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http://pedsccm.wustl.edu/All-Net/template/template-1.htm

empyema/incidence & epidemiologyEmpyema is the presenceof gross pus in the pleural cavity; it consists of aneffusion containing polymorphonuclear leukocytes and fibrin. The Greek

philosopher, Aristotle, recognized empyema and described the drainage of pus

with incision and a metal tube as early as 300 BC. A parapneumonic process is

defined as a pleural effusion associated with pneumonia, lung abscess or

bronchiectasis.Not all parapneumonic processes are empyemas.anatomy & physiology

The pleural space is actually a potential space created by the visceral and parietal

pleura. It normally contains a scant amount of fluid which facilitates movement of

the lung with the diaphragm and chest wall. Several mechanisms contribute to the

development of an effusion. Pleural fluid can accumulate when alterations in

hydrostatic and oncotic pressure accompany cardiac, renal, hepatic or metabolic

disease, or when there are changes in pleural fluid permeability secondary to

inflammation, infection, toxin, malignancy or trauma. Common provocations that

increase permeability include:congestive heart failure (increased capillary hydrostatic pressure)

nephrotic syndrome (decreased plasma oncotic pressure)

post thoracentesis (decreased hydrostatic pressure of the pleural space), and

malignancy (impaired lymphatic drainage).A pleural effusion provides a rich culture medium in which white blood cell

defenses can be impaired and an empyema may flourish.stages in the development of an empyema

By convention, the formation of an empyema can be divided into three phases:

exudative, fibrinopurulent and organizing. During the first or exudative phase, pus

accumulates. This is followed by fibrin deposition and loculation of pleural fluid

known as the fibrinopurulent phase. The last phase, the organizing phase, is

characterized by fibroblast proliferation; at this time there is the potential for lung

entrapment by scarring.

incidence & epidemiologyPleural effusions are most common in children with pneumonia. However,

empyema is a rare complication of pneumonia. The reported incidence of

empyema following pneumonia varies (0.7% to 9%) in the pediatric literature. A

recent review of 50 cases of pediatric empyema reported that the incidence of

empyema is increasing and the epidemiology is changing. In the 1940's, before the

development of penicillin and sulfa antibiotics, empyema was usually caused by

http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?uid=2643182&form=6&db=m&Dopt=bhttp://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?uid=8722927&form=6&db=m&Dopt=bhttp://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?uid=2643182&form=6&db=m&Dopt=bhttp://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?uid=8722927&form=6&db=m&Dopt=b

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Streptococcus pneumonia. Over the next two decades, Staphylococcus aureus

bacteria was reported as the most frequently cultured organism from empyema

fluid until the discovery of penicillinase resistant penicillins.

In the 1980's Haemophilus influenza type b caused a majority of pediatric

empyema but with the development of the H. flu vaccine, Streptococcus

pneumonia has again taken the lead as the most frequent pathogen cultured from

empyema fluid in children. The age of patients presenting with empyema is also

changing. Twenty years ago, the average child with empyema was less than 2 years

old and recently the median age was reported as 7 years. Empyema still affects

both males and females equally and has a seasonal distribution, occurring more

frequently in the winter and spring.we found a good related case on the web:

empyemahttp://pedsccm.wustl.edu/All-Net/template/template-2.htm/diagnosisMost children with empyemawill have persistent symptoms despiteantibiotic therapy for pneumonia. Symptoms include fever, cough, dyspnea, and

pleuritic chest pain. A chest radiograph will demonstrate a parapneumonic

effusion; a sample of the fluid should be obtained by thoracentesis. The diagnosis

of empyema is made when gross inspection of the pleural fluid reveals pus. Apositive gram stain by microscopic analysis also clinches the diagnosis.

Other tests routinely ordered include pleural fluid analysis for glucose, CBC with

differential, lactate dehydrogenase (LDH) and culture. These additional tests can

assist in distinguishing an exudate from a transudate but are not pathognomonic for

the diagnosis of empyema. Pleural fluid cultures are often negative in patients with

empyema and may be negative secondary to antibiotic therapy or inability to grow

the organism. Radiographs including a posterior, lateral, and lateral decubitus

films, ultrasound and CT scan determine if an effusion is free flowing (suggestive

of an transudate) or walled off, loculated, or abscess-like. Although loculated fluid

is suggestive of an exudate, it is not specific for an empyema.transudate versus exudate: criteria

adapted from: Wilson, Braunwald, Isselbacher et al. Harrisons Priciples of Internal Medicine 12th edition. 1991 Mc

Graw Hill. p 1111.transudate exudate

appearance clearclear, cloudy,

bloodyprotein < 3.0 gm/dL > 3.0 gm/dLpleural fluid : < 0.6 > 0.6

http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?uid=8783710&form=6&db=m&Dopt=bhttp://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?uid=6514596&form=6&db=m&Dopt=bhttp://www.vh.org/Providers/TeachingFiles/TAP/Cases/Case05/Case05.htmlhttp://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?uid=3536342&form=6&db=m&Dopt=bhttp://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?uid=3536342&form=6&db=m&Dopt=bhttp://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?uid=8783710&form=6&db=m&Dopt=bhttp://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?uid=6514596&form=6&db=m&Dopt=bhttp://www.vh.org/Providers/TeachingFiles/TAP/Cases/Case05/Case05.htmlhttp://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?uid=3536342&form=6&db=m&Dopt=bhttp://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?uid=3536342&form=6&db=m&Dopt=b

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serum protein ratio

lactate

dehydrogenase< 200 IU/L > 200 IU/L

glucose > 60 mg/dLvariable (same

as blood)leukocytes < 1000 /mL > 1000 /mL

polymorphonuclear

WBC's < 50% > 50%

erythrocytes < 5000/mL variable

empyemahttp://pedsccm.wustl.edu/All-Net/template/template-3.htm

/managementControversy remains in the management of empyema. Current practicefor pediatric empyema is largely based on the personal experience of pediatricians

and surgeons and thus varies from institution to institution. Most of the literature

on the therapy of empyema consists of case reviews and retrospective studies. In

1992, Light attempted to identify those patients with a parapneumonic effusion

who would require tube thoracostomy or have positive bacterial cultures. He

suggested that empyemas usually have the following characteristics:Light's criteria for empyema

pH

< 7.0

glucose < 40 mg/dL

LDH > 1000 IU/l

He concluded that if pleural fluid analysis met the above criteria or if Gram stain

was positive, then a thoracostomy tube should be placed. In a follow up study in

adults, Light's criteria were applied to 91 patients. The authors concluded that the

criteria were specific but not sensitive in identifying patients who would benefit

from chest tube placement. Some patients who had a negative gram stain or pleural

fluid that did not meet the above criteria still developed an empyema requiring

chest tube drainage or surgery. The debate over when and in whom a thoracostomytube should be placed still continues.

Other treatment modalities include urokinase/ streptokinase infusion into catheter

drainage systems, thorascopic adhesiolysis, and open chest thoracotomy with lysis

of adhesions/decortication. Overall, clinicians agree that all patients should be

placed on antibiotics and a sample of pleural fluid obtained. However, there is no

consensus on when and in whom to place a chest tube, instill urokinase or take to

http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?uid=1914612&form=6&db=m&Dopt=bhttp://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?uid=8131463&form=6&db=m&Dopt=bhttp://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?uid=8308676&form=6&db=m&Dopt=bhttp://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?uid=3260313&form=6&db=m&Dopt=bhttp://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?uid=1914612&form=6&db=m&Dopt=bhttp://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?uid=8131463&form=6&db=m&Dopt=bhttp://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?uid=8308676&form=6&db=m&Dopt=bhttp://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?uid=3260313&form=6&db=m&Dopt=b

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the operating room. The general consensus is that patients who are not

defervescing clinically after a few days of therapy may require alternative or more

aggressive therapy. Also, a delay in antibiotic therapy and drainage has been

associated with a longer hospital stay and the increased likelihood of surgical

intervention.link to related sub-chapter (esp. highlight

controveries or alternative theories/opinions)

..\english/pulmpage/infect/empyema4.htm..\english/pulmpage/infect/empyema4.htmMicheal J Romano

MD: an alternative viewmicrobiology & appropriate antibiotics

Pleural cultures are positive in approximately one half of pediatric patients with

empyema. Blood culture and urine latex agglutination / counter-

immunoelectropheresis may help to identify a bacterial pathogen. Currently,

Streptococcus pneumoniae is the most common isolate from community acquiredempyema, followed by Staphylococcus aureus and Haemophilus influenza.

IV Cefuroxime or a similar second-generation cephalosporin is recommended as

first line therapy. If an organism is identified, antibiotics can be tailored to culture

and sensitivity results. There appears to be an increasing incidence of

Streptococcal pneumococcal drug resistance; one recent article notes the following

resistances: penicillin (15%), erythromycin (15%), chloramphenicol (31%), and

cefotaxime (23%). High dose penicillin, third generation cephalosporins or

vancomycin may be considered for drug resistant pneumococcal empyema. In a

hospital acquired empyema or an empyema in a compromised host, there is agreater possibility of gram negative, anaerobic or opportunistic organism.outcome

The hospital stay for children with empyema varies but the mean has been reported

between 13 and 26 days. Children treated for empyema generally recover and have

no residual sequela. Radiographs at the time of discharge usually show pleural

thickening which later resolves. Follow up pulmonary function tests and physical

exam are also usually normal. Infants, patients with nosocomial disease,

Staphylococcus aureus, or polymicrobial infection and those with underlying

deficiency have an increased morbidity and mortality.

http://pedsccm.wustl.edu/All-Net/english/reading/empyema.htm

empyema

http://var/www/apps/conversion/tmp/english/pulmpage/infect/empyema4.htmhttp://var/www/apps/conversion/tmp/english/pulmpage/infect/empyema4.htmhttp://var/www/apps/conversion/tmp/english/pulmpage/infect/empyema4.htmhttp://var/www/apps/conversion/tmp/english/pulmpage/infect/empyema4.htmhttp://var/www/apps/conversion/tmp/scratch_2/template-4.htmhttp://var/www/apps/conversion/tmp/scratch_2/template-4.htmhttp://var/www/apps/conversion/tmp/scratch_2/template-4.htmhttp://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?uid=8783710&form=6&db=m&Dopt=bhttp://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?uid=9557062&form=6&db=m&Dopt=bhttp://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?uid=9557062&form=6&db=m&Dopt=bhttp://var/www/apps/conversion/tmp/english/pulmpage/infect/empyema4.htmhttp://var/www/apps/conversion/tmp/english/pulmpage/infect/empyema4.htmhttp://var/www/apps/conversion/tmp/scratch_2/template-4.htmhttp://var/www/apps/conversion/tmp/scratch_2/template-4.htmhttp://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?uid=8783710&form=6&db=m&Dopt=bhttp://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?uid=9557062&form=6&db=m&Dopt=bhttp://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?uid=9557062&form=6&db=m&Dopt=b

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/treatment optionsEmpyema presents a troublesome challenge to the intensivist. While manycases respond to closed thoracostomy drainage and antibiotics, some advocate the

addition of fibrinolytic therapy. Surgical referral is common, although medicalmanagement is often not optimized prior to referral for surgery.

The median duration of hospitalization forS. pneumonia empyema has been

reported as 11.5 days. The best data on natural history and duration of fever in

pediatric empyema can be found in McLaughlin et al (mean 14 days) and Murphy

(7.1 days). It is difficult to make a case for the failure of medical management after

3-4 days of fever. Likewise, Gocmen reports that the chest x-ray does not change

early in management, but almost invariably resolves with time. These three

pediatric references suggest that long term restrictive lung disease is uncommon in

children.Fibrinolytic therapy. In the case of loculated pleural effusions, it may behelpful to instill a fibrinolytic agent into the chest cavity. Kornecki reports the use

of urokinase: 100,000 units (diluted in 100 mL normal saline) is instilled, the

thoracostomy tube is clamped for 12 hours, and then re-opened for another 12

hours. While fibrinolytics will certainly increase pleural fluid drainage, there has

been no prospective trial demonstrating shorter resolution of fever, or shorter

hospitalizations.

Surgical intervention. There is one prospective controlled trial of immediate

surgical intervention vs. medical management. Video-assisted thoracoscopicsurgery (VATS) was compared to pleural drainage and fibrinolytics. The study

found a benefit to early VATS. Two comments about this trial: the main criterion for failure of medical management (and cross-over to surgery) was persistence of more

than 50% of pleural fluid on chest x-ray. It is difficult to convincingly measure pleural fluid and separate itfrom pleural reaction on a plain film chest x-ray. This criterion might favor crossing patients over to

surgery

the recovery from a formal thoracotomy or even 'mini-thoractomy" is much longer than from VATS.

Unless an institution offers VATS these results are not applicable

Other papers reporting surgical interventions fall into the descriptive category, or

categorize surgery as rescue therapy. Commonly stated reasons for surgery are

persistent fever (without stating what was the duration of fever was) or failure ofthe chest x-ray to clear, or concern about "trapped lung" and long term pulmonary

abnormalities.

An interesting study from Denmark compared outcomes of patients with empyema

referred to medical vs. surgical services. Of the patients cared for by the medical

service 3/51 patients received operations, compared to 24/43 patients cared for by

http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?uid=9349773&form=6&db=m&Dopt=bhttp://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?uid=9349773&form=6&db=m&Dopt=b

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the surgical service. Duration of hospitalization was 2.3 weeks in the medical

group vs. 5.0 weeks in the surgical group.

Foglia and Randolph describe ten children over seven years at two large

institutions who underwent thoracotomy after an average of 20 days of medical

management. The discussion section after the article is most informative,

suggesting that "...the indications for decortication in children are extraodinarily

rare." One physician is quoted as remarking: "I do not remember any in the last

nine years that have needed decortication."

Ultrasound. Ultrasound has been used to evaluate empyema. A retrospectivereport describes its use in 46 patients over thirteen hospital-years at major pediatric

programs (i.e., less than four patients/year).

In summary, the vast majority of pediatric patients with empyema will recoverwith medical management consisting of tube thoracostomy drainage and

antibiotics. Hospitalization lasts 1-2 weeks on average. The chest x-ray willeventually return to normal, but may take up to six months. The chance of

restrictive lung disease is very low in previously healthy children. Fibrinolytic

therapy will probably increase drainage through the thoracostomy tube, with

urokinase possibly being safer than streptokinase.

http://pedsccm.wustl.edu/All-Net/template/template-4.htm

empyema/other treatment optionsEmpyema presents a troublesome challenge to the intensivist. While manycases respond to closed thoracostomy drainage and antibiotics, some advocate the

addition of fibrinolytic therapy. Surgical referral is common, although medical

management is often not optimized prior to referral for surgery.

The median duration of hospitalization forS. pneumonia e empyema has been

reported as 11.5 days. The best data on natural history and duration of fever in

pediatric empyema can be found in McLaughlin et al (mean 14 days) and Murphy

(7.1 days). It is difficult to make a case for the failure of medical management after

3-4 days of fever. Likewise, Gocmen reports that the chest x-ray does not change

early in management, but almost invariably resolves with time. These three

http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?uid=7395826&form=6&db=m&Dopt=bhttp://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?uid=7395826&form=6&db=m&Dopt=bhttp://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?uid=8210723&form=6&db=m&Dopt=bhttp://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?uid=7395826&form=6&db=m&Dopt=bhttp://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?uid=7395826&form=6&db=m&Dopt=bhttp://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?uid=8210723&form=6&db=m&Dopt=b

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pediatric references suggest that long term restrictive lung disease is uncommon in

children.

Fibrinolytic therapy. In the case of loculated pleural effusions, it may behelpful to instill a fibrinolytic agent into the chest cavity. Kornecki reports the use

of urokinase: 100,000 units (diluted in 100 mL normal saline) is instilled, thethoracostomy tube is clamped for 12 hours, and then re-opened for another 12

hours.

One problem with interpreting the usefulness of fibrinolytics has been the use of

volume of drainage as an endpoint, which may or may not be clinically important

if the urokinase for example, irritates the pleural surface, increasing transudation.

Recently, urokinase was compared to normal saline in a blinded trial. Aside from

more drainage, the urokinase group had a shorter duration of fever and

hospitilization and much better success rate.

Surgical intervention.There is one prospective controlled trial of immediate

surgical intervention vs. medical management. Video-assisted thoracoscopic

surgery (VATS) was compared to pleural drainage and fibrinolytics. The study

found a benefit to early VATS. Two comments about this trial: the main criterion for failure of medical management (and cross-over to surgery) was persistence of more

than 50% of pleural fluid on chest x-ray. It is difficult to convincingly measure pleural fluid and separate it

from pleural reaction on a plain film chest x-ray. This criterion might favor crossing patients over to

surgery

the recovery from a formal thoracotomy or even 'mini-thoractomy" is much longer than from VATS.

Unless an institution offers VATS these results are not applicable

Other papers reporting surgical interventions fall into the descriptive category, or

categorize surgery as rescue therapy. Commonly stated reasons for surgery arepersistent fever (without stating what was the duration of fever was) or failure of

the chest x-ray to clear, or concern about 'trapped lung' and long term pulmonary

abnormalities.

An interesting study from Denmark compared outcomes of patients with empyema

referred to medical vs. surgical services. Of the patients cared for by the medical

service 3/51 patients received operations, compared to 24/43 patients cared for by

the surgical service. Duration of hospitalization was 2.3 weeks in the medical

group vs. 5.0 weeks in the surgical group.

Foglia and Randolph describe ten children over seven years at two large

institutions who underwent thoracotomy after an average of 20 days of medicalmanagement. The discussion section after the article is most informative,

suggesting that '...the indications for decortication in children are extraodinarily

rare.' One physician is quoted as remarking: 'I do not remember any in the last nine

years that have needed decortication.'

http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?uid=9349773&form=6&db=m&Dopt=bhttp://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?uid=9872815&form=6&db=m&Dopt=bhttp://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?uid=9187172&form=6&db=m&Dopt=bhttp://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?uid=3819989&form=6&db=m&Dopt=bhttp://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?uid=9349773&form=6&db=m&Dopt=bhttp://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?uid=9872815&form=6&db=m&Dopt=bhttp://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?uid=9187172&form=6&db=m&Dopt=bhttp://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?uid=3819989&form=6&db=m&Dopt=b

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Ultrasound. Ultrasound has been used to evaluate empyema. A retrospectivereport describes its use in 46 patients over thirteen hospital-years at major pediatric

programs (i.e., less than four patients/year).

In summary, the vast majority of pediatric patients with empyema will recover

with medical management consisting of tube thoracostomy drainage andantibiotics. Hospitalization lasts 1-2 weeks on average. The chest x-ray will

eventually return to normal, but may take up to six months. The chance of

restrictive lung disease is very low in previously healthy children. Fibrinolytic

therapy will probably increase drainage through the thoracostomy tube, with

urokinase possibly being safer than streptokinase.