ROLE OF MEDICAL THORACOSCOPY IN TREATMENT OF PARAPNEUMONIC EFFUSIONS

Dr. Mohamed Mostafa Kamel MBBCh,MSc, MD

Professor of Pulmonology Kasr El Aini Faculty of Medicine

Cairo University

mmkhope@hotmail.com

Identification: pleural fluid aspiration

All patients with a pleural effusion in association with sepsis or a pneumonic illness require diagnostic pleural fluid sampling. (C)

• If a pleural effusion is identified on the chest x-ray of a patient with possible pleural infection, it is impossible clinically to differentiate the presence of a complicated parapneumonic effusion requiring chest tube drainage from a simple effusion that may resolve with antibiotics alone.

Imaging guidance should be used since this minimises risks of organ perforation and improves the recovery rate of pleural fluid. Sampling using thoracic ultrasound is simple, safer and will reduce patient discomfort.

Sampling can be performed by sterile procedure using a needle and syringe with local anaesthetic if necessary.

Small effusions (ie, <10 mm thickness) will usually resolve with antibiotics alone.

The presence of frank pus is diagnostic of an empyema.National Patient Safety Agency (NPSA). Rapid Response Report: Risks of chest drain insertion (Reference NPSA/2008/RRR03). 2008:1e10. (4).Diacon AH, Brutsche MH, Soler M. Accuracy of pleural puncture sites: a prospective comparison of clinical examination with ultrasound. Chest 2003;123:436e41. (2+).Jones PW, Moyers JP, Rogers JT, et al. Ultrasound-guided thoracentesis: is it a safer method? Chest 2003;123:418e23 .

Pleural fluid pH should be assessed in all non-purulent effusions when pleural infection is suspected. (B)

If pleural fluid pH measurement is not available, pleural fluid glucose assessment should be performed where pleural infection is possible. (B)

• A patient with pleural infection requiring drainage will develop a pleural fluid acidosis associated with a rising LDH level and a falling glucose level.

• A pleural fluid pH of <7.2 is also the single most powerful indicator to predict a need for chest tube drainage, and that pleural fluid LDH (>1000 IU/l) and glucose (<3.4 mmol/l) did not improve diagnostic accuracy.

• Where pleural fluid pH measurement is not available glucose and LDH should be measured, a pleural fluid glucose level <3.4 mmol/l may be used as an alternative marker to indicate a need for chest drain insertion.

• Pleural fluid cytokine and/or inflammatory mediator levels (IL-8, TNFa, vascular endothelial growth factor or CRP) may be useful to differentiate complicated parapneumonic effusions from other exudative collections.

Indications for pleural fluid drainage in pleural infection

Patients with frankly purulent or turbid/cloudy pleural fluid on sampling should receive prompt pleural space chest tube drainage. (B)

The presence of organisms identified by Gram stain and/or culture from a non-purulent pleural fluid sample indicates that pleural infection is established and should lead to prompt chest tube drainage. (B)

Pleural fluid pH <7.2 in patients with suspected pleural infection indicates a need for chest tube drainage. (B)

Parapneumonic effusions that do not fulfill any of these criteria for chest tube drainage could be treated with antibiotics alone provided clinical progress is good. (B)

Poor clinical progress during treatment with antibiotics alone should lead to prompt patient review, repeat pleural fluid sampling and probably chest tube drainage.(B)

Patients with a loculated pleural collection should receive early chest tube drainage. (C)

Large non-purulent effusions could be drained by aspiration and/or chest tube if required for symptomatic benefit. (C)

Chest tube drainage

A small-bore catheter 10-14 F will be adequate for most cases of pleural infection. However, there is no consensus on the size of the optimal chest tube for drainage. (C)

If a small-bore flexible catheter is used, regular flushing

is recommended to avoid catheter blockage. (C)

Chest tube insertion should be performed under imaging guidance wherever possible. (D)

• In the absence of clear septation on ultrasonography, simple pleural drainage could be the standard treatment, whereas patients with clear septation are felt by many to require a form of thoracoscopy as a first-line treatment.

Davies HE, Davies RJ, Davies CW: Management of pleural infection in adults: British Thoracic Society Pleural Disease Guideline2010. Thorax 2010; 65:ii41–ii53.

• Empyema can be subdivided into 3 stages:

1. Exudative or acute (characterized by an effusion that is free moving in the pleural cavity),

2. Fibro-purulent (in which a reduced endocavitary fibrinolysis causes fibrin deposition on the pleural surfaces with a cloudy and viscous fluid and a tendency toward loculation and the formation of limiting membranes), and

3. Organizing or chronic (characterized by fibrous thickening of the visceral pleura, a sort of ‘peel’ which traps the lung).

Ferguson AD, Prescott RJ, Selkon JB, Watson D, Swinburn CR: The clinical course and management of thoracic empyema. QJM

AIM OF WORK

• To report experience and analyze the efficacy and safety of medical thoracoscopy in patients with multiloculated and organized empyema stratified early by chest ultrasonography.

Material and Methods

• Retrospective study reviewing all files of 41 patients referred for empyema and treated with medical thoracoscopy at the Pulmonology Department of a referral hospital for respiratory diseases (Forli Italy) from July 2005 to February 2011.

• All patients underwent chest radiography and also chest CT scan and ultrasonography to localize pleural fluid collection and to assess the echogenicity of the effusion and diaphragmatic motility.

• Thoracentesis was performed at our department in all patients and empyema was defined as frank pus on thoracocentesis (turbid

malodorous liquid) with or without positive Gram stain smear and bacteriologic culture findings or pH < 7.2 with signs of infection.

• Multiloculated empyema was defined as ultrasonographic presence of multiple empyema loculations with presence of intrapleural septae, and Organized empyema was characterized by fibrous thickening of the pleura

• Medical thoracoscopy was carried out in the lateral decubitus position under local anesthesia with 2% lidocaine and moderate

sedation.

• A 7.5- and/or 10-mm trocar was inserted under ultrasonographic guidance in the appropriate intercostal space

thorocoscopy 

• With the closed biopsy forceps, step by step, fibrinous septae were perforated, the pleural space was irrigated with saline, and fluid and fibrinopurulent material were aspirated and removed from the pleural cavity.

• At the end of the procedure, a drain (20–32 F) was inserted and connected to underwater seal suction with a negative pressure suction of 20 cm H20.

• All patients received IV antibiotics for at least 1 week after the procedure; in 23 patients, 100,000 U of urokinase diluted in 100 ml of normal saline solution was administered into the pleural space once daily for 3–5 days and, after rinsing with the saline solution, the drain was clamped for 2 hours.

Antibiotics

All patients should receive antibiotics targeted to treat the bacterial profile of modern pleural infection and based on local antibiotic policies and resistance patterns. (B)

Antibiotics to cover anaerobic infection should be used in all patients except those with culture proven pneumococcal infection. (B)

Macrolide antibiotics are not indicated unless there is objective evidence for or a high clinical index of suspicion of ‘atypical’ pathogens. (B)

Where possible, antibiotic choice should be guided by bacterial culture results and advice from a microbiologist.(B)

Penicillins, penicillins combined with b-lactamase inhibitors, metronidazole and cephalosporins penetrate the pleural space well. Aminoglycosides should be avoided. (B)

Empirical antibiotic treatment for hospital-acquired empyema should include treatment for MRSA and anaerobic bacteria. (B)

Intravenous antibiotics should be changed to oral therapy once there is clinical and objective

evidence of improvement in sepsis. (D)

Intrapleural antibiotics are not recommended. (D)

Prolonged courses of antibiotics may be necessary and can often be administered as an outpatient after discharge. (D)

Intrapleural fibrinolytics There is no indication for the routine use of intrapleural

fibrinolytics in patients for pleural infection. (A)

On occasions, such treatment may be indicated for the physical decompression of multiloculated (and so tube drainage resistant) pleural fluid collections that are responsible for dyspnoea or respiratory failure if discussion with a thoracic surgeon identifies that either surgery is not immediately possible due to additional patient co-morbidity, the feasibility of transfer to a surgical unit or other clinical or logistical reasons.

• Urokinase is non-antigenic but may still cause acute reactions with fever and cardiac arrhythmia.

• Doses of fibrinolytics used in studies have varied but include streptokinase 250 000 IU daily or 250 000 IU 12-hourly or urokinase 100 000 IU daily retained for 2to 4 h in the pleural space.

Bouros D, Schiza S, Patsourakis G, et al. Intrapleural streptokinase versus urokinase in the treatment of complicated parapneumonic effusions: a prospective,double-blind study. Am J Respir Crit Care Med 1997;155:291e5. (1+).Bouros D, Schiza S, Tzanakis N, et al. Intrapleural urokinase versus normal salinein the treatment of complicated parapneumonic effusions and empyema.A randomized, double-blind study. Am J Respir Crit Care Med 1999;159:37e42. (1+).Cameron R, Davies HR. Intra-pleural fibrinolytic therapy versus conservative management in the treatment of parapneumonic effusions and empyema. CochraneDatabase Syst Rev 2004:CD002312. (1++).Davies RJ, Traill ZC, Gleeson FV. Randomised controlled trial of intrapleural streptokinase in community acquired pleural infection. Thorax 1997;52:416e21.

• Treatment success was defined as :

Radiologic confirmation of successful pleural drainage (i.e. reduction of the size of the pleural fluid on the chest X-ray and a thoracic ultrasound of less than one third of the hemithorax in complete resolution or greater than one third in partial resolution), with no need for further treatment (subsequent chest tube insertions or surgical interventions) and

Objective evidence of sepsis resolution (improvement in temperature and clinical condition and decreasing inflammatory laboratory markers).

Results

• Patients were examined with radiologic techniques (ultrasound, X-ray, and CT scan); empyema was considered multiloculated in 24 patients (58.5%), organizing in 8 patients (19.5%), and free-flowing in 9 patients (22%).

• Free-flowing and multiloculated pleural empyema stratified by chest ultrasonography could be treated safely and successfully by medical thoracoscopy, while organizing empyema can be resistant to drainage with medical thoracoscopy, requiring, video-assisted thoracic surgery or open surgical decortication.

• Other studies, however, do not consider medical thoracoscopy as an alternative to surgical intervention in the presence of loculations.

• Medical thoracoscopy is a much less invasive video-assisted thoracoscopy, it is performed under local anesthesia and moderate sedation.

• Medical thoracoscopy can achieve opening of multiple loculations and aspiration of the purulent liquid and removal of the fibrinous adhesions, and it can provide local treatment with fibrinolytics

19 Cafiero F: Jacobaeus operation during parapneumothoracic empyema. Minerva Med.20 Kern L, Robert J, Brutsche M: Managemen t of parapneumonic effusion and empyema:medical thoracoscopy and surgical approach.Respiration 2011; 82: 193–196.21 Waller DA: Thoracoscopy in management of postpneumonic pleural infections. Curr Opin Pulm Med 2008; 4: 323–326 .

• The advantages of medical thoracoscopy compared with VATS include a lower cost and better tolerance by frail patients who may not tolerate general anesthesia with tracheal intubation.

• Some limitations to this technique can be related to the fact that, in contrast to surgical VATS, it is usually performed via a single port so the lung is not fully collapsed during the intervention and it can be more time consuming.

Timing of chest drain removal in pleural infection

• Removal of the chest drain is appropriate after radiological confirmation of successful pleural drainage ; that is, reduction in the size of the pleural collection on the chest x-ray or thoracic ultrasound and objective evidence of sepsis resolution ; that is, improvement in temperature and clinical condition and decreasing inflammatory markers (eg, CRP).

Persistent sepsis and pleural collection ????

Patients with persistent sepsis and a residual pleural collection should undergo further radiological imaging. (C)

Patients with persistent sepsis and a residual

pleural collection should be discussed with a thoracic surgeon to consider all possible surgical options available. (D)

THANK YOU