Cardiothoracic Surgery: Parapneumonic Effusion & Empyema

Parapneumonic Effusion & Empyema

Definitions

  • Parapneumonic Effusion – Pleural Fluid that Develops in Response to Adjacent Pneumonia
    • Uncomplicated – Sterile Effusion
    • Complicated – Infected Effusion
  • Empyema – Purulent Fluid within the Pleural Cavity
    • The Majority are Due to Infection of a Parapneumonic Effusion
    • *Can Be Considered a Subclass of Complicated Parapneumonic Effusion if Develops in Response to Adjacent Pneumonia

Rates

  • Rate of Parapneumonic Effusion in Hospitalized Patients with Pneumonia: 20-40%
  • Rate of Empyema in Hospitalized Patients with Parapneumonic Effusion: 5-10%
  • Empyema Mortality of Hospitalized Patients: 15%

Stages/Phases

  • Stage I: Uncomplicated/Exudative
    • Timing: < 5 Days
    • Sterile Free-Flowing Fluid Develops from Increased Capillary Permeability
  • Stage II: Complicated/Fibrinopurulent
    • Timing: > 5 Days
    • Bacteria Enter the Fluid & Cause Inflammation
  • Stage III: Complicated/Organizing
    • Timing: > 2-3 Weeks
    • Fibroblasts Form a Fibrous Pleural Peel Causing Lung Trapping
    • Usually Resolves After 3-6 Months but Scarring Can Be Permanent

Diagnosis

  • Indications for Thoracentesis:
    • Size > 100 cc
    • Loculations
  • Associated Findings:
    • Uncomplicated Parapneumonic Effusion:
      • Size < 100 cc
      • No Loculations
    • Complicated Parapneumonic Effusion:
      • Positive Culture/Gram Stain
      • pH < 7.20
      • Large Size > 1,000 cc
      • Loculations
      • Thickened Pleura
      • Air Bubbles within Effusion
    • Empyema:
      • Frank Purulence on Thoracentesis

Treatment

  • Uncomplicated Parapneumonic Effusion: Antibiotics
  • Complicated Parapneumonic Effusion or Empyema: Antibiotics & Chest Tube Drainage
    • May Require Multiple Chest Tubes for Adequate Drainage
      • May Also Consider Intrapleural tPA/DNase
    • If Fails or Have Significant Organization: Surgical Decortication
      • Approach: Video-Assisted Thoracic Surgery (VATS) or Open Thoracotomy
      • If Not a Surgical Candidate: Eloesser Flap (Open Thoracic Window)

Empyema on CT 1

Empyema with Necrotic Purulent Debris on Thoracoscopy 2

Eloesser Flap 3

References

  1. Tsubakimoto M, Murayama S, Iraha R, Kamiya H, Tsuchiya N, Yamashiro T. Can Peripheral Bronchopleural Fistula Demonstrated on Computed Tomography be Treated Conservatively? A Retrospective Analysis. J Comput Assist Tomogr. 2016 Jan-Feb;40(1):86-90. (License: CC BY-NC-ND-4.0)
  2. Patil CB, Dixit R, Gupta R, Gupta N, Indushekar V. Thoracoscopic evaluation of 129 cases having undiagnosed exudative pleural effusions. Lung India. 2016 Sep-Oct;33(5):502-6. (License: CC BY-NC-SA-3.0)
  3. Wait MA, Beckles DL, Paul M, Hotze M, Dimaio MJ. Thoracoscopic management of empyema thoracis. J Minim Access Surg. 2007 Oct;3(4):141-8. (License: CC BY-2.0)