747 STATE-OF-THE-ART CLINICAL ARTICLE Pleural Empyema Richard E. Bryant and Christopher J. Salmon Historical Perspective It is interesting that Aristotle recognized the clinical entity of empyema and described drainage of pus with incision, cautery, and a metal tube [24]. He also described the risk oflethal pneumothorax when such interventions were undertaken before loculation of pleural pus had occurred. Twenty-five centuries later, appreciation of that risk formed the basis for the recommendation of Dr. Evarts A. Graham and the World War I Received 19 December 1995; revised 19 January 1996. Reprints or correspondence: Dr. Richard E. Bryant, Director, Infectious Diseases Division, Oregon Health Sciences University, 3181 SW Sam Jackson Park Road, L457, Portland, Oregon 97201. Clinical Infectious Diseases 1996;22:747-64 © 1996 by The University of Chicago. All rights reserved. 1058-4838/96/2205-0016$02.00 Empyema Commission that an empyema should not be treated by open drainage in the "acute pneumonic phase" in order to lessen the risk of fatal pneumothorax [25]. Thereafter, simple but ingenious closed drainage systems favorably modified the risks associated with the pleural evacuation, facilitating earlier and more efficacious drainage. Although closed chest tube drainage of empyema had been described by Hewitt in 1875, it came into widespread use only after Graham's report of 1918 [26]. More recently, sophisticated imaging technologies have greatly enhanced our ability to identify, sample, and drain collections of infected pleural fluid [4-10, 27]. Despite such rapid advances in diagnosis and therapy, it is still possible for an empyema to remain undetected unless the risks of this complication are appreciated and appropriate diagnostic measures are used. Although currently available antimicrobial agents can control some of the systemic manifestations of empyema, the morbidity and mortality caused by undrained pleural pus are still high [28- 31]. Optimal treatment requires drainage. This was recognized by Osler, who underwent a rib resection for treatment of postpneumonic Haemophilus influenzaeempyema, which ultimately caused his death [20, 30]. Current technology has increased the speed and finesse with which pleural empyemas can be drained and has improved our understanding of why it is necessary to drain them [1, 2, 4-13]. Anatomy The pleura is derived embryologically from the primitive coelomic cavity [14]. It consists of two mesothelial layers with their associated vascular, lymphatic, and connective tissue portions. The visceral and parietal pleurae are continuous with one another at the root of the lung, where the hilar airways and vessels enter the lung parenchyma, and are closely apposed to the individual pulmonary lobes, the inner aspect of the thoracic cage, and the lateral margin of the mediastinum. The resultant pleural space contains scant fluid and is normally a potential space that becomes a true space only in disease states that cause accumulation of pleural fluid (liquid or air). The visceral pleura is attached to the lung surface and is contiguous with the subpleural pulmonary interstitium [32]. It is ~200 ,um thick and apparently derives its blood supply from both pulmonary and systemic arteries, draining to the pulmonary veins. The visceral pleura individually invests pul- Downloaded from http://cid.oxfordjournals.org/ by guest on September 9, 2014 Pleural empyema is a serious complication of infection adjacent to or within the chest that rarely resolves without appropriate medical therapy and drainage procedures [1- 3]. Host defenses are seriously compromised by the anatomy and physiology of an infected pleural space, and subtleties ofpresentation may delay recognition and appropriate management. Empyema is usually a complication of pneumonia but may arise from infections at other sites. Presentation and microbial etiology are modified by local trauma or surgery or by underlying conditions such as malignancy, collagen vascular disease, immunodeficiency disorders, and adjacent infection involving the oropharynx, esophagus, mediastinum, or subdiaphragmatic tissues. Clinical features depend upon the primary organ or space infected, the microbial pathogen(s), and host defense defects. Recent advances in imaging and instrumentation have facilitated the recognition and management of bacterial empyema [4-9], and scholarly work in the field has improved our understanding of its pathophysiology and clinical presentation [1, 10-14]. Use of the thrombolytic agent urokinase, in conjunction with precise and timely placement of drainage catheters under imaging guidance, has made it possible to reduce the risk of pleural fibrosis and lung entrapment while avoiding thoracotomy [15- 21]. Likewise, video-assisted thoracoscopic techniques also provide an effective, less invasive means of assessing and managing the infected pleural space without full thoracotomy [22, 23]. From the Divisions of Infectious Diseases and Thoracic Imaging. Oregon Health Sciences University. Portland. Oregon 748 Bryant and Salmon Pathophysiology The diagnosis and treatment of bacterial empyema are best understood in relation to the altered anatomy and pathological physiology of the pleura and the associated host defense dysfunctions. Pleural effusions develop because of increased hydrostatic pressure or decreased oncotic pressure associated with cardiac, renal, hepatic, or metabolic disease [I, 2]. Other factors contributing to their development include alterations in pleural permeability due to noninfectious inflammatory diseases, infection, toxic injury, malignancy, or trauma [37-41]. The pleural space is normally sterile yet readily colonized once pleural fluid has accumulated. Host factors predisposing patients to empyema include pneumonia and parapneumonic effusions as well as contiguous infections of the esophagus, mediastinum, or subdiaphragmatic areas that may extend to the pleura. Both traumatic and iatrogenic injury to adjacent structures may lead to secondary infection and involvement of the pleura [3741]. Similarly, retropharyngeal, retroperitoneal, vertebral, or paravertebral infection can extend to the pleura. Pleural effusions are nutritionally rich culture media in which WBC defenses are severely impaired. The classic studies of Wood and co-workers showed that effective phagocytosis of bacteria by neutrophils requires a structure upon which WBCs can move and can ingest bacteria prior to development of specific antibodies [42]. Later in the course of infection, phagocytosis is enhanced by antibodies and opsonic factors. However, in a fluid-filled environment, bacteria can float away from phagocytic cells and multiply relatively unimpeded [42]. In current parlance this defect reflects the fact that "white cells can't jump" (or swim) and thus cannot efficiently fulfill their host defense function in a liquid medium, whether in the infected pleura, pericardium, joint, or meninges. The formation of an empyema has been arbitrarily divided into an exudative phase, during which pus accumulates; a fibropurulent phase, during which fibrin deposition and loculation of pleural exudate occurs; and an organization phase, during which fibroblast proliferation and scar formation cause lung entrapment [43]. Prompt diagnosis and intervention should circumvent the second and third phases of empyema formation. To achieve this goal, physicians need to appreciate the subtleties of clinical expression of pleural empyema and the adverse effects of the suppurative environment on antimicrobial efficacy and tissue injury in the pleural space. Bacteria in pleural fluid elicit a complex series of host defense responses that are incompletely understood despite significant recent advances in our knowledge of the role ofTNF, the cytokine cascade, and perturbations of endothelialcell and leukocyte interactions during infection [44, 45]. When the inflammatoryresponse is too little or too late, bacteria may multiply until they reach a stagnant growth phase, associated with concentrationsof ~810glo bacteria per mL [46]. Empyema fluid is relatively deficient in opsonins and complementand becomes progressivelymore acidic, hypoxic, and depleted of glucose as infection proceeds [46,47]. Gram-negative aerobic bacilli may release endotoxins, and streptococci or staphylococci may release enzymes that lyse granulocytes in pleural fluid. During the inflammatory process, leukocytes release intracellular constituents such as bactericidal permeabilityincreasing protein, defensins, lysozyme, cationic proteins, lactoferrin, and zinc-binding proteins [48]. The latter two components may contribute to suppression of bacterial growth by Downloaded from http://cid.oxfordjournals.org/ by guest on September 9, 2014 monary lobes. The interlobar fissures seen radiographically or by CT are due to the additive thickness of the visceral pleural layers of the participating lobes. The normal pleural fluid volume is negligible and invisible by imaging. The major, or oblique, fissure separates the lower lobe from the upper lobe of the left lung (or the lower lobe from the upper and middle lobes on the right side). The minor, or horizontal, fissure separates the right middle lobe from the upper lobe. The parietal pleura is composed of four layers but is slightly thinner than the visceral pleura [32]. It is surrounded by a thin layer of extrapleural or subcostal fat, which is surrounded by the fibroelastic endothoracic fascia that constitutes the boundary of the thoracic cavity. The endothoracic fascia is attached to the perichondrium of the costal cartilage, the ribs and intercostal muscles, and the prevertebral fascia surrounding the vertebral bodies and intervertebral disks. The extrapleural fat layer is normally ~250 j1,m thick but may become radiologically detectable in normal patients. It increases diffusely in the presence of empyema, but not in obese patients. The parietal pleura is supplied and drained by systemic vessels. The lymph of the pleural space is drained by stoma in the parietal pleura, which represents the predominant-if not exclusive- mechanism by which liquid is cleared from the pleural space [33, 34]. The parietal pleura has abundant sensory innervation and should be well anesthetized before it is manipulated or punctured [35]. Although the quantity of pleural fluid is small, it efficiently couples the lung to the diaphragm and chest wall during breathing and lubricates the movement of those structures. Nevertheless, little or no functional impairment results when the pleural space is obliterated either experimentally or because of clinical necessity [1]. Anatomic anomalies of the pleura are rarely of clinical consequence but can cause confusing radiological patterns [36]. Accessory fissures are very frequently encountered at surgery or post mortem, but only two types are commonly encountered in practice. The inferior accessory fissure separates the medial basal segment of the right lower lobe (or the medial subsegment of the anteromedial basal segment of the left lower lobe) from the other basal segments of the lower lobe. Such fissures occur in ~40%-50% of people, usually in incomplete forms invaginating the lower lobe at its diaphragmatic aspect. Superior accessory fissures are present in ~ 30% of patients. These variant fissures are roughly horizontal and separate the superior segment of a lower lobe from the basal segments of that lobe. They may mimic a horizontal fissure on a chest radiograph. em 1996;22 (May) em 1996;22 (May) 749 Pleural Empyema Table 1. Conditions associated withnontuberculous bacterial empyema [31, 38-41, 60]. Cause Pulmonary infection Surgery Trauma Esophageal perforation Complication of thoracentesis/chest tube placement Subdiaphragmatic infection Spontaneous pneumothorax Septicemia Other or unknown Total No. ('Yo) of patients 301 119 20 21 21 15 7 (56) (22) (4) (4) (4) (3) (1) 8 (I) 30 (5) 542 (100) Experimental Empyema Animal models of pleural empyema lack many of the features of human disease [55, 56]. Empyema in man is usually monomicrobial, whereas it is difficult to produce disease in animals without injection of multiple pathogens and concomitant use of foreign bodies like umbilical tape. Empyema did not occur after tape placement and injection of guinea pigs with 4 log 10 cfu of Bacteroidesfragilis; however, similar preparations and injection with 4 IOglO cfu of Staphylococcus aureus produced empyema in 20% of animals, and concomitant injection with both B. fragilis and S. aureus produced empyema in >50% [55]. More than 6 IOglO cfu of E. coli and B. fragilis are required to produce empyema in 50% of animals. Umbilical tape did not affect lethality of disease induced by E. coli and B. fragilis, but addition of blood did increase lethality in that model [56]. Empyema has been produced in rabbits by injection of Streptococcus pneumoniae or Klebsiella pneumoniae into a pleural exudate induced by turpentine [57]. Those lesions will heal spontaneously and therefore do not appear analogous to human disease. That model has been used to assess the effect of streptokinase injection on experimental empyema. Although streptokinase effectively reduced the incidence of adhesion, it increased the volume of effusion, possibly because pleural fluid was not drained [58]. Shohet and co-workers used the turpentine-induced empyema model to study gentamicin efficacy against K. pneumoniae infection in the pleural space [59]. Cure rates were reduced when animals were treated with gentamicin alone, but 100% of animals were cured when placed in an oxygen chamber, despite the fact that the pharmacokinetics of gentamicin were unchanged. These studies add further proof of the suppressive effect of the abscess environment on the activity of aminoglycosides used as single-drug therapy. Microbial Pathogens In approximately one-half of patients, empyema develops as a complication of pneumonia (table I). Therefore, the fre- Downloaded from http://cid.oxfordjournals.org/ by guest on September 9, 2014 lowering concentrations of iron and zinc. Pneumococci and perhaps other organisms may undergo autolysis in overtly purulent empyema fluid, thus accounting for a portion of the 12%18% rate of sterility of empyema fluid. Late in the course of infection, the inflammatory response leads to loculation of pus and occasionally to its spontaneous drainage by erosion through the chest wall (i.e., empyema necessitatis, which currently represents failure of diagnostic, medical, and surgical care). Bacteria within empyemas are relatively unresponsive to antibiotics. In that milieu bacteria may release ,B-lactamase enzymes capable of degrading ,B-lactamase-susceptible ,B-lactam antibiotics [49]. Similarly, microbial enzymes in pus may degrade chloramphenicol. Overtly purulent empyema fluid may be quite acidic, even in the absence of esophageal rupture. Since aminoglycoside incorporation by bacteria is ordinarily oxygen-dependent and acid-inhibitable, aminoglycoside efficacy is suppressed in the hypoxic and acidic milieu of pleural empyema [50]. Furthermore, the calcium and magnesium concentrations in pus, the avid binding of aminoglycosides to the DNA in pus, and the reduced bacterial metabolism in pus may inhibit aminoglycoside activity in empyema fluid [50, 51]. Bacteria within abscesses or involved in chronic inflammatory states multiply slowly, with generation times that may reach 8-24 hours [52]. Tuomanen and co-workers found that there was a direct relationship between the multiplication rate of Escherichia coli and their death rate after exposure to cephalosporins in vitro-i.e., rapidly multiplying organisms were killed quickly, whereas slowly growing organisms were killed less rapidly in proportion to their growth rate [53]. When killing curves were expressed in relationship to the doubling time of the bacteria exposed to antibiotics, there was a linear relationship between cell division and the rate at which bacteria were killed by ,B-lactam agents [53]. The mechanisms by which growth rates of bacteria modify their susceptibility to ,B-lactam antibiotics are incompletely understood. Stevens and colleagues demonstrated a progressive reduction of penicillin-binding proteins in streptococci as they entered a stagnant phase of growth [54]. It appears likely that the rate of bacterial division affects the quantity and type of penicillin-binding proteins that are available to interact with ,B-lactam antibiotics. This may in part explain why bacteria in pus are refractory to antibiotics and why it is necessary to give prolonged antibiotic therapy to patients with poorly drained, suppurative infections [54]. Prolonged therapy may be needed because slowly growing organisms in pus require prolonged contact with ,B-lactamantibiotics in order to induce sufficient cell wall injury to kill bacteria. Fortunately, this impediment can be circumvented by abscess drainage, which removes large numbers of metabolically inert bacteria and their toxins and removes inflammatory components of the empyemic milieu that are capable of suppressing bacterial responsiveness to antibiotics and injuring host tissues. In addition, there are both new and better ways to achieve adequate drainage of pleural pus [6- 9, 15- 21]. 750 eID 1996; 22 (May) Bryant and Salmon Table 2. Bacteria isolated from nontuberculous pleural empyema fluid in various studies. Percentage of patients with empyema [reference] Bacteria isolated Aerobic Streptococcus species Streptococcus pneumoniae Staphylococcus aureus Staphylococcus epidermidis Escherichia coli Enterobacter species Proteus species Klebsiella species Pseudomonas aeruginosa Other gram-negative bacillus Aerobic organisms only Anaerobic Bacteroides species Clostridium species Actinomyces species Eubacterium species Proprionibacterium species Veillonella species Fusobacterium species Microaerophilic streptococci Peptostreptococcus species Anaerobic organisms only No organisms In combined series [2,29,31] (n = 217) 26 8 18 Following trauma [6] (n = 31) 8 37 8 9 5 5 5 5 6 12 5 16 16 27 30 5 2 4 3 4 13 10 13 23 8 ~18 Approximately one-quarter of empyemas are associated with trauma or surgery [61, 70]. As shown in table 2, there is a disproportionate increase in staphylococcal infection and a decrease in anaerobic infection in such patients [70]. Ill-advised or incomplete resection of lung nodules or cavities containing cryptococci or spontaneous rupture of coccidioidomycosisassociated lung cavities into the pleura may lead to fungal empyemas. Similarly, instrumentation or surgery causing injury or perforation of the esophagus or stomach may lead to mediastinitis or subdiaphragmatic infection that can extend to the pleura [2]. Sinus drainage from the skin and pleural involvement are suggestive of infection caused by Actinomyces species, Mycobacterium tuberculosis, or Nocardia species. Empyema may also occur with Entamoeba histolytica infection but is rare in the United States [71-74]. Childhood Empyema Nelson reported that 54% of the empyemas in children ,;;;6 months of age were caused by S. aureus, and only 6% were sterile [75]. Empyemas in children in the age groups of 0.5-2 and 2-5 years were caused by S. aureus in 20%, by S. pneumoniae in ~ 25%, and by H. influenzae in 20% and Downloaded from http://cid.oxfordjournals.org/ by guest on September 9, 2014 quency with which certain microbes cause parapneumonic empyema in different patient groups reflects the frequency with which the vulnerable patients in those groups are exposed to, become colonized with, and fail to clear aspirated secretions containing those bacteria. Immunocompromised patients are prone to pleural involvement with fungal or aerobic gramnegative bacillary infection [30, 31,41,61]. In patients with a malignancy, fungal or tuberculous foci may be reactivated and empyema may develop. Similarly, fungal or mycobacterial empyema may develop in transplant recipients and patients with AIDS, but usually because of disseminated disease. The microbe-specific factors favoring development of empyema as a complication of pneumonia have special clinical relevance. In overtly healthy adults, the bacteria most commonly causing pleural empyema are S. aureus, S. pneumoniae, and Streptococcus pyogenes [1, 62]. Although pneumococcal pneumonia may present with parapneumonic pleural effusions in 40% of patients, empyema occurs in ,;;;5% of patients with pneumococcal pneumonia [1]. Group A streptococcal pneumonia occurs much less frequently than pneumococcal pneumonia but is associated with a higher frequency of large pleural effusions that progress rapidly to produce empyema and sepsis [62,63]. It is well appreciated that klebsiella pneumonia and empyema may occur in alcoholic males with multiple host defense defects that impair containment of or perception of disease until it is well advanced [64, 65]. It is not clear which host defense defects are the most important causes of gram-negative bacillary pneumonia in such patients, but the proteolytic enzyme-mediated removal of fibronectin from the nasopharynx and the subsequent ability of gram-negative bacilli to colonize the exposed nasopharyngeal membranes are probably two of the key determinants of ultimate infection [66]. Likewise, the fetid mouth and a predisposition to aspiration are clearly the forerunners of the fetid lung, lung abscesses, and/or anaerobic empyema [2, 67, 68]. Such infections are usually polymicrobic and linked to pyorrhea or gingivitis and altered consciousness. Extensive local tissue injury and bacterial synergistic infection are hallmarks of anaerobic pneumonia and empyema. The frequency of aerobic and anaerobic isolates seen in three combined series is shown in table 2 [2,29,31]. It is likely that the role and frequency of anaerobic organisms are substantially underestimated by such reports. Bartlett and Finegold found exclusively anaerobic organisms in 35% of 83 medical service patients with empyema, anaerobic plus aerobic pathogens in 41%, and aerobic pathogens alone in 23% [67]. S. aureus is a relatively common cause of empyema in otherwise healthy adults, in children, and in patients who have had chest trauma or surgery. S. aureus pneumonia and empyema have been linked to prior influenza A virus infection [69]. Empyema complicating traumatic hemothorax predisposes patients to infection with S. aureus, whereas pneumothoraces or serous effusions are often secondarily infected by aerobic gramnegative bacilli. em 1996;22 (May) Pleural Empyema Clinical Presentation and Medical Evaluation Patients with empyema require careful assessment of their underlying diseases, the severity and duration of their infection, and the microbes causing it. Physicians should seek hostspecific and epidemiologic information that helps to identify risks of infection with specific pathogens. The need for urgent treatment is linked to the severity of infection and to the severity of the patient's host defense defects, inasmuch as the sickest and the most susceptible patients need the most rapid intervention [39, 60, 78, 79]. Initial findings may be nonspecific, although otherwise-normal patients usually have chest pain, chills or fever, and night sweats at a higher frequency than do patients with host defense defects. Weight loss and general disability occur with more indolent presentation. The occurrence of persistent fever, diaphoresis, and/or leukocytosis despite the administration of effective antibiotics should suggest the presence of an empyema in patients with pulmonary or adjacent infection. Physical examination is remarkably nonspecific and may be limited to findings of effusion. A high index of suspicion and an appreciation of factors that predispose patients to development of empyema facilitate its recognition (table 3). It is difficult to demonstrate loculation of a pleural effusion on physical examination, and the presence of a friction rub is not distinctive. Radiographic demonstration of a pleural fluid accumulation may depend on a volume of ~200 mL to broaden the costophrenic angle [80]. Likewise, lateral views may show a suggestive fluid meniscus, which can be obscured by the presence of infiltrates or overlapping of the diaphragmatic shadows. Lateral decubitus views facilitate recognition of smaller volumes of fluid and can be utilized in the intensive care unit, where patients are sicker and less tolerant of being moved. Positional changes permit recognition of the extent of parenchymal infection and may reveal loculated fluid (refer to the section on radiology of empyema). Light has proposed useful criteria for the assessment and management of parapneumonic effusions and empyema [I, 80] (table 4). He classifies effusions into seven categories of increasing purulence and configurational complexity. Class 1 consists of parapneumonic collections that are < 1 em in width, as measured on a lateral decubitus chest radiograph. These can usually be managed medically and do not require fluid aspiration as long as the patient is doing well and there is radiographic evidence of improvement. Higher classes require increasing degrees of intervention. It is important to determine fluid character and detect loculations promptly and accurately. If thoracentesis reveals fluid that is culture-negative and devoid of microorganisms on microscopic examination (class 2 or 3), then antibiotics with or without serial thoracenteses may be used. Tube drainage is reserved for smear-positive collections or those with overt purulence (classes 4 to 7). The presence of an empyema (classes 6 and 7) is demonstrated by pleural pus and indicates the need for tube drainage and thrombolytic therapy. Pleural fluid that is not clearly purulent on inspection should be cultured and analyzed by chemical, physical, and microscopic procedures. Infected parapneumonic effusions are initially thin and serous but become more purulent as disease progresses. The pH, glucose, and lactic dehydrogenase levels and WBC count in the fluid should be determined, and appropriate microscopic examinations of stained smears should be performed [10, 1\, 80, 81]. Empyemas usually have a pH value of <7.00, a glucose level of <40 mg/dL, and a lactic dehydrogenase level of >1,000 IU/L [12-14, 81]. If analysis of a parapneumonic effusion reveals these biochemical features and/or gram-stain positivity, then tube drainage should be performed. If determined properly, the acid pH value correlates best with the extent and stage of infection and is more helpful than a neutrophil count or microscopic estimate of purulence. Improper handling of pleural fluid specimens can cause spurious elevation of the pH value or a reduction in the glucose value. Therefore, specimens need to be tightly capped and kept on ice until tested. Overtly purulent empyemic effusions are acidic and viscous. Values of5.5 to ~6.8 can be found in cases of chronic loculated empyemas [82]; comparable pH values can be found in empyemas caused by esophageal rupture [82]. However, low pH is neither a specific nor a sensitive indicator of esophageal rupture into the pleural space. Abbott et al. found Downloaded from http://cid.oxfordjournals.org/ by guest on September 9, 2014 10%, respectively [75]. Among older children there was a 47-fold higher incidence of empyema fluid culture sterility that probably reflected autolysis of pneumococci or possibly death of Haemophilus strains in purulent secretions. Prior antibiotic therapy reduces the frequency of positive cultures [76]. Hoff and co-workers reported that 71% of patients with sterile empyemas had received antibiotics before cultures were performed, as compared with 41 % of patients whose empyema fluid contained viable bacteria (P < .05) [76]. These differences would probably be even more striking if the susceptibility of specific bacteria, the potency and duration of antibiotic therapy, and the problem of antibiotic "carryover" into culture media could be subjected to multivariant analysis. In the past, H. injluenzae infection has occurred principally in children aged <6 to 8 years, and its incidence undoubtedly will be reduced by the efficacy of the current Haemophilus conjugate vaccine. Anaerobic lung and pleural infections are rare in children [75]. Most of the diagnostic and therapeutic considerations with regard to empyema are the same for children and adults. However, children more frequently have pneumatoceles and pneumothoraces associated with staphylococcal infection, as well as scoliosis as a complication of empyema. Because of the lower incidence of severe underlying disease in children, they are better candidates for early thorascopic intervention if antibiotic treatment, drainage procedures, and thrombolytic therapy fail [75-77]. 751 752 Bryant and Salmon em 1996;22 (May) Table 3. Clinical, radiological, and laboratory clues to the possibility of pleural empyema. Clinical clues History. Chills, fever, dyspnea, chest pain, or referred pain; recent pulmonary or contiguous infection in the oropharynx, mediastinum, or subdiaphragmatic area; symptoms suggesting adjacent tissue infection extending to the pleura, i.e., dysphagia, dyspepsia, hiccups, or pharyngeal, abdominal, back, or shoulder pain; recent instrumentation, surgery, or trauma of the chest, oropharynx, esophagus, or abdomen; delayed or incomplete response to appropriate medical therapy for an infection that could extend to the pleura; comorbid diseases such as alcoholism, malnutrition, immunodeficiency, immunosuppression, or diabetes. Physical examination. Diminished breath sounds or basilar dullness to percussion; pleural friction rub; bronchophony or egophony above effusion or adjacent to pneumonia; tracheal or mediastinal shift; scoliosis following a respiratory infection (in children); focal chest wall heat, erythema, swelling, and/or pain (rare); draining dermal sinuses (rare); hyperpyrexia, shock, tachypnea (>30 respirations/min), and lor altered consciousness (all of which may be indicative of disproportionately severe infection). Clinical course. Rapid onset of clinical deterioration and sepsis with respiratory failure; persistent fever, sepsis, and/or organ failure despite appropriate antibiotic therapy (in a susceptible patient); worsening clinical and laboratory indicators of infection despite appropriate antibiotic therapy. Radiological clues (imaging method) Laboratory clues Pleural fluid. Cloudy, bloody, or purulent; WBC count, ;;>50,000 X 109IL (usually); pH level, ",7.1 (or ;;>0.3 lower than serum pH); lactic dehydrogenase level, ;;>1,000 lUlL; glucose level, <40 mg/dL; positive smear stains or cultures; fetid (-% of anaerobic empyemas). Findings indicating severe infection. Neutropenia or neutrophilia with immature forms; hypoxia (partial pressure [arterial] of O2 , ",60 mm Hg); azotemia, anemia, or acidosis; thrombocytopenia or disseminated intravascular coagulopathy; multiorgan failure; polymicrobic infection or infection with S. aureus, aerobic gram-negative bacilli, or anaerobic organisms; amoebic pleural empyema, with parasites seen on smear; overtly purulent tuberculous empyema, with high-density acid-fast bacilli seen on smear. the pH value of empyema fluid to be <6.0 in 6 of 10 patients with a perforated esophagus, but in the other 4 patients it was neutral or alkaline [83]. The notion that empyema pH values of <6.0 are suggestive of a ruptured esophagus could be misleading unless considered in the context of how long the patient has been ill [84]. Although chronic, well-localized empyemas can occasionally have pH values of <6.0, such levels would not be expected to occur in newly formed lesions [46, 82]. However, pleural fluid accumulation due to a ruptured esophagus might be expected to have a low pH value after a relatively brief illness. This distinction is critically important because the mortality associated with a > 24-hour delay in treatment of esophageal rupture is ;;;.50% [80]. The pleural fluid amylase level is elevated in cases of esophageal rupture and helps to confirm that diagnosis [84, 85]. Imaging and endoscopic procedures are especially helpful in this setting. Serum pH measurement can help to assess the significance of low pleural fluid pH values that reflect systemic acidosis. Pleural fluid pH values that are at least .3 pH units less than serum pH values support the need for a drainage procedure [1]. Spurious elevation of empyema fluid pH values may occur in patients with urea-splitting proteus infections [86]. Malodorous empyema fluid suggests the presence of anaerobic infection but is present in only about two-thirds of anaerobic empyemas [2, 87]. Demonstration of high levels of pleural fluid protein or specific gravity is rarely helpful. Microbes may be seen on gram-stained empyema fluid that is sterile. In other instances organisms are neither seen in nor grown from frank pus. An acridine orange stain is occasionally helpful for identifying bacteria whose gramstain morphology is distorted by prior antibiotic therapy. Legionella pneumophila is not well visualized by gram stain but can be detected by direct fluorescent microscopy or by culture. Testing urine for Legionella antigen is probably the most sensitive test for pneumonia caused by L. pneumophila serogroup 1 [88]. Patients at risk offungal empyema require appropriate smears and cultures of empyema fluid for detection of fungi. Serological tests may assist in the diagnosis of histoplasmosis or coccidioidomycosis. Disseminated histoplasmosis involving the pleura of patients with AIDS may be diagnosed by serum or urine antigen detection [89]. Similarly, Aspergillus antigen quantitation may be useful in the diagnosis of aspergillus infection involving the pleura in compromised patients [90]. Patients suspected of having amebiasis should undergo CT studies for identification of subdiaphragmatic disease as well as serological testing for disseminated extraintestinal amebiasis [91, 92]. Pleuropulmonary amebiasis may develop after erosion of an amebic liver abscess through the diaphragm, in association with sudden respiratory distress, cough, and pleurisy [71]. The lung may be involved, in which case a hepatobronchial fistula and amebae visible in copious bronchial secretions may be noted. Downloaded from http://cid.oxfordjournals.org/ by guest on September 9, 2014 Pleural fluid (conventional or lateral decubitus radiography); pleural effusion loculation (lateral decubitus radiography, ultrasonography, or CT); evidence of pleural effusion and contiguous infection (ultrasonography or CT); pleural mass (conventional radiography); hemothorax, pleural air, amoebic abscess, or contiguous infection extending to pleura; bronchopleural fistula and empyema (CT). ern 1996;22 (May) Pleural Empyema 753 Table 4. Classification and treatment of parapneumonic effusions and empyema. Mode of therapy required Pleural fluid indices of suppuration Class of effusion or empyema pH <I em NO NO NO >1 em ;;,7.2 >40 7-7.2 NO + + <1,000 + + +* >40 >1,000 + + +* .;7.0 <40 >1,000 + + + + + +* complex <7.0 <40 >1,000 :+:/:+: Multiple + + + + +*t :+:t Empyema 6: Not complex 7: Complex NN NN NN NN NN NN :+: + ±/± + + + + + + +*' +*' +' NOTE. Table is modified from [1]. NO * Repeat ~ not determined; NN ~/-::t. ~ + + Multiple determination not necessary; - + ~ no; + ~ yes; ± ~ +t :+: possibly. as needed. 'More invasive procedures may be required if patient's condition fails to respond. This presentation is associated with a mortality of - 30%, whereas the mortality associated with serous effusion without abscess rupture is <5% [71,92]. Since 98%-99% of patients with amebiasis have detectable antibodies to E. histolytica, serological diagnosis is often definitive [91]. For patients at risk of nocardial infection of the lung and pleura, modified acid-fast stains of purulent secretions should be done and the laboratory should be notified to hold plates for at least 2 weeks. For patients with smear- and culture-negative pleural effusions that appear purulent, the possibility of chylous effusions should be excluded by the testing of fluid for neutral fat, pH, and sedimentation values after centrifugation at 5,000g [1]. Pus will have an acid pH and cell fragments will sediment, whereas chylous effusions will have a neutral pH and remain opaque after centrifugation. Primary pleural eosinophilia is a rare condition suggesting paragonimiasis and can be diagnosed by demonstration of parasites in stool, sputum, or bronchoscopy secretions and by the finding of elevated serum antibody titers [73]. Levels of IgE and IgG antibodies to Paragonimus westermani may be significantly higher in pleural fluid than in serum [93]. Pleural tuberculosis can be confirmed by acid-fast smears of pleural fluid in fewer than one-quarter of cases but can be diagnosed by pleural biopsy and culture in >90% of patients [94]. Chronic pleural tuberculosis may cause platelike pleural calcification. Liquid culture media and the rapid radiomimetic culture techniques often provide proof of tuberculosis within 2 weeks. Demonstration of pleural fluid adenosine deaminase levels of > 70 U/L supports the diagnosis of pleural tuberculo- sis, but the test for that is not available in the United States [1]. The diagnostic utility of PCR detection of mycobacterial antigen in pleural fluid is still under investigation. Skin test conversion and symptoms of weight loss, night sweats, and fever as well as epidemiologic and sociologic risks of tuberculosis are important diagnostic clues. Pleural fluid from patients with collagen-vascular disease, subdiaphragmatic infections, malignancy, or pancreatitis will occasionally mimic bacterial empyemic fluid. Pleural effusions of rheumatologic or pancreatic origin are rarely frankly exudative and can be distinguished by serological tests for rheumatoid factor or pleural fluid amylase level in most instances. Rheumatoid effusions usually have an antinuclear antibody titer of ~ 1:160 or a rheumatoid factor titer of ~ 1:320 and occasionally contain lupus erythematosus cells [95, 96]. Malignant effusions with a pH value of <7 are readily diagnosed by cytological examination and are associated with a poor prognosis [82]. Radiology of Empyema Chest radiography remains the important first study for patients with pleural disease [97]. As little as 25 mL of pleural fluid can elevate the hemidiaphragm radiographically, but blunting of the posterior costophrenic sulcus usually requires -200 mL [1, 80]. If effusions are "free-flowing" volumes, as little as 5 mL can be detected on the lateral decubitus view [98]. The newer modalities of ultrasonography and CT have greatly facilitated diagnosis and treatment ofpatients with parapneumonic effusions and empyema. Downloaded from http://cid.oxfordjournals.org/ by guest on September 9, 2014 I: Nonconsequential pleural effusion 2: Parapneumonic effusion Inflammatory effusions 3: Minimally complex 4: Moderately complex 5: Extremely ThoraLoculation(s) Bacteria Clinical status coscopy Full Lactic in gram of pleural :+: decortidehydrostain fluid noted AntiNeedle Tube Throm- decortication Glucose genase and/or Frank in radiologic Stable or (mgldL) (lUlL) culture pus studies improving Sepsis biotics aspiration drainage bolysis cation procedure Width of effusion on lateral decubitus radiograph 754 Bryant and Salmon Ultrasonography Computed Tomography The development of rapid, newer-generation CT scanners has revolutionized the evaluation and treatment of thoracic empyema. Empyemas usually appear well-defined, smooth, and round or elliptical on CT scans. Their margins are composed of inflamed visceral and parietal pleura that often have a markedly thickened appearance and enhance after administration of intravenous contrast material. The visceral and parietal layers are separated by the interposed empyema fluid, giving rise to the "split pleura sign" of empyema [106]. When air is introduced into the empyema cavity, either iatrogenically following thoracentesis or in association with a bronchopleural fistula, the inner aspect of the visceral and parietal margins is usually smooth. The extrapleural or subcostal fat external to the thickened parietal pleura and deep to the ribs is also noted to thicken in both acute and chronic empyema. This clearly discernible fatty hyperplasia has imaging characteristics similar to those of subcutaneous fat and is much lower in CT attenuation than the thickened pleura itself. Conventional chest radiographs can- not distinguish "pleural thickening" that reflects pleural fluid accumulation from that due to accentuation of this fatty layer. Empyema is frequently associated with nearby pulmonary consolidation and sometimes lung abscess. Alternatively, a lung abscess can resemble effusion or empyema [106]. Differentiation between these diagnostic possibilities is often difficult, if not impossible, with use of clinical and conventional radiographic approaches. Fortunately, CT usually allows definitive diagnosis. Lung abscesses are often poorly defined, roughly spherical, and surrounded by irregularly consolidated lung. They often contain one or more cavities with shaggy intramural contours. When abutting a pleural surface, abscesses form acute angles with the adjacent chest wall. Because they arise within and occupy consolidated lung, they rarely appear to displace adjacent pulmonary structures such as peripheral airways and vessels. Empyemas may form acute or obtuse angles yet have the other CT characteristics mentioned in the preceding paragraph. Treatment Effective therapy for an empyema requires control of infection, drainage of pus, and expansion of the lung. Occasionally, procedural or surgical correction of adjacent infection is required. Empirical antimicrobial therapy is initiated on the basis of its anticipated bactericidal activity against the suspected microbial pathogens and is changed when the susceptibilities of the infecting microorganism(s) are known. Drug delivery to the pleura is not a problem. In general, (3lactam agents are given in high doses for 2-4 weeks, but therapy may need to be prolonged if drainage is not optimal or if an adjacent abscess or osteomyelitis is present. Nafcillin is the drug of choice for S. aureus infection, and penicillin is the drug of choice for penicillin-susceptible streptococcal infections. Infection due to S. pneumoniae with high-level resistance to penicillin (MIC, >2 flg/mL) and to ceftriaxone or cefotaxime (MIC, ~4 flg/mL) should be treated with vancomycin. Cephalosporin-susceptible pneumococci with intermediate susceptibility to penicillin should be treated with ceftriaxone or cefotaxime. Monotherapy with an aminoglycoside is contraindicated because of its poor activity in pus and the risks of toxicity [49]. The synergistic activity of aminoglycosides with (3-lactam drugs has justified their use in combination therapy for Pseudomonas aeruginosa, Enterobacter cloacae, Serratia marcescens, and Acinetobacter calcoaceticus infections, because (3lactam antibiotics appear to overcome the suppressive effect ofthe hypoxic and acidic abscess environment on incorporation of the aminoglycoside by bacteria [50]. Ciprofloxacin is a logical alternative to aminoglycosides for use in combined therapy against those pathogens in early infection and can be given orally during later stages of infection. lmipenem is the drug of choice for E. cloacae infection and should be used in conjunc- Downloaded from http://cid.oxfordjournals.org/ by guest on September 9, 2014 Ultrasonographic devices are widely available, provide realtime guidance for thoracentesis or pleural catheter placement [4], and can be transported to the bedside of unstable or critically ill patients. This imaging adjunct is particularly useful for sampling fluid that does not layer freely on decubitus films, and it reduces the incidence of pneumothorax during thoracentesis [99, 100]. The sonographic appearance of pleural fluid collections is quite variable, ranging from anechoic (completely echo-free or sonolucent) to very echogenic. When highly echogenic, the collections may be mistaken for consolidated lung or pulmonary abscess [101]. In such instances it is important to coordinate sonographic and radiographic interpretations. Sonography can distinguish solid from liquid pleural abnormalities with 92% accuracy (vs. the 68% accuracy of chest roentgenography). With combined use of radiography and sonography, the accuracy rises to 98% [8]. The ability of ultra sonography to detect variation in the shape ofpleural fluid collections during respiration is helpful in excluding a solid lesion. Similarly, evidence of "fluid bronchograms" in cases of consolidated lung is another distinguishing feature detectable by ultrasonography [102]. Discrete intrapleural septations can be demonstrated sonographically in up to 74% of exudative effusions [103], and some may appear mobile on real-time examination [104]. Ultrasonography may show limiting membranes suggesting the presence of loculated collections, even when they are invisible by CT. The presence of septations has prognostic importance because loculated collections (Light's class 5 or higher; see table 4) require drainage and are usually larger than simple collections [105]. Anechoic collections may be exudative or transudative [7]. em 1996;22 (May) em 1996;22 (May) Pleural Empyema Empyema Drainage Drainage of pus is still a major component of adequate treatment of pleural empyema. Serous pleural fluid that is not loculated, is devoid of microorganisms on microscopic examination, or has ambiguous indicators of suppuration (such as a high pH, a glucose concentration of ~40 mg/dL, and a lactic dehydrogenase level of < 1,000 lUlL) can be treated with antibiotics and reevaluated, with repetition of thoracentesis in 12-18 hours (table 4). Patients with loculated fluid, frank pus, or smear-positive purulent fluid with a pH of <7.0, glucose concentration of <40 mgldL, and lactic dehydrogenase level of > 1,000 lUlL require drainage procedures. Repeated thoracentesis is rarely successful in such cases. Small-bore percutaneous catheters can be used if fluid is serous and thin. A chest tube with an underwater seal can be placed by the pulmonologist, the radiologist, or the surgeon and can be expected to provide successful drainage in two-thirds of patients with easily accessible, nonloculated fluid collections. When no response occurs within 24 hours, loculation should be excluded by ultrasonography and urokinase should be infused to enhance drainage. Urokinase should be used in all patients who are considered at risk for multiple loculations or especially thick or viscous pus, and its infusion can be repeated daily as needed for several weeks. Recently published reports support an expanded role for the interventional radiologist in the management of empyema [35, llO-112]. Imaging guidance allows precise placement of small-bore catheters into small pockets of unusual configuration that were previously difficult to drain with tube thoracostomy alone. Thus, 16-French or smaller catheters can be placed safely with much less discomfort and morbidity for the patient and are at least as efficacious as 28-French or larger surgical chest tubes in empyema therapy [27, 35, 113-115]. For the occasional collection of very thick pus, a 24-French catheter can be placed over a guide wire by a Seldinger technique [9]. Blind, bedside drainage of empyema via surgical tube thoracostomy that is performed with reference only to the patient's chest radiograph is often unsuccessful. A large fraction of such patients may require further invasive treatment [31, 116]. Relatively high morbidity and even mortality as high as 5% have been reported [60]. Identification of loculation and the extent of an empyema by CT allows optimal planning for sampling and drainage of the fluid collections. An appropriate site of percutaneous entry can be selected and the skin marked for thoracentesis. The decision to proceed with catheter drainage depends on fluid characteristics and the size and configuration of the empyema, and it is facilitated by reference to the scheme proposed by Light (table 4) [1]. Performance of the drainage procedure under direct CT guidance is most convenient if the empyema collection is small [112] or in a position that would otherwise be difficult to access (such as anterior, medial, or intrafissural). Postoperative Downloaded from http://cid.oxfordjournals.org/ by guest on September 9, 2014 tion with at least one other effective antibiotic for treatment of empyema caused by that pathogen. Patients with chronic pleural empyemas that are poorly drained may require prolonged antibiotic therapy. Similarly, empyemas caused by Actinomyces or Nocardia species, mycobacteria, or fungi require protracted therapy. Anaerobic empyema can be treated like anaerobic suppurative infection at other sites; however, metronidazole is minimally active against streptococci, Actinomyces, and propionibacteria and less apt to be effective for partially drained infections because it is not metabolized to its active derivative in partially oxygenated environments [50]. Since many anaerobic infections are polymicrobic, therapy is usually selected from among clindamycin, ,8-lactamaseinhibitor combination drugs, and imipenem on the basis of the specific concomitant aerobic and/or microaerophilic organisms present in pus. Neither chloramphenicol nor tetracycline should be used to treat anaerobic empyema. Anaerobic and polymicrobic anaerobic empyemas that have extended to the pleura from adjacent sites of infection often require surgical treatment of the primary site of infection. Patients with pleuropulmonary amebiasis should receive metronidazole (usually 750 mg po thrice daily for 10 days), and drainage should be performed as appropriate [71]. Severely ill patients may also require brief therapy with dehydroemetine or chloroquine [71, 92]. Those with polymicrobic pleuropulmonary amebiasis should receive antibiotics appropriate for the concomitant bacteria and may require large-chest-tube drainage if the empyema fluid is especially thick. The treatment of choice for pleuropulmonary paragonimiasis is praziquantel [73]. If the causative organisms are susceptible, tuberculosisrelated pleural effusions respond well to the usual antituberculous regimens and rarely require drainage. In practice, the organisms' susceptibilities may not be known until patients are well into their second month of treatment with a four-drug regimen of isoniazid, rifampin, ethambutol, and pyrazinamide. Thereafter, patients infected with susceptible strains receive isoniazid and rifampin for 4 months. Patients with multidrug-resistant tuberculosis require individualized regimens based on antimicrobial susceptibility findings [107]. If possible, all patients should receive directly observed therapy. Patients with pleuropulmonary rifampinresistant tuberculosis require ~ 18 months of therapy with two or more effective drugs. Frankly purulent tuberculous empyema is (fortunately) rare and usually follows a long history ofunsuccessful medical and/or surgical therapies. The pleura is usually quite thick, is occasionally calcified, and often has high concentrations of mycobacteria. Therapy should be initiated with repeated thoracentesis and multidrug regimens [107, 108]. Tube drainage should be avoided in order to prevent secondary bacterial infection of a tuberculous empyema [109]. Control of infection may require decortication or tailoring procedures such as thoracoplasty or surgical correction of associated bronchopleural fistulae [l08]. 755 756 Bryant and Salmon Transcatheter Intrapleural Thrombolytic Therapy Despite catheter placement and drainage of empyema fluid, patients may still have residual pockets of undrained fluid and display signs and symptoms of persistent infection [60, 80]. This is not surprising, since empyema fluid is often loculated. The act of placing a catheter over a guide wire is helpful in breaking down at least some loculations, but additional measures may be required to achieve complete drainage. One approach has been to place additional catheters [4, 27, 35, 110, 113]. In addition, there has been renewed interest in thrombolytic therapy. Loculation(s) may form early during development of either complicated parapneumonic effusion or empyema [1]. Their appearance indicates that the effusion has progressed to the fibropurulent stage, with extensive deposition of fibrin on the pleural surfaces. Pleural fibrosis will occur unless the loculated collections are drained and appropriate antibiotics are given. Strange and colleagues used an animal model of pleural empyema to show that the initial dense fibrin layer began to be replaced by a network of connective tissue elements by the fifth day [58]. When fibrin was not removed promptly, fibrinous strands became firmly anchored to the pleural surfaces. The authors postulated that fibrin deposition enhances the development of subsequent fibrosis by creating a diffusional barrier to oxygen, since pleural fluid hypoxia and lactic acidosis have been shown to enhance fibroblast collagen production in an empyema [58]. These findings support the clinical urgency of draining empyema fluid to prevent the formation of intrapleural fibrosis, which often requires surgical extirpation. It also provides a rationale for therapies specifically directed at prevention of deposition and removal of intrapleural fibrin early in the course of an empyema. Streptokinase and streptodornase, derived from streptococcal sources, were first used to help drain loculated pleural pus by Tillett and Sherry in 1949 [117]. Initial enthusiasm was later dampened by concern about allergic reactions to the agents. Currently, there is renewed enthusiasm for intrapleural fibrinolysis in cases of complicated parapneumonic effusions and empyema, in part because of the availability of urokinase, which is nonantigenic and nonpyrogenic [15, 16, 19, 20]. Although "purified" forms of streptokinase are now available [17,21], these have been documented to produce an antibody response [118]. The antibody response is responsible for the febrile reaction to the agent, which may falsely mimic persistence of empyemas [20]. Urokinase is produced by the human kidney and does not cause an allergic or febrile reaction. We usually perform intrapleural urokinase instillation according to methods of Moulton et al. [19] and Robinson et al. [20]. Each dose consists of 100,000 units given in 100 mL of 0.9% sterile saline solution. The 100-mL aliquot is left in the pleural space for at least 2 hours. The catheter or chest tube is then "unclamped" and suction restored. This process can be repeated as needed. Robinson and colleagues suggest that the instillation begin in the evening and continue overnight while the patient sleeps [20]. Unused portions of the urokinase solution should be refrigerated between instillations. While it is possible to give urokinase by transmurally injecting the solution into an indwelling surgical chest tube, it is more efficient to introduce it through a radiologically placed pleural catheter via a threeway stopcock, which is then turned off in the direction of the catheter. Use of the catheter ensures that the agent reaches and stays within the pleural collection. The larger "dead space" of surgical chest tubes decreases the effective dose instilled into the pleura and may decrease the efficacy of a given instillation. The pleural catheter may be repositioned as needed (see figure 1). Use of urokinase in the pleural space is safe. Systemic side effectshave not been reported. The total dose given into the pleural cavity is approximately one-tenththe dose of the agent commonly given intravascularly to lyse clots.Urokinase has an average serum Downloaded from http://cid.oxfordjournals.org/ by guest on September 9, 2014 empyemas are often small and loculated [110] and therefore ideal for treatment with small catheters under CT guidance. Alternatively, after placement of skin markers, drainage can be completed under fluoroscopy. Some authors favor the use of ultrasonography in management of pleural fluid collections, especially those that are large [4, 9, 27, 100]. Ultrasonography is usually quicker and more convenient to perform but is more operator-dependent than CT. Empyema collections occasionally may be difficult to identify or to distinguish from nearby consolidated lung by ultrasonography if they contain air or thick pus with extensive echogenic debris [27]. Several recent reviews provide detailed descriptions of the techniques for percutaneous pleural catheter placement [27, 35, 110, 113]. Two general approaches can be taken. The first is a direct trocar technique, in which the catheter is advanced under imaging guidance over a stiff coaxial cannula, entering the collection at the site of a preliminary diagnostic thoracentesis [27]. The second method uses a modified Seldinger technique, in which an 18-gauge needle is placed into the collection under imaging guidance and a guide wire is advanced through the needle; serial subcutaneous fascial dilations are then performed over the guide wire with dilators ofprogressively larger diameter, and finally the catheter is placed and anchored to a skin dressing. The choice of technique may be individualized to the patient's requirements. Collections with tenacious pus and thick margins often require a direct trocar placement to provide the mechanical advantage needed for entry and to prevent buckling of the catheter in the subcutaneous tissues. Trocar placement is also generally quick to perform and can be done without assistance. Exchanges over a guide wire require two operators. Fluid is aspirated through the catheter, followed by local irrigation with saline until clear. The catheter is then attached to a standard underwater-seal drainage system for continuous suction at the bedside. em 1996;22 (May) em 1996;22 (May) Pleural Empyema Video-Assisted Thoracoscopy for Mechanical Debridement of Intrapleural Loculations When a multiloculated empyema fails to respond to intrapleural urokinase, the use of video-assisted thoracoscopic surgery (VATS) may provide a significant new alternative to thoracotomy with decortication. The development ofminiaturized video technology has made it possible to perform this less invasive procedure under general anesthesia [22]. The thoracoscope uses a light-sensitive silicon chip to generate a real-time image on a television monitor. It is introduced into the pleural space through a cylindrical conduit. One or two additional small (1.0-1.5 em long) skin incisions are made to allow passage of surgical instruments used under thoracoscopic guidance and for placement of a chest tube. VATS can disrupt intrapleural adhesions and achieve complete drainage of loculated effusions refractory to intracavitary thrombolytic therapy [119, 121-123]. The procedure can usually be done with endotracheal intubation and general anesthe- sia, without unilateral (contralateral) ventilation [121). Intrapleural septations are mechanically lysed under direct thoracoscopic control. The pleural space is then copiously irrigated with saline. When the space is evacuated, the pleura can be inspected by videothoracoscopy to determine if organized septa and/or an organized pleural peel is present, indicating the need for a more extensive procedure or full thoracotomy for decortication [122, 124). VATS has been proven safe and useful for evacuating empyema and avoiding full thoracotomy in adult and pediatric patients [122, 124]. Bronchopleural fistulae rarely heal spontaneously and usually require surgical closure. CT has greatly facilitated their recognition. Those not healing with closed tube drainage may be treated with muscle flap transposition, in which the muscle is used to obliterate the empyema cavity and is sutured directly to the bronchus or adjacent area. There are several surgical approaches for chronic empyema or empyema following pneumonectomy. Rib resection, decortication, empyemectomy, or permanent external drainage procedures are selected on the basis of the ability of the patient to tolerate the procedure and on the anticipated likelihood of its success. Approaches vary by region and personal experience of the surgeon [30, 39, 125). Postpncumonectomy empyema may be treated with intracavitary antibiotic solutions, openwindow thoracostomy (as devised by Eloesser for those unable to tolerate more extensive procedures), or obliteration of empyema cavities by muscle flaps. Thoracoplasty is usually the procedure of last resort. A complicated parapneumonic infection adjacent to a neoplastic bronchial obstruction may require a special approach. Traditional techniques can be applied if radiation or chemotherapy can relieve bronchial obstruction. However, if that is not possible, chest tube drainage is likely to continue for the duration of the patient's life and represents a substantial disability and nuisance for the patient. In some instances this can be managed with prolonged antibiotic therapy that suppresses symptoms without eradicating the disease [1]. Prognosis The morbidity and mortality associated with pleural empyema are affected by the microbial etiology, host defense defects, severity and duration of infection, and adequacy of antibiotic therapy and drainage. Patients with polymicrobic or resistant gram-negative bacillary empyema often are elderly, have nosocomial infection complicating severe underlying disease, and may die at rates in the range of 40%-70% [29, 39). Among otherwise healthy young patients, mortality rates are 2%-15%, depending on the duration and severity of their infection [30, 76]. Patients with inadequately drained empyemas often die [126]. Therefore, early cardiothoracic surgical consultation and a team approach are required. Ultrasonography and CT should be used to facilitate early recognition of pleural space Downloaded from http://cid.oxfordjournals.org/ by guest on September 9, 2014 half-life of ~ 20 minutes. The presence of a bronchoplcural fistula is considered by some authors to contraindicate the use of intrapleural urokinase [16, 19]. However, no adverse effects associated with its use in that setting have been documented, Indeed, empyema and bronchopleural fistula have been effectively managed without complications with use of streptokinase [18]. Urokinase therapy is much less expensive than surgical debridement and may successfully circumvent the added morbidity and mortality associated with thoracoscopy or thoracotomy [20, 119]. The need for further closed tube drainage is assessed by quantitation of the volume expelled daily and the size of the pleural cavity. Drainage of <50 mUd and cavities <50 mL in size are indications for tube withdrawal [10). When closed chest tube drainage fails, thoracostomy, decortication, or open chest tube drainage may be necessary; such cases are usually managed surgically. Failure of closed tube drainage may be due to extensive disease, prior trauma, or surgery. Hematomas usually require extraction [120] but on occasion have been successfully lysed with urokinase [19]. There has recently been enthusiasm for video-assisted thoracostomy decortication as an alternative to prolonged closed chest tube drainage or full decortication. This approach is particularly well suited for otherwise healthy children or young adults whose condition is identified early in its course, and the procedure should be done shortly after thrombolysis fails. Thoracostomy should probably be considered in the second week of illness rather than later, because adhesions may limit natural dissection planes thereafter. Traditional teachings suggest that formal decortication should be performed prior to the third week or after the sixth week of empyema formation to minimize lung injury attributed to a poorly demarcated pleural peel. That concept has been questioned and would undoubtedly be modified by the degree oflung entrapment, extent of pleural adhesions, and response to thrombolysis [121, 122]. 757 758 Bryant and Salmon e m 1996;2 2 (M ay) Downloaded from http://cid.oxfordjournals.org/ by guest on September 9, 2014 Figure 1. This case illustrates the use of ultrasonography and CT in identifying and characterizing thoracic empyema, as well as the use of imaging-guided catheter drainage and transcatheter intracavitary urokinase for managing empyema. A. contrast-enhanced CT image shows pleural collection. No septations are visible within the pleural collection since they are the same density as the pleural liquid. B. Ultrasonography reveals dependent, echogenic debris in the effusion and a network of clearly defined limiting membranes forming loculations. The large loculation on the right was targeted for thoracentesis and catheter placement. C and D, Posteroanterior and lateral chest radiography was done following catheter placement and the immediate removal of 150 mL of fluid. Only minimal additional fluid was removed over the next 24 hours, during which time the catheter remained folded within the loculation. Urokinase was then introduced through the catheter to improve drainage. E and F, chest radiographs obtained after the first urokinase treatment show that the walls of the loculation have been lysed, permitting the catheter to uncoil. G and H, serial urokinase treatments and drainages were done over 48 hours and the catheter was repositioned. These maneuvers yielded an additional 1,200 mL of empyema fluid. (Reprinted with permission from Mandell GL, ed. Atlas of infectious diseases. Philadelphia: Current Medicine, 1996 [in press].) em 1996; 22 (May) Pleural Empyema 759 Downloaded from http://cid.oxfordjournals.org/ by guest on September 9, 2014 infection. Patients with compromised host defenses are especially vulnerable to the adverse effects of undrained pus (e.g., malnutrition, sepsis, and mult iorgan failure) and therefore are in urgent need of adequate drainage early in the course of their infection [13, 81, 127, 128]. Delay in diagn osis generally correlates with an adverse outcome [30, 76, 8 1, 126]. Hoff and co-workers found that the mean duration of illness prior to the hospitalization of children for empyema was 4.8 days for those cured with antibiotics alone, 5.8 days for those requiring chest tube drainage, and 8.0 days for those requiring decorti cation [76]. They found scol iosis of "",5° in 44% of child ren presenting with empyema. None of 760 Bryant and Salmon References 1. Light RW. Parapneumonic effusions and empyema. In: Light RW, ed. Pleural diseases. 3rd ed. Baltimore: Williams & Wilkins, 1995: 129-53. 2. Bartlett JG, Finegold SM. Anaerobic infections of the lung and pleural space. Am Rev Respir Dis 1974; 110:56-77. 3. Finland M, Barnes MW. Duration of hospitalization for acute bacterial empyema at Boston City Hospital during 12 selected years from 1935 to 1972. J Infect Dis 1978; 138:520-30. 4. O'Moore PV, Mueller PR, Simeone JF, et a1. Sonographic guidance in diagnostic and therapeutic interventions in the pleural space. AJR Am J Roentgenol1987; 149:1-5. 5. 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Intrapleural streptokinase in management of parapneumonic effusions: report of series and review of literature. 1 FI Med Assoc 1989;76:1019-22. 19. Moulton JS, Moore PT, Mencini RA. Treatment of loculated pleural effusions with transcatheter intracavitary urokinase. AJR Am J Roentgeno11989; 153:941-5. 20. Robinson LA, Moulton AL, Fleming WH, Alonso A, Galbraith TA. Intrapleural fibrinolytic treatment of multiloculated thoracic empyemas Ann Thorac Surg 1994;57:803-14. 21. Taylor RFH, Rubens MB, Pearson MC, Barnes NC. Intrapleural streptokinase in the management of empyema. Thorax 1994;49:856-9. 22. Kaiser LR, Shrager 18. Video-assisted thoracic surgery: the current state of the art. AJR Am J Roentgenol 1995; 165:1111-7. 23. O'Brien J, Cohen M, Solit R, et a1. Thoracoscopic drainage and decortication as definitive treatment for empyema thoracis following penetrating chest injury. J Trauma 1994; 36:536-40. 24. Symbas PN. Chest drainage tubes. Surg Clin N Am 1989;69:41-6. 25. Peters RM. Empyema thoracis: historical perspective. Ann Thorac Surg 1989;48:306-8. 26. Miller KS, Sahn SA. Chest tubes: indications, technique, management and complications. Chest 1987;91:258-64. 27. Silverman SG, Mueller PR, Saini S, et a!. Thoracic empyema: management with image-guided catheter drainage. Radiology 1988; 169:5-9. 28. Orringer MB. Thoracic empyema-back to basics [editorial]. Chest 1988;93:901-2. 29. Mandai AK, Thadepalli H. Treatment of spontaneous bacterial empyema thoracis. J Thorac Cardiovasc Surg 1987;94:414-8. 30. Mayo P. Early thoracotomy and decortication for nontuberculous empyema in adults with and without underlying diseases: a 25-year review. Am Surgeon 1985;51:230-6. 31. Varkey B, Rose HD, Kutty CPK, Politis 1. Empyema thoracis during a ten-year period: analysis of 72 cases and comparison to a previous study (1952 to 1967). Arch IntemMed 1981;141:1771-6. 32. 1m J-G, Webb WR, Rosen A, Gamsu G. Costal pleura: appearances at high-resolution CT. Radiology 1989; 171:125- 31. 33. Broaddus VC, Wiener-Kronish JP, Berthiaume Y, Staub Ne. Removal of pleural liquid and protein by lymphatics in awake sheep. J Appl PhysioI1988;64:384-90. 34. Shinto RA, Light RW. Effects of diuresis on the characteristics of pleural fluid in patients with congestive heart failure. Am J Med 1990; 88: 230-4. 35. Westcott JL. Percutaneous catheter drainage of pleural effusion and empyema. AJR Am J Roentgenol1985; 144:1189-93. 36. Godwin JD, Tarver RD. Accessory fissures of the lung. AJR Am J Roentgenol 1985; 144:39-47. Downloaded from http://cid.oxfordjournals.org/ by guest on September 9, 2014 those children were cured by antibiotics alone, and 17 of 27 required decortication. Children with scoliosis secondary to empyema had been ill for an average of 7.3 days prior to admission. Pleural thickening or opacification of a hemithorax correlated with poor prognosis in their series. There is controversy over the best criteria and techniques for performance of pleural fluid drainage [126, 127]. The approach suggested by Light is supported in principle by many authors (table 4). In general, early intervention by the least noxious means is preferred [1,13,76,81,126]. Storm and co-workers found that daily infusion of intrapleural antibiotics and irrigation with saline over a 2-week period reduced the need for rib resection or decortication to 6% among 51 patients on their medical service [128]. During that period, 77% of 43 patients treated on a surgical service in that hospital required resection or decortication [128]. There are insufficient data to evaluate this approach, and further studies are needed. Posttraumatic empyema has a poor prognosis, and patients appear to benefit from early decortication if sepsis is poorly contained despite antibiotic therapy, iflung entrapment impairs ventilatory function, or if pleural drainage is inadequate after 2 weeks of therapy [39, 70]. Tube drainage is rarely successful for management of an infected hemothorax because clots obstruct the tube. There is a vicious cycle of delayed diagnosis and therapy for patients with multiple underlying host defense defects, nosocomial infection, and multiply resistant organisms that adversely affects prognosis. Such patients may have fewer signs and symptoms of their disease, have increased complications of malnutrition and multiple organ failure, and respond poorly to medical and surgical therapy. CID 1996;22 (May) eID 1996; 22 (May) Pleural Empyema 37. Light RW. Physiology of the pleural space. In: Light RW, ed. Pleural diseases. 3rd ed. Baltimore: Wiliams & Wilkins, 1995:7-17. 38. 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Am J Med Sci 1961;242:157-65. 63. Braman SS, Donat WE. Explosive pleuritis: manifestation of group A beta-hemolytic streptococcal infection. Am J Med 1986; 81:723-6. 64. Homes RB. Friedlander's pneumonia. Am J RadioI1956;75:728-47. 65. Torres A, Serra-Batlles J, Ferrer A, et al. Severe community-acquired pneumonia: epidemiology and prognostic factors. Am Rev Respir Dis 1991; 144:312-8. 66. Mackowiak PA, Martin RM, Jones SR, Smith JW. Pharyngeal colonization by gram-negative bacilli in aspiration-prone persons. Arch Intern Med 1978; 138:1224-7. 67. Bartlett JG, Gorbach SL, Thadepalli H, Finegold SM. Bacteriology of empyema. Lancet 1974; 1:338-40. 68. Bartlett JG. Anaerobic bacterial pleuro-pulmonary infections. Seminars in Respiratory Medicine 1992; 13:158-66. 69. Kaye MG, Fox MJ, Bartlett JG, Braman SS, Glassroth J. The clinical spectrum of Staphylococcus aureus pulmonary infection. Chest 1990; 97:788-92. 70. Caplan ES, Hoyt NJ, Rodriguez A, Cowley RA. Empyema occurring in the multiply traumatized patient. J Trauma 1984;24:785-9. 71. Kubitschek KR, Peters J, Nickeson D, Musher DM. Amebiasis presenting as pleuropulmonary disease. West J Med 1985; 142:203-7. 72. Ibarra-Perez C. Thoracic complications of amebic abscess of the liver: report of 501 cases. Chest 1981;79:672-7. 73. Skerrett SJ, Plorde JJ. Parasitic infections of the pleural space. Seminars in Respiratory Medicine 1992; 13:242-58. 74. Thompson JE Jr, Forlenza S, Verma R. Amebic liver abscess: a therapeutic approach. Rev Infect Dis 1985; 7:171-9. 75. Nelson JD. Pleural empyema. Pediatr Infect Dis 1985;4(3)(suppl): S31-3. 76. Hoff SJ, Neblett WW, Edwards KM, et al. Parapneumonic empyema in children: decortication hastens recovery in patients with severe pleural infections. Pediatr Infect Dis J 1991; 10:194-9. 77. Kern JA, Rodgers BM. Thoracoscopy in the management of empyema in children. J Pediatr Surg 1993;28:1128-32. 78. Pothula V, Krellenstein OJ. 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Stark DD, Federle MP, Goodman PC, Podrasky AE, Webb WR. Differentiating lung abscess and empyema: radiography and computed tomography. AJR Am J Roentgenol1983; 141:163-7. 107. Iseman MD, Madsen LA. Chronic tuberculous empyema with bronchopleural fistula resulting in treatment failures and progressive drug resistance. Chest 1991; 100:124-7. 108. Neihart RE, Hof DG. Successful nonsurgical treatment of tuberculous empyema in an irreducible pleural space. Chest 1985; 88:792-4. 109. Magovern CJ, Rusch VW. Parapneumonic and post-traumatic pleural space infections. Chest Surg Clin North Am 1994;4:561 -82. 110. Merriam MA, Cronan Jl, Dorfman GS, Lambiase RE, Haas RA. Radiographically guided percutaneous catheter drainage of pleural fluid collections. AJR Am J Roentgenol1988; 151:1113-6. III. Goldberg MA, Mueller PR, Saini S, et al. Importance of daily rounds by the radiologist after interventional procedures of the abdomen and chest. Radiology 1991; 180:767-70. 112. 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Which of the following parapneumonic pleural fluid characteristics does not suggest the need for pleural fluid drainage? A. pH, <7.1 B. Glucose, <40 mg/dL C. Lactic dehydrogenase, > 1,000 lUlL D. Bacteria seen on gram stain microscopically E. Protein, >3.5 g/dL 6. Which infectious cause of empyema is unlikely to necessitate chest tube drainage? A. Mycobacterium tuberculosis B. Anaerobic organisms I. Which of the following is not a feature of the CT appearance of pleural empyema? A. Thickened visceral and parietal pleural layers B. Pleural enhancement with intravenous contrast C. Extrapleural fat hypertrophy D. Collection appears to occupy rather than displace lung E. Smooth inner pleural margins 2. Which of the following is the chief physiological mechanism for fluid removal from the pleural space? A. Lymphatic drainage through stoma located in the visceral pleura B. Lymphatic drainage through stoma located in the parietal pleura C. Several species of microorganisms D. Streptococcus pyogenes E. Escherichia coli 7. Which infection is associated with marked pleural fluid eosinophilia? A. Tuberculosis B. Anaerobic/polymicrobic infection C. Entamoeba histolytica infection D. Paragonimiasis E. None of the above 8. Which of the following features of empyema fluid is not helpful in excluding the disease causing pleural fluid accumulation? C. Venous drainage through systemic veins A. Pleural fluid amylase level- ruptured esophagus D. Venous drainage through pulmonary veins B. Positive cytology-malignancy E. Venous drainage through pulmonary and systemic C. Rheumatoid factor or antinuclear antibody titer-rheumatoid effusion vems 3. What is the smallest quantity of pleural fluid shown to be detectable on a lateral decubitus roentgenograph? A. 5 mL B. 25 mL D. CT liver abscess-pleural amebiasis E. pH of <6.5-chylothorax 9. Which of the following is most helpful for diagnosing pleural tuberculosis in the United States? Downloaded from http://cid.oxfordjournals.org/ by guest on September 9, 2014 This test affords you the opportunity to assess your knowledge and understanding of the material presented in the preceding clinical article, "Pleural Empyema," by Bryant and Salmon, and to earn continuing medical education (CME) credit. The Office of Continuing Medical Education, UCLA School of Medicine, is accredited by the Accreditation Council for Continuing Medical Education to sponsor continuing medical education for physicians. The Office of Continuing Medical Education, UCLA School ofMedicine, certifies that this continuing medical education activity meets the criteria for 1 credit hour in Category I of the Physician's Recognition Award of the American Medical Association and the California Medical Association Certificate in Continuing Medical Education. To earn credit, read the State-of-the-Art Clinical Article carefully and answer the following questions. Mark your answers by circling the correct responses on the answer card (usually found toward the front of the issue), and mail the card after affixing first-class postage. To earn credit, a minimum score of 80% must be obtained. Certificates of CME credit will be awarded on a per-volume (biannual) basis. Each answer card must be submitted within 3 months of the date of the issue. This program is made possible by an educational grant from Roche Laboratories. 764 em 1996;22 (May) CME Test A. Acid-fast smear A. Overt pus B. Culture B. Fetid odor C. Smear and culture of pleural biopsy specimen C. Loculation revealed by CT or ultrasonography D. Determination of adenosine deaminase level D. Persistent fever despite appropriate antimicrobial therapy 10. Which of the following suggests that pleural fluid drainage is not required? E. None of the above Downloaded from http://cid.oxfordjournals.org/ by guest on September 9, 2014
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