Internal Medicine

0521779407-17 CUNY1086/Karliner 0 521 77940 7 June 13, 2007 7:57

1182 Pleural Diseases: Effusion/Empyema

II. Complicated parapneumonic: as for empyema

III. Empyema:

Nonsurgical:

■Sterilization:≥4–6 weeks antibiotics

■Early drainage (loculations form quickly)

■Large thoracostomy tubes or smaller radiologically guided catheters

■Multiple tubes if multiloculated

■Chest tube until <50 mL/day and closure of cavity

■No role for serial thoracenteses

Intrapleural fibrinolytics:

■Multiloculated stage II/III

■Streptokinase or urokinase (in 100 mL NS) into largest loculation;

clamp 2–4 hours

Surgical:

■Inadequate drainage or incomplete obliteration of cavity

■Thoracoscopy, open thoracostomy, open-flap drainage, thoraco-

scopic or open decortication

Special

■Empyema with bronchopleural fistula: requires immediate

drainage (risk of pneumonia)

■Empyema distal to obstructed bronchus:must relieve obstruction

(radiotherapy or laser) to allow re-expansion

■Recurrent effusion (e.g., malignant):consider talc, bleomycin pleu-

rodesis

■Hemothorax:insert tube early to monitor bleeding and prevent

fibrothorax

follow-up

■Uniloculated stage II/III: CT 24 hours after chest tube

■Multiloculated stage II/III: Marginal/poor surgical candidates; tube

drainage with

■Fibrinolysis: CT in 72 hours

complications and prognosis

■Average 1.8 procedures/patient for empyema

■Success rates:

➣chest tube alone: 11% (better for aerobic infection)

➣image-directed catheter: 57%

➣decortication: 95%

■Follow for recurrent infections, persistent intrapleural space