Guidelines for Surgical Treatment of Empyema and Related Pleural Diseases

Introduction

The principles of management of empyema have been recognized by Hippocrates and the ancient physicians of Greece1. The management of postinfectious empyema historically involved aspiration for diagnosis, repeated aspirations if warranted, and tube or open drainage procedures once the empyema cavity was stable.

Current treatment of empyema in children is highly variable due to in part both provider experiences and a wide spectrum of clinical presentations. The numerous surgical options available to surgeons, and the variability of clinical presentation, suggest no singular approach is uniformly effective. With the advent of video-assisted techniques, the traditional approaches to management of empyema in children are being challenged.

Currently, the role of early thoracoscopy in the management of empyema is being defined. Video-assisted techniques offer distinct advantages in the accurate staging of the disease process, effectiveness of management of organizing pleural disease, and postoperative patient comfort and cosmesis. This document outlines the indications for and appropriate surgical treatment of empyema in children.

Definition

Empyema thoracis is defined as a pleural space suppurative fluid collection. Pleural space infections may complicate thoracic injury or arise secondary to a subjacent pneumonia. In the pediatric population, parapneumonic effusion is the most frequent etiology for empyema.2 Furthermore, the America Thoracic Society delineates three progressive phases of empyema: an early exudative phase, an intermediate fibrinopurulent phase, and a late organizing phase.3

Diagnosis

The diagnosis of empyema thoracis is principally made in the clinical setting of febrile illness in children with pulmonary symptoms (e.g. cough, tachypnea, sputum production, desaturations, and leukocytosis), radiographic studies include anteroposterior and lateral chest radiographs which demonstrate parenchymal infiltrates or consolidations, and pleural space fluid with the following:

Central to the staging schema is the development of restrictive pleural rinds or peels encasing the lung. Determination of the presence of this finding would be useful not only in staging the empyema process, but also in clinically guiding intervention. Layering of pleural fluid and the absence of pleural thickening or scoliosis on plain film radiographs may suggest an absence of the peel. Computed tomography and ultrasonography can delineate the nature and degree of parenchymal disease (such as the presence of underlying parenchymal abscesses) and the character of the pleural fluid or rind when complete opacification of the hemithorax is noted on plain films. Unfortunately, neither computed tomography nor ultrasonography has been uniformly predictive of the presence of pleural peels.4,5

Management

The management of empyema involves three core principles: prompt initiation of appropriate antibiotics, the complete evacuation of suppurative pleural fluid, and the preservation or restoration of lung expansion. Needle thoracentesis for chemistry analysis and culture is usually the initial diagnostic (and occasionally therapeutic) step coincident with the initiation of intravenous antibiotics. Thin exudates can occasionally be completely evacuated with this maneuver. Thoracentesis and antibiotics alone have been successful in treatment of empyema in 6 to 20% of patients, particularly with early stage disease.2,6,7 Large closed-tube thoracostomy with or without the adjunctive use of fibrinolytics has been the traditional management with the fibrinopurulent stage of the empyema process with reported success rates of 24 to 78%.2,6,7,8 The organizing phase of empyema requires direct removal of the restrictive coagulum (decortication) with open or thorascopic technique.

"Decortication" earlier in the clinical course (presumably during the fibrinopurulent stage) has been demonstrated to reduce morbidity and hospital stay.6,9  However, the morbidity of open thoracotomy often delayed surgical referral. The introduction of the “mini-thoractomy” technique reduced the operative morbidity of open thoracotomy while hastening recovery.10  More recently, thorascopic pleural evacuation and/or decortication have been shown to reduce not only hospital stay due to the infectious process, but also the morbidity of surgical decortication.11,12,13  Subsequently, many centers now receive referrals for surgical intervention much earlier in the clinical course of parapneumonic effusions. Indeed, the current trend in management of suspected infected pleural space disease is towards primary thorascopic pleural evacuation, decortication if warranted based on the character of the pleural collection, and tube thoracostomy.

Surgical Treatment of Empyema

Preoperative Evaluation

Evaluation of the child with suspected empyema includes clinical stabilization (intravenous fluids, antibiotics, supplemental oxygen and/or ventilatory support), and radiographic evaluation. Plain films confirm pleural fluid and may suggest the presence of loculations. Needle thoracentesis may aid in confirming the diagnosis of a suppurative pleural effusion and yield useful specimens for culture and antibiotic selection. An empyema severity score (ESS) was derived by Hoff et al based on pleural pH, glucose, radiographic findings (scoliosis, peel with significant pulmonary entrapment), and anaerobic infection.9   Chest sonography may be useful in localizing loculated pleural fluid prior to aspiration or tube thoracostomy.  Chest sonography may be useful in localizing loculated pleural fluid prior to aspiration or tube thoracostomy. Computed tomography may be useful in distinguishing pleural peel from consolidated parenchyma and identifying lung abscesses.

Indications for Surgery

Patients who fail to respond to intravenous antibiotics with defervescence and improving pulmonary symptoms, whose pleural fluid does not aspirate with needle or tube thoracostomy, or present with ESS scores of 2 or greater responded more quickly with earlier decortication.9 The presence of associated necrotizing pneumonias and lung abscesses inspire caution for the use of surgical decortication for fear of the development of prolonged air leaks and bronchopleural fistulae.

Surgical Technique

Closed-tube thoracostomy is an oft-employed primary surgical maneuver. Recently, the placement of the chest tube via a radially-expanding trocar port with the aid of sedation was described.8  The use of sonography or chest computed tomography facilitates the ideal placement of chest tubes and intercostal site selection. Fibrinolytic agents instilled via the tube thoracostomy may facilitate dissolution of intrapleural loculation and improve drainage.14

Rib resection, open drainage techniques used in adults for empyemas not responding to closed-tube thoracostomy are rarely utilized as such in children. Nonetheless, the “mini-thoracotomy” technique as described by Raffensperger is a variation of this historical technique. A 5-centimeter incision is placed directly overlying a rib with a subjacent empyema collection. A short segment of rib is excised and the pleural pocket is entered through the periosteal bed. The pleural space loculations are broken down with fingertip or suction tip dissection. The pleural coagulum is aspirate fully and the space irrigated with antibiotic solution. A chest tube is placed into the pocket and exits through a separate site. 10

Open thoracotomy for decortication utilizes a posterolateral thoracotomy incision for access into the pleural space. Muscle-sparing technique may diminish post-operative pain somewhat. The pleural space is carefully entered to minimize parenchymal injury, and subsequent air-leak, during costal retraction. As in the mini-thoracotomy technique, the coagulum is fully debrided and excised. Fibrosing pleural peel is carefully removed from the parenchymal and parietal pleurae. Earlier intervention facilitates removal of the peel from the parenchymal pleural surface with less resulting tissue injury. Lung expansion can be assessed prior closure and any remaining peel carefully removed. Open thoracotomy also permits lung resection if necessary for nonresponsive necrotizing pneumonias, fungal pneumonias, and parenchymal abscesses.

Video-assisted techniques

With the introduction of thorascopic techniques to the management of empyema, the indications for surgical decortication appear to be liberalizing. Certainly shortened hospital courses and decreased morbidity with early decortication encourage this approach. Moreover, the concept of diagnostic maneuvers (cultures and chemical analyses), complete pleural space fluid evacuation, and definitive decortication (when warranted) all performed at a single intervention under general anesthesia provides the least morbid (and certainly least painful) approach to empyema in children.

Numerous variations of video-assisted decortication, including one-, two-, and three-port approaches, have been described.11,12,15 One-lung ventilation has been described, either with aid of a double-lumen endotracheal tube or mainstem intubation, but is rarely necessary. The patient is placed in a lateral or semilateral decubitus position. Placing the patient over a large axillary role widens the contralateral intercostals spaces and facilitates trocar insertion. Based on preoperative imaging studies, suitable intercostal sites are selected for port placement. 3, 5, or 10 mm instruments may be utilized based on patient size, though the narrow intercostals spaces in even older children make 10 mm instruments unwieldy. Low CO2 insuffulation pressures (e.g. 4 mm Hg) initially aids both in slow disruption of pleural adhesions and lung collapse. The pleural space is inspected and coagulum removed completely. Interlobar collections should also be sought and removed. Adherent peel is carefully removed from visceral and parietal pleural surfaces. The placement of at least one 5 mm port aids in the removal of the coagulum and peel from the chest cavity.

Once the coagulum is completely evacuated and the peel removed, the lung is inflated. It is essential that the lung occupy the complete hemithorax upon inflation to minimize pleural space problems such as persistent atelectesis and recurrent empyema. The pleural space is irrigated with antibiotic solution and a chest tube is placed via a port site. A single chest tube usually suffices. As in open thoracotomy, chest tubes are removed when there is cessation of air leak and minimal pleural drainage.

The safe and effective use of thoracoscopic techniques in pediatric pleural diseases requires care and understanding of thoracoscopy in small children with preexisting lung disease. The use of angled telescopes, two-handed intracorporeal manipulation and gentle technique in often-confined spaces requires specific training in advanced thorascopic techniques. Such training is acquired through a residency, fellowship, or course specific to video-assisted techniques in pleural diseases and/or lung resection. Such course should provide documentation of attendance and specific skills taught. Before attempting this procedure independently, the surgeon should seek preceptorship from a surgeon experienced in video-assisted thorascopic surgery. Finally, appropriate instrumentation and a well-trained operating team familiar with the equipment, instruments, and technique are essential.

Summary

Infection of a pleural effusion, particularly as consequence to an underlying pneumonia, results in significant morbidity to the patient and health care costs to the family and payers. Early surgical intervention has been demonstrated to hasten recovery and reduce morbidity. The use of video-assisted techniques in the management of pleural space disease not only reduces surgical morbidity further, but also appeals to non-surgical providers thereby facilitating an earlier referral. Early video-assisted decortication provides an effective, singular procedure that combines characterization of the pleural space fluid, cessation of the progression of the parapneumonic process, removes the infected pleural material, allows for maximal lung expansion and function, all with reduced pain and morbidity to the patient and a shortened hospital stay.

References

1. Fallon WF, Jr: Post-traumatic Empyema. J Am Coll Surg 179:483-492, 1994

2. Alkrinawi S, Chernick V: Pleural infections in children. Semin Respir Infect 11:148-154, 1996

3. American Thoracic Society: Management of nontuberculous empyema. Ann Rev RespirDis 85:935-936, 1962

4. Cleveland RH, Foglia RP: CT in the evaluation of pleural versus pulmonary disease in children. Pediatr Radiol 18: 14-19, 1988

5. Kearney SE, Davies CW, Davies RJ, et al: Computed tomography and ultrasound in parapneumonic effusions in children with pneumonia. Pediatrics 101: 68-71, 1998

6. Hoff SJ, Neblett WW, Heller RM, et al: Postpneumonic empyema in children:selecting appropriate therapy. J Pediatr Surg 24: 659-664, 1989

7. Chan W, Keyser-Gauvin E, Davis GM, et al: Empyema thoracis in children: a 26-year review of the Montreal's Children's Hospital experience. J Pediatr Surg 32: 870-872, 1997

8. Patrick DA, Rothenberg SS: A new minimally invasive technique for chest tube insertion in infants and children. 10th Annual Congress for Endosurgery in Children, Brisbane, 22 -23 March, 2001

9. Hoff SJ, Neblett WW, Edwards KM, et al: Parapneumonic empyema in children: decortication hastens recovery in patients with severe pleural infections. Ped Infect Dis J 10:194-199,1990

10. Raffensperger JG, Luck SR, Shkolnik A, et al: Mini-thoracotomy and chest tube insertion for children with empyema. J Thorac Cardiovasc Surg 84:497-504, 1982

11. Kern JA, Rodgers BM: Thoracoscopy in the management of empyema in children. J Pediatr Surg 28: 1128-1132, 1993

12. Doski JJ, Lou D, Hicks BA, et al: Management of parapneumonic collections in infants and children. J Pediatr Surg: 35:265-270, 2000

13. Chen LE, Langer JC, Dillon PA, et al: Management of late-stage parapneumonic empyema. J Pediatr Surg 37: 371-374, 2002

14. Aye RW, Froese DP, Hill LD: Use of purified streptokinase in empyema and hemothorax. Am J Surg: 161:560-562, 1991

15. Kogut K: One-port technique for thorascopic debridement of empyema in young children and infants. Pediatr Endosurg Innov Tech 3

This guideline was prepared by the IPEG Guidelines Committee and was reviewed and approved by the Executive Committee of the International Pediatric Endosurgery Group (IPEG) October, 2002.

Requests for reprints should be sent to:
International Pediatric Endosurgery Group (IPEG)
11300 West Olympic Blvd., Suite 600
Los Angeles, CA 90064
Phone (310) 437-0553
Fax:  (310) 437-0585
E-mail: ipegweb@ipeg.org

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