were correlated with the presence of empyema as determined by thoracentesis or thoracoscopy. RESULTS: Thirty patients were identified as having a parapneumonic pleural effusion revealed on contrast-enhanced CT scans and by pleural fluid analysis. Twenty-one of these parapneumonic effusions met the clinical criteria for empyema, and nine were considered not to be empyemas. Neither any individual CT finding nor the CT score accurately differentiated empyema from transudative parapneumonic effusions (p > .1): pleural enhancement (empyema 100%, transudative effusion 89%), pleural thickening (empyema 57%, transudative effusion 56%), abnormal extrapleural space (empyema 66%, transudative effusion 67%), extracostal chest wall edema (empyema 33%, transudative effusion 56%), and average CT score (empyema 2.5. transudative effusion 2.3). CONCLUSION: CT characteristics of parapneumonic effusions do not allow radiologists to accurately predict empyema. The presence or absence of such CT findings should not influence therapeutic decisions concerning the management of parapneumonic effusions.

Adolescent↗
PubMedDate not supplied

Review of one hundred cases of empyema thoracis.

One hundred cases of empyema thoracic have been reviewed. Aetiology of empyema was tubercular in 21 per cent cases and non-tubercular in 79 per cent cases. Gram negative organisms were cultured in 84.6% cases, whereas gram positive organisms were cultured only in 15.4% cases. It was observed that management of cases of empyema differed considerably with the presence or absence of BPF, thick or thin pus and size of empyema. 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 above method, all cases of simple empyema with thick pus and with moderate to large size of empyema and all cases of empyema with BPF should be straightway managed by intercostal drainage tube connected to water seal. On the whole, cases of empyema with BPF were difficult to manage and needed major surgery in 45.8 per cent cases in comparison to only 2.9 per cent cases of simple empyema.

Adolescent↗
PubMed2001

Clinical course and management of patients undergoing open window thoracostomy for thoracic empyema.

BACKGROUND: While open window thoracostomy (OWT) is a safe procedure and is indicated in patients who have thoracic empyema either with or without a bronchopleural fistula, it may prolong the hospital stay. OBJECTIVES: We retrospectively analyzed the relationship between the etiology of thoracic empyema and the open window interval (OWI). METHODS: Between January 1986 and May 1997, 53 patients resistant to conventional therapy underwent OWT for thoracic empyema at the Department of Surgery of the National Minami-Fukuoka Chest Hospital. The patients were classified into five groups based on the etiological findings of thoracic empyema. 44 patients also underwent closure of the window until June 1999. RESULTS: The average OWI was 180.4 +/- 51.9 (mean +/- SE) days for postoperative empyemas in lung cancer, 128.0 +/- 32.1 days for bacterial nontuberculous empyemas, 189.6 +/- 24.1 days for fungal empyemas, 365.8 +/- 201 days for empyemas caused by atypical mycobacteria and 322.0 +/- 58.7 days for tuberculous empyemas. There was no evidence that the OWI was related to either sex, age, etiology of thoracic empyemas, performance status, the existence of bronchopleural fistulae, complications of diabetes mellitus or preoperative malnutrition status in multivariable models. 5 patients underwent a second OWT because of recurrence of empyema. Mortality rate was 7.5%. CONCLUSIONS: There was no relationship between clinical factors including nutritional assessment and OWI. OWT generally is a safe and effective procedure for thoracic empyema resisting to conventional therapy except that it can make an extended hospital stay necessary.

Adult↗
PubMed1998

Childhood chronic pleural empyema: a continuing surgical challenge in developing countries.

BACKGROUND: Surgical treatment may be necessary in childhood chronic pleural empyema. METHODS: Over a 21-year period 642 children with pleural empyema were hospitalized and 104 of them underwent surgical treatment. The records of the children who underwent surgery for the treatment of empyema were retrospectively reviewed to describe the role, indications, and results of surgical treatment of childhood chronic pleural empyema. RESULTS: Etiologic diseases or conditions leading to empyema were pneumonia in 69 patients, tuberculosis in 13, hydatid cyst in eight, postpneumonectomy empyema in five, and other causes in nine patients. Indications for surgery were severe pleural thickening in 54 cases (51.9%), trapped lung in 36 cases (34.6%), loculated empyema in eight cases (7.7%) and broncho-pleural fistula in six cases (5.8%). Operations performed were decortication in 90 patients, pulmonary resection and decortication in seven, muscle flap closure in five, and pneumonectomy in two. Success rates in the treatment of nonspecific and tuberculous empyema were 93% and 54%, respectively. CONCLUSIONS: Surgical treatment is still necessary in childhood pleural empyema in developing countries, and success rates are very high in nonspecific pleural empyema and acceptable in tuberculous pleural empyema.

Child↗
PubMed1986

Empyema thoracis: a ten-year experience.

Over a ten-year period, 50 patients with thoracic empyema have been treated at the Metropolitan Nashville General Hospital, where a systematic, stepwise approach to the management of empyema has been followed. The initial step was thoracentesis; if this failed to resolve the empyema, dependent thoracostomy tube drainage was used. Closed thoracostomy drainage was converted to open drainage when closed drainage failed to obliterate the empyema cavity. When all other measures failed, thoracotomy with pleural decortication was done. Of the 27 patients who had empyema as a consequence of pneumonia, most (14) were successfully treated with open empyema tube drainage, though five required decortication. Eight of the ten posttraumatic empyemas resolved with open drainage, but pleural decortication was necessary in the remaining two cases. Nine patients had postoperative empyemas; six were managed with open drainage, and three resolved with closed thoracostomy drainage. Of the four remaining empyemas, two resolved with closed drainage and two required open drainage. Treatment was successful in 85% of cases, with six deaths (15%). This experience with empyema shows that early, staged surgical management is successful in most cases. In our experience, the causative organism had no bearing on outcome. Resolution of the condition was possible only after adequate drainage and obliteration of the empyema space was accomplished.

Adolescent↗
PubMed2004

Intrapleural fibrinolytic treatment of multiloculated pediatric empyemas.

Our objective was to compare the efficacy of adjunctive intrapleural fibrinolytic agents (IPFA) (streptokinase, urokinase) on fibrinopurulent stage empyema and chronic stage empyema in children. IPFA were used in 78 pediatric patients with empyema (36 fibrinopurulent stage empyemas, 42 chronic stage empyemas) between December 1994 and September 2002. Pleural biopsy was done for staging in all cases. Streptokinase 250,000 units in 100 ml normal saline (62 patients) or 100,000 units urokinase in 100 ml normal saline (16 patients) was instilled daily into the patient's chest tube, and the tube was clamped for 4 h, followed by suction. This treatment was continued daily for 2-8 days until resolution was demonstrated by chest radiographs and/or computed chest tomography. Success of treatment was 97.2% (complete response 24/36, partial response 11/36) in the fibrinopurulent stage and 9.4% (complete response 2/42, partial response 2/42) in chronic empyema cases. In one patient with fibrinopurulent empyema, the treatment was stopped due to allergic reaction and pleural hemorrhage; this patient died 1 day later in a septic condition. Although an invasive method, the pleural biopsy technique may be an alternative way of more properly staging thoracic empyema in selected children in whom staging based on radiographic and biochemical findings is doubtful. Intrapleural fibrinolytic treatment is an effective and safe therapy of choice and may have significant benefit in most children with fibrinopurulent phase empyema, except for those with bronchopleural fistula. IPFA do not seem to be effective in children with chronic phase empyema.

Adolescent↗