Transcript Protocol for managing para-pneumonic effusions

Antigona Trofor
U.M.P.”Gr. T. Popa” Iasi
Plan A
Pleural effusion
Plan B
Pneumonia
When..plan A
Investigate
Pleural effusion
A
A
Work-up of pleuritis
Thoracocenthesis
exudate

Proteins > 35 G/l

Light’s criteria
transudate
 PF/S protein >0.5
appearance
Glucose/pH
cytology/cell count
TB-markers/culture
 PF/S LDH >0.6
 PF LDH > 2/3 of the
Thoracoscopy
Diagnosis
Blind pleural biopsy
Diagnosis ?
Thoracoscopy
upper limit of normal
Work-up of pleuritis
Thoracocenthesis
exudate
Cytology is nondiagnostic in 40%

Pulmonary embolism ?

Malignancy
Tuberculosis
Idiopathic effusion
transudate
appearance
Glucose/pH
cytology/cell count
TB -markers/culture
Thoracoscopy

Blind pleural biopsy


Diagnosis
Diagnosis ?
Thoracoscopy
Exudative pleural effusions
pH< 7.30 (or glucose < 60 mg/dL)

Diagnosis is limited to 6 causes:
 Empyema
 Malignancy
Pus
 Esophageal rupture
 Tuberculous pleurisy
 Lupus pleurisy
Empyema
Positive
culture
 Rheumatic pleurisy
Positive
Gram
stains
Eosinophilic pleuritis
(pf eosin./total nucl. pf cells>10%)







Pneumothorax
Hematothorax
Drug reactions
Benign asbestos pleuritis
Lymphoma, carcinoma
Churg-Strauss syndrome
Infections (fungal, parasitic)
 > 10% eosinophils rules out tuberculosis!
> 80% lymphocytes in pf








Tuberculosis
Chylothorax
Lymphoma
Trapped lung
Sarcoidosis
Chronic Rheumatic pleuritis
Yellow nail syndrome
Post- coronary artery by pass
Tuberculous pleuritis

PPD may be negative in 30% of cases
 12% in HIV negative patients
 47% in HIV positive patients
Eosinophils > 10% rule out tuberculosis
 Mesothelial cells > 5% rule out TBC
 Pleural fluid TB culture may be positive
in only 20%

Why should you perform thoracoscopy ?
(Pleural effusions)

Thoracocenthesis
 Non-diagnostic in 20-60%
 False-negative for malignancy
 Specific diagnosis rare
Work-up of pleuritis
Thoracocenthesis

exudate
transudate
appearance
Glucose/pH
cytology/cell count
tb-markers/culture
Thoracoscopy
Diagnosis
Blind pleural biopsy
Diagnosis ?
Blind pleural biopsy
should only be
performed in areas with
high incidence of
tuberculosis (in
resource-poor countries)
Thoracoscopy
Diacon et al. Eur Resp J 2003;22: 589-91
Light RW. J Bronchology 1998;5:332-336
When ..plan
B
Investigate
pneumonia
B
Para-pneumonic effusion (PPE)?
Pleural effusion complicate 20-57% of
hospitalized pneumonias
 Depending on responsible organism for
pneumonia
 Any pneumonia should be assessed for
para-pneumonic effusion
 If more than minimal effusion, pleural
fluid needs to be sampled.

Pathogens to cause infectious PE
Pathogenic organism
Type
Bacteria
Gram-positive aerobes
Gram-negative aerobes
Anaerobes
Special:
Mycobacterium tuberculosis
Actinomyces
Nocardia
Mycoplasma pneumonii
Coxiella burneti
Factors Associated with Poor
Prognosis
( require invasive procedures)







1. Pleural fluid is pus
2. Pleural fluid bacterial smears are
positive
3. Pleural fluid glucose is less than 60
mg/dl
4. Pleural fluid bacterial cultures are
positive
5. Pleural fluid pH is less than 7.20
6. Pleural fluid LDH is more then three
times the upper limit of normal
7. Pleural fluid is loculated
Categorizing Risk for Poor
Outcome in Patients With PPE
Pleural Space
Anatomy
Pleural Fluid
Bacteria
Pleural
Chemistry
Fluid
Category
Risk of
Poor
Outcome
Drainage
A0 Minimal
free flowing
PPE (<10 mm
in lateral
decubitus
Bx
Culture and
Stain Gram
unknown
Cx
pH
unknown
1
Very low
No
Co
pH > 7.20
2
Low
No
C1
pH < 7.20
3
Moderate
Yes
4
High
Yes
AND
A1
Small/
Moderate
(>10 mm,
< ½hemithorax
AND
A2
Large, freeflowing effus.
½hemithorax
loculated effus.
thickened
parietal pleura
OR
Bo
Negative culture
and Gram stain
B1
positive culture
and Gram stain
B2
pus
AND
AND
OR
Colice GL et al. Medical and surgical treatment of parapneumonic effusions: An evidence-based guideline, Chest, 2000
Pleural fluid sampling
Diagnostic thoracentesis
 Therapeutic thoracentesis
 Insertion of small chest tube

Treatment goals and options in
pleural infection
Therapeutic goals
Treatment
Relief of symptoms (fever, pain,
dyspnoea)
Anti-inflammatory drugs
Analgesic drugs
Therapeutic thoracentesis
Removal of cause(s)
Antibiotics
Drainage
Surgery
Prevention of loss of function
Early drainage
Corticosteroids in tuberculosis (?)
Decortication
Prevention of recurrence
Definitive cure by antibiotics and/or
by surgery
Loddenkemper R. et. al, Eur.Respir.Mon.,2004
Fibrinolytics?

“It is my recommendation that
fibrinolytics should be reserved for
patients in centers without access to
video assisted thoracic surgery (VATS)
and for patients who are not surgical
candidates.” *
* R.Light, 2008
Antibiotic therapy
Empyema
complicating
Common isolates
Empirical therapy
Community-acquired Pneumococci
pneumonia
Streptococcus spp.
Staphylococcus
aureus
Haemophilus
influenzae
Anaerobes
b-lactam/b-lactamase
inhibitor combination
2nd/3rd-generation
cephalosporin plus
clindamycin
Moxifloxacin
Nosocomial
pneumonia
3rd and 4th-generation
cephalosporins
plus clindamycin
Piperacillin/Tazobactam
(zaminoglycoside
for Pseudomonas
aeruginosa)
Carbapenems
Linezolid (Methicillin
resistant S. aureus)
Enterobacteriaceae
Pseudomonas spp.
S. aureus
Bacteroides spp.
Fusobacterium spp
Loddenkemper R. et. al, Eur.Respir.Mon.,2004
Local pleural treatment options
Treatment Options
Medical
Surgical
(Serial) therapeutic
VATS (surgical thoracoscopy)
thoracenteses
Standard thoracotomy
(Image guided)small bore
Open drainage (fenestration)
tubes
Standard chest tubes#
Medical thoracoscopy
(pleuroscopy)
+/- fibrinolytic agents/ˇirrigation
Loddenkemper R. et. al, Eur.Respir.Mon.,2004
Procedural approach in the local treatment of
empyema (Lungenklinik Heckeshorn)






Drainage: Toracoscopic/image-guided double-lumen trocar
catheter insertion, 20–28F, length 40 cm.
Irrigation: 1,000 mL normal saline solution 20 mL 2%
povidone iodine,until clear irrigation fluid recovered.
Instillation (fibrinolysis) 200,000 IU streptokinase 50,000 IU
streptodornase, tube clamped 4–8 h (tolerance dependent).
Duration 14 days
Side effects Fever> 38 C (42%), pain (10%)
Precautions Postural maneuvers (diseased side in
dependent position), no bronchial- pleural fistula, no allergy.
Medical
toracoscopy
Medical or surgical treatment in PPE
and empyema?
Stage
Definition
Treatment
0
Pleuritis sicca
stage
Medical domain
I
Exsudative stage
Medical domain
II
Fibrinopurulent
stage
Grey zone
III
Organisational
stage
Surgical domain
Loddenkemper R. et. al, Eur.Respir.Mon.,2004
Features suggesting additional local
treatment in para-pneumonic effusions
Features
Clinical
Prolonged symptoms prior to presentation
Leucocytosis, anaemia and
hypalbuminaemia
Failure of response to antibiotic therapy
Anaerobic infection
Virulence of pathogen
Imaging
Chest radiographs/CT:
Effusion of 40% of the hemithorax
Presence of an air-fluid level
Loculation, multiple loculations
Pleural thickening
Ultrasound: Septation, fibrin strands,
necrotic debris
Pleural fluid
Putride fluid
Positive Gram stain or culture
pH < 7.30 or 7.20
Glucose < 40 mg
LDH > 1,000 IU
Loddenkemper R. et. al, Eur.Respir.Mon.,2004
Loculated pleural effusions
Insertion of multiple chest tubes
 Intrapleural administration of fibrinolitics
VATS is
 Thoracoscopy
prefered
 Decortication
 Open drainage procedure

Options?
Evidence based guidelines of PPE
treatment (ACCP)
PPE should be considered in all pneumonia (C)
 Drainage of PPE should be based on estimated
poor outcome risk (D)
 Risk 1 and 2 may not require drainage (D)
 Drainage recommended in risk 3 , 4 category (D)
 Therapeutic thoracentesis or tube thoracostomy
alone appears insufficient in most of risk 3, 4 (C);
reevaluation after several hours is useful (D)
 Fibrinolytics, VATS and surgery are acceptable
approaches in risk 3, 4 categories (C)

* Colice et. all, Chest, 2000
TREATMENT OF PARAPNEUMONIC PLEURAL EFFUSION AND EMPYEMA
DIAGNOSIS
(Etiology, stage,
complications)
Exudative
stage
Fibrinopurulent
stage
Organisational stage
complications
Other causes
Antibiotics
only
Additional
local
treatment
Surgery
(VATS or
thoracotomy)
Drainage
Successful
+/-Pleuroscopy
Continue
No
success
+fibrinolytics
+irrigation
No success