Management of refractory empyema with early decortication

Muskett, Alan; Burton, Nelson A.; Karwande, Shreekanth V.; Collins, Michael

doi:10.1016/s0002-9610(88)80546-4

Cited by 35 publications

(13 citation statements)

References 10 publications

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“…[13], In contrary to the radical surgery recommendations such as rib resection and decortication of Gourlay et al [14] in 1962, there is now sufficient evidence to support the conservative approach to childhood empyema [3,7,8,15]. The mortality rate from surgical operations is not neglectable [4][5][6], and long-term functional and cosmetical effects of surgery may be far from desirable. It seems that the child has greater capacity to resorb the thickened pleura effectively in contrast to adults.…”

Section: Discussionmentioning

confidence: 99%

“…Appropriate treatment is a matter of controversy, though the conservative approach of antibiotics and/or tube drainage is the leading schedule of treatment [4,5]. Decortication has been suggested only infrequently in recent years [6] and many feel that all chil dren with empyema can be adequately treated with appro priate drug therapy and conservative approaches with fa vorable prognosis. This study reviews the treatment schemes and outcomes of 72 children that were hospital ized and treated for parapneumonic empyema during [1985][1986][1987][1988][1989][1990].…”

Section: Introductionmentioning

confidence: 99%

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Conservative Treatment of Empyema in Children

Göçmen

Ki̇per²,

Toppare³

et al. 1993

Respiration

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Seventy-two children with no underlying diseases were treated for empyema. Radical surgical approaches like decortication were necessary for only 3 children. In 66 children tube drainage was applied. Staphylococcus aureus was cultured or was shown in Gram’s stain in 32 (44%) and children with this microorganism had longer duration of tube drainage (p < 0.05). The period for normalization of chest X-ray was positively related with the age of the patient (p < 0.05). In 60 of 72 children, chest X-ray was normal after 3 months. Follow-up of the patients 18 months after the infection revealed that pulmonary radiograms were normal in all cases and pulmonary function tests were within normal limits in all of the tested children (n = 25). It is emphasized that avoiding major surgical approaches must be encouraged in childhood empyema.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Conservative Treatment of Empyema in Children

Göçmen

Ki̇per²,

Toppare³

et al. 1993

Respiration

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“…Open thoracotomy for CPPE and empyema is recommended for persistent pleural sepsis and failure of less invasive procedures to control the infection [44,51,52]. Conversion to thoracotomy can be effective when VATS cannot adequately access the pleural space [44,[51][52][53] and is the optimal method for successful debridement and decortication.…”

Section: Managementmentioning

confidence: 99%

“…Conversion to thoracotomy can be effective when VATS cannot adequately access the pleural space [44,[51][52][53] and is the optimal method for successful debridement and decortication. However, decortication is a major operation and can often not be performed in debilitated patients.…”

Section: Managementmentioning

confidence: 99%

“…Decortication (i.e., stripping of the visceral pleural peel) can be performed early to control pleural sepsis and late (3-6 months after the onset of empyema or CPPE) to treat a symptomatic, restrictive ventilatory defect. The success rate of standard thoracotomy for CPPE and empyema is 87%-100%, with the mortality rate ranging from 0% to 9% [44,51,52]. Open drainage for empyema is an alternative to decortication in the debilitated patient who cannot undergo a standard thoracotomy [53].…”

Section: Managementmentioning

confidence: 99%

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Diagnosis and Management of Parapneumonic Effusions and Empyema

2007

Clinical Infectious Diseases

173

144

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Approximately 1 million patients develop parapneumonic effusions (PPEs) annually in the United States. The outcome of these effusions is related to the interval between the onset of clinical symptoms and presentation to the physician, comorbidities, and timely management. Early antibiotic treatment usually prevents the development of a PPE and its progression to a complicated PPE and empyema. Pleural fluid analysis provides diagnostic information and guides therapy. If the PPE is small to moderate in size, free-flowing, and nonpurulent (pH, 17.30), it is highly likely that antibiotic treatment alone will be effective. Prolonged pneumonia symptoms before evaluation, pleural fluid with a pH !7.20, and loculated pleural fluid suggest the need for pleural space drainage. The presence of pus (empyema) aspirated from the pleural space always requires drainage. Fibrinolytics are most likely to be effective during the early fibrinolytic stage and may make surgical drainage unnecessary. If pleural space drainage is ineffective, video-assisted thoracic surgery should be performed without delay.Parapneumonic effusion (PPE; i.e., pleural fluid that results from pneumonia or lung abscess) is the most common cause of an exudative pleural effusion. PPE may be the consequence of either community-acquired or nosocomial pneumonia. Between 20% and 57% of the 1 million patients hospitalized yearly in the United States with pneumonia develop a PPE [1][2][3]. Although PPEs are relatively common, empyema (i.e., the accumulation of pus in the pleural space) is less common, occurring in 5%-10% of patients who experience PPE [4]. In a review of 14 studies of empyema that involved a total of 1383 patients, 70% of PPEs were secondary to pneumonia (figure 1) [4]. CLASSIFICATIONA practical, clinical classification of PPE is as follows: (1) an uncomplicated parapneumonic effusion (UPPE) resolves with antibiotic therapy alone, without pleural space sequelae; (2) a complicated parapneumonic effusion (CPPE) requires pleural space drainage to resolve pleural sepsis and prevent progression to an empyema; and (3) empyema, the end stage of a PPE, occurs. Empyema is defined by its appearance; it is an opaque, whitish-yellow, viscous fluid that is the result of serum coagulation proteins, cellular debris, and fibrin deposition. Empyemas develop primarily because of delayed presentation by the patient with advanced pneumonia and progressive pleural infection and, less often, from inappropriate clinical management. Early antibiotic treatment prevents progression of pneumonia and the development of a PPE. Early antibiotic treatment will prevent development of an UPPE and progression to empyema. Risk factors for empyema include age (empyemas occur most frequently among children and elderly persons), debilitation, male sex, pneumonia requiring hospitalization, and comorbid diseases, such as bronchiectasis, chronic obstructive pulmonary disease, rheumatoid arthritis, alcoholism, diabetes, and gastroesophageal reflux disease [5]. Bacterial pneumonia, pneumon...

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