Empyema with Dr. Shawn St. Peter
With Dr. Shawn St. Peter · hosted by Dr. Todd Ponsky · StayCurrentMD
Part of
Empyema 3 items
Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
Effusions greater than one-third of the chest with severe respiratory symptoms typically warrant aspiration, though this threshold is arbitrary and clinical judgment is required.
Pleural fluid with greater than 10,000 white blood cells defines empyema and was used as enrollment criteria for the randomized trial.
The randomized trial comparing primary VATS to primary fibrinolysis showed no difference in length of stay between the two approaches.
Patients receiving fibrinolysis do not get sicker during treatment, unlike some patients after VATS who can be critically ill due to trauma to both lungs.
Historical practice at Children's Mercy showed an average of 25 days total antibiotics with 19 days after becoming afebrile, with 40% of patients experiencing antibiotic-related complications.
The current antibiotic protocol is 7 days after meeting three criteria: completing fibrinolysis, being afebrile, and being off oxygen.
Recurrent empyema after successful treatment is extremely rare because the pleural space typically becomes obliterated.
The fibrinolysis protocol uses 4mg TPA mixed in 40mL normal saline with 1-hour dwell time, administered at 0, 24, and 48 hours (3 doses over 48 hours).
Both the Kansas City trial and Great Ormond Street study found a 1 in 6 (approximately 16%) failure rate for fibrinolysis.
In 100 consecutive patients treated with fibrinolysis after the trial, results remained consistent with a 15% failure rate and similar length of stay.
There was no difference in operative time or blood loss for VATS performed after failed fibrinolysis compared to primary VATS.
Placing a chest tube in the operating room with sedation but without intubation and positive pressure ventilation preserves some advantages of the non-operative approach.
Chest X-rays are not useful for daily monitoring or determining fibrinolysis failure, as the radiographic appearance remains poor even after successful treatment.
Failure of fibrinolysis is defined clinically by persistent illness (oxygen requirement, poor feeding) at 3-4 days, not by fever alone.
A second round of fibrinolysis is indicated only when the chest tube is walled off and a separate collection exists that was not in continuity with the initial tube placement.
Extensive pulmonary necrosis is an absolute contraindication to surgical intervention, as manipulation of necrotic lung risks severe complications including bronchopleural fistula.
During VATS for empyema, necrotic lung should be left alone rather than debrided, following the principle of cleaning the pleural space while avoiding lung manipulation.
A patient with complete pulmonary necrosis died after needle biopsy, exsanguinating into the wound and bronchi, demonstrating that necrotic lung does not tolerate being touched.
A 3-year-old with bilateral pulmonary necrosis survived after nearly one month on VV ECMO with non-operative management and came off ECMO without oxygen requirement.
Well-defined peripheral pulmonary abscesses can be drained percutaneously, but multifocal or complex abscesses should be managed conservatively like necrosis.
In the United States, TPA is the only available fibrinolytic agent for empyema since urokinase is not available and streptokinase has come off the market.
Mary Anne Jackson, an infectious disease specialist, recommended the 10,000 white cell threshold as an entry criterion for the trial, which proved accurate.
Ted Carter and colleagues in Seattle proposed an algorithm categorizing effusions as small (<25%), moderate (25-50%), or large (>50%), with symptomatic versus asymptomatic branches.
The IDSA community-acquired pneumonia guidelines recommend 10 days of antibiotics after being afebrile, but this is a grade D recommendation based on no data.
Ultrasound has no disadvantage compared to CT for diagnosing pleural disease and identifying septations in empyema.
A Spanish randomized trial of 100 patients using urokinase found no difference in length of stay and a 15% failure rate, confirming earlier findings.
An adult randomized trial suggested adding DNase to TPA may provide more rapid clearance, but DNase requires an investigational new drug (IND) application for intrapleural use.