Approach to Purulent Pleurisy Purulent Pleurisy/ empyema Definition :

Empyema is an accumulation of pus in the pleural space Causes :

        

pneumonia due to Streptococcus pneumoniae, Staphylococcus aureus is most common in developing nations in post-traumatic empyema Haemophilus influenzae empyema Group A streptococcus, gram-negative organisms, tuberculosis, fungi, malignancy

Parapneumonic effusions (PE) are pleural fluid collections developing secondary to an adjacent bacterial infiltrate. According to the criteria of RW Light parapneumonic effusions are exudates (as opposed to transudates) if at least one of the following criteria is fulfilled: (1) pleural fluid lactate dehydrogenase (LDH)/plasma LDH>0.6 or pleural >200 IU/l (2) pleural fluid protein/plasma protein >0.5 (3) glucose levels <60 mg/dl. The development of PE is a continuum from clear fluid with low numbers of white blood cells to overt pus. continuum is subdivided into three stages: (1) Exudative stage with low white blood cell counts (2) Fibrinopurulent stage with abundant white blood cells, fibrin deposition, and possible formation of loculi (3) Organizational stage characterized by fibroblast infiltration and formation of fibrous pleural peel, the presence of which may hinder lung re-expansion
DR Ranjith kumar C.S/KKCTH/Chennai

Uncomplicated PE usually fits in with stage (1), while for stages (2) and (3), the term complicated would be appropriate.
CLINICAL MANIFESTATIONS:

 The initial signs and symptoms are primarily those of bacterial pneumonia.  Children treated inadequately or with inappropriate antibiotic agents may have an interval of a few days between the clinical pneumonia phase and the evidence of empyema.  Patients are febrile.  In infants moderate exacerbation of respiratory distress.  The older child is likely to appear more ill and have greater respiratory difficulty.  Physical findings are identical to those described for serofibrinous pleurisy.

LABORATORY FINDINGS:

(1) Pleural fluid analysis: a. In pneumococcal empyema the culture is positive in 58% of patients. b. In patients with negative culture for pneumococcus, the pneumococcal PCR is most helpful in
making a diagnosis

(2) Imaging : a. Radiographically, all pleural effusions appear similar, but no shift of fluid with a change of
position indicates a loculated empyema

b. Ultrasound imaging: i. Gives some idea on staging but does not provide a high level of accuracy. ii. It estimate the size of the effusion and reveals the presence of loculi and/or pleural thickening . iii. Ultrasound staging correlates with pleural fluid markers like pH and can be used to guide chest tube insertions Ultrasound to stage pleural effusions Stage 1 : Anechoic fluid Stage 2 : Echoic fluid without septation Stage 3 : Fibrinous septation of pleural fluid Stage 4 : Septations with solid appearing components comprising >1/3 of effusion (3) Chest computerized tomography (CT) : a. should not be performed routinely in the context of PE since it is even less suitable for staging. b. It gives detailed information on anatomy and location of the infectious process (pleural versus pneumonic). c. It can help to guide chest drain placement or to prepare for surgery
DR Ranjith kumar C.S/KKCTH/Chennai 2

(4)Magnetic resonance imaging (MRI) : y can detect loculi y differentiates between inflammatory and noninflammatory changes if contrast enhancement is used.

Treatment options: There are several options in the treatment of PE: y antibiotics, y chest drainage, y fibrinolysis, y surgical debridement.
Systemic antibiotic therapy : y selection of the antibiotic should be based on the in vitro sensitivities of the responsible

y y y

organism. for treatment of infections by Staphylococcus, Streptococcus pneumoniae, and H. influenzae, With staphylococcal infections, resolution of the process is very slow, and systemic antibiotic therapy is required for 3 4 wk. Clinical response in nonstaphylococcal empyema is also slow, even with optimal treatment; there may be little improvement for as long as 2 wk. Instillation of antibiotics into the pleural cavity does not improve results obtained with systemic antibiotic therapy alone and is associated with local reactions

Thoracentesis:

y y y y y y

When pus is obtained by thoracentesis, closed chest tube drainage should be instituted immediately and controlled by an underwater seal or continuous suction. A catheter with the largest possible internal diameter should be inserted; sometimes more than 1 tube is required to drain loculated areas. Closed drainage is usually continued for about 1 wk chest tubes that are no longer draining should be removed. PE exceeds 1 cm on ultrasound, a tap is indicated. Low pleural pH and glucose may support the need for drain insertion

DR Ranjith kumar C.S/KKCTH/Chennai

Instillation of fibrinolytic agents : y y y y promote drainage, decrease fever, lessen need for surgical intervention, and shorten hospitalization PE stages 2 and 3 are characterized by fibrin deposition and peel formation, fibrinolysis has been advocated for enzymatic debridement the optimal drug and dosage have not been determined. Streptokinase 15,000 U/kg in 50 mL of 0.9% saline daily for 3 5 days, and urokinase 40,000 U in 40 mL saline for children aged 1 year and above; for children under age 1, 10,000 units in 10 ml is used, every 12 hr for 6 doses. There is a risk of anaphylaxis with streptokinase both drugs can be associated with hemorrhage.

y y

VATS:
Indications: y In the child who remains febrile and dyspneic >72 hr after initiation of therapy with intravenous antibiotics and thoracostomy tube drainage, surgical decortication by VATS. If pneumatoceles form, no attempt should be made to treat them surgically or by aspiration, unless they reach sufficient size to cause respiratory embarrassment or become secondarily infected. Pneumatoceles usually resolve spontaneously in time.

Prognosis:
y y The long-term clinical prognosis for adequately treated empyema is excellent follow-up pulmonary function studies suggest that residual restrictive disease is uncommon, with or without surgical intervention.

DR Ranjith kumar C.S/KKCTH/Chennai

Approach :

Reference: 1.Nelson text book of pediatrics 18th edition 2.purulent pleurisy Europian journal of pediatrics 2011 march
DR Ranjith kumar C.S/KKCTH/Chennai 5