Empiema Pleural - Simpósio Brasil-Itália
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U.O. di Pneumologia - Endoscopia Toracica U.O. di Pneumologia - Endoscopia Toracica
P.te Indiano (Singh): 43 anni
28-10-2011
Sintomas: dor “abdominal” no flanco direito, febre (37,8)
Investigação:•Ecografia abdominal: negativa•Rx tórax: •negativo
U.O. di Pneumologia - Endoscopia Toracica U.O. di Pneumologia - Endoscopia Toracica
1-11-2011
Sintomas: • dor toracica• febre (38°)• Dispneia
Laboratorio:GB: 7.81 (N=78%)VHS: 96D-Dimero: 3150
Rx Torax:Pequeno derrame pleural a D.
U.O. di Pneumologia - Endoscopia Toracica U.O. di Pneumologia - Endoscopia Toracica
P.te Indiano (Singh): 43 anni
2-11-2011
U.O. di Pneumologia - Endoscopia Toracica U.O. di Pneumologia - Endoscopia Toracica
P.te Indiano (Singh): 43 anni
4-11-2011
Drenagem Toracica (pig tail)
700 ml de liquido pleurico corpuscolado e amarelado
pH: 6,56!!!
Proteinas: 4,1 (no soro 5,5)
Glicose: 19
LDH: 10955!
U.O. di Pneumologia - Endoscopia Toracica U.O. di Pneumologia - Endoscopia Toracica
P.te Indiano (Singh): 43 anni
U.O. di Pneumologia - Endoscopia Toracica U.O. di Pneumologia - Endoscopia Toracica
P.te Indiano (Singh): 43 anni
U.O. di Pneumologia - Endoscopia Toracica U.O. di Pneumologia - Endoscopia Toracica
P.te Indiano (Singh): 43 anni
• Pleurite parapneumônica– pleurite simples– Derrame parapneumônico complicado e empiema
• Derrame pleurico tubercular.– pleurite– empiema (raro)
• Pleurite atípica (Em pacientes imunodeprimidos é frequente a infecção oportunista.)– fungos
• candida, aspergillo, criptococco, coccidioides, histoplasma, blastomyces, sporotrichose
– bactérias incomuns• Actinomicosi, nocardiosi, chlamidia, rickettsiae
– parasitas• Amebiase, echinococcose, paragonimiase, trichominiase
– virus (não se conhece a real epidemiologia!)• Adenovirus, hantavirus, cytomegalovirus, herpes virus, hepatite, mononucleose,
dengue
U.O. di Pneumologia - Endoscopia Toracica U.O. di Pneumologia - Endoscopia Toracica
• Dificil isolar os agentes patogênicos– Dificuldades com os métodos atuais. Identificação do agente patogênico em
menos de 40% dos casos com os métodos tradicionais.– Frequentemente não vem procurados!!!– A pleurite viral, em particular no adulto, é uma realidade, um “mito” ou um
diagnóstico “refúgio”???• Derrames parapneumônicos: mesma etiologia das pneumonias?
– Poucos estudos, com indicações de seleção, retrospectivo e com poucos casos, porém, orientam para etiologias diferentes.
• Empiema:– Toracocentese precoce e tratamento correto (drenagem): muitas vezes
inexplicavelmente retardados– Mortalidade em 12 meses de 22%; 35% no P.te imunodepresso.– Diferença entre adquiridas na comunidade e hospitalar? etiologia.. mortalidade.
• Derrame pleural tubercular:– Acredita-se de se tratar de uma patologia muito rara.– Se dá muita importancia a procura do BK no liquido pleurico– Descuida-se da importancia fundamental da biopsia pleurica
U.O. di Pneumologia - Endoscopia Toracica U.O. di Pneumologia - Endoscopia Toracica
U.O. di Pneumologia - Endoscopia Toracica U.O. di Pneumologia - Endoscopia Toracica
U.O. di Pneumologia - Endoscopia Toracica U.O. di Pneumologia - Endoscopia Toracica
U.O. di Pneumologia - Endoscopia Toracica U.O. di Pneumologia - Endoscopia Toracica
U.O. di Pneumologia - Endoscopia Toracica U.O. di Pneumologia - Endoscopia Toracica
454 Pts
Bacterial identification: 74%
streptococcus
staphylococcus
enterococcus
Gram negatives
anaerobes
Myc tuberc
actinomyces
others
Bacteriology of community acquired pleural infection
U.O. di Pneumologia - Endoscopia Toracica U.O. di Pneumologia - Endoscopia Toracica
• The group Streptococcus milleri (SM) includes several species of pathogenic streptococci associated with pyogenic infections: at least three well-differentiated species:
– S. constellatus, S. intermedius and S. anginosus– The SM group is part of the usual flora of the mouth, it is also found among
normal faecal flora in 16–67% of healthy adults
• The most important clinical feature of these micro-organisms is their tendency to cause suppurative infections at various sites, ranging from dental abscesses to deep visceral abscesses
U.O. di Pneumologia - Endoscopia Toracica U.O. di Pneumologia - Endoscopia Toracica
Conclusions
community-acquired pleural infection is caused by penicillin-sensitive streptococci in about 50% of cases, with the other 50% being due to organisms that are usually penicillin resistant, including staphylococci and Enterobacteriaceae.
About 25% of community-acquired pleural infections include anaerobic bacteria.
Appropriate empiric antibiotic choices for these patients should therefore cover streptococci, penicillin-resistant staphylococci, and Enterobacteriaceae and should usually also include anaerobic bacterial therapy.
U.O. di Pneumologia - Endoscopia Toracica U.O. di Pneumologia - Endoscopia Toracica
One year Mortality
•53/304 (17%) in community-acquired infection
•17/36 (47%) in hospital ac inf
U.O. di Pneumologia - Endoscopia Toracica U.O. di Pneumologia - Endoscopia Toracica
Approximately 60% of hospital-acquired infections included bacteria frequently
resistant to antibiotics
•Mortality in different bacterial subsets:
•23/137 (17%): streptococcal inf.
•10/49 (20%): anaerobic-mixed inf.
•15/34 (44%) S. aureus inf.
•10/22 (45%) gram-negative inf.
•13/28 (46%) mixed aerobic inf.
U.O. di Pneumologia - Endoscopia Toracica U.O. di Pneumologia - Endoscopia Toracica
U.O. di Pneumologia - Endoscopia Toracica U.O. di Pneumologia - Endoscopia Toracica
U.O. di Pneumologia - Endoscopia Toracica U.O. di Pneumologia - Endoscopia Toracica
•Long delays in diagnosis
•long hospital stays
•recovery with surgery
•The mean delay in diagnosis was 44.2 days
•On average each patient:
• underwent CT 10.1 times
•had 2.6 percutaneous drainage procedures
•The mean time from the first percutaneous chest drainage to the date of diagnosis was 29.8 days
•the mean delay until thoracic surgery referral was 47.4 day
•The mean length of hospital stay postoperatively was 15.2 days
Ultrasonography and CT scanning, however, have greater sensitivity for fluid detection and provide additional information for determining the extent and nature of pleural infection.
U.O. di Pneumologia - Endoscopia Toracica U.O. di Pneumologia - Endoscopia Toracica
U.O. di Pneumologia - Endoscopia Toracica U.O. di Pneumologia - Endoscopia Toracica
empyema
U.O. di Pneumologia - Endoscopia Toracica U.O. di Pneumologia - Endoscopia Toracica
U.O. di Pneumologia - Endoscopia Toracica U.O. di Pneumologia - Endoscopia Toracica
• Exudative stage: pleural fluid culture is negative, pH > 7.20, LDH <1000: 5 to 7 days
• fibrino-purulent stage: pleural fluid becomes purulent, early loculations, positive microbial culture. pH <7.20, LDH > 1000: 7 days up to 2 weeks
• organizing stage: fibroblasts grow into the pleural space; this results in a thik pleural peel: generally occurs within 2 to 4 weeks of onset of the pleural effusion.
U.O. di Pneumologia - Endoscopia Toracica U.O. di Pneumologia - Endoscopia Toracica G.F. Tassi, G.P. Marchetti. Il versamento parapneumonico e l’empiema. In Pneumologia
Interventistica. A.G. Casalini. Springer Italia. 2007
Clinical and pathological evolution
stage Pleural fluid Biochemical aspects
treatment
Simple parapneumonic pleural effusion
yellow •pH>7.20•LDH<1000•GRAM neg
antibiotics
Complicated parapneumonic effusion
Yellow/turbid
•pH<7.20•LDH>1000•GRAM pos
Chest tube drainage
empyema Purulent Chest tube drainage
U.O. di Pneumologia - Endoscopia Toracica U.O. di Pneumologia - Endoscopia Toracica
U.O. di Pneumologia - Endoscopia Toracica U.O. di Pneumologia - Endoscopia Toracica
Cochrane Database of Systematic Reviews 2008, Issue 2. Art. No.:CD002312.
U.O. di Pneumologia - Endoscopia Toracica U.O. di Pneumologia - Endoscopia Toracica
The primary outcome of the review was treatment failure resulting in death and surgery.
Cochrane Database of Systematic Reviews 2008, Issue 2. Art. No.:CD002312.
U.O. di Pneumologia - Endoscopia Toracica U.O. di Pneumologia - Endoscopia Toracica
The primary outcome of the review was treatment failure resulting in death and surgery.
U.O. di Pneumologia - Endoscopia Toracica U.O. di Pneumologia - Endoscopia Toracica
Conclusions: In patients with loculated, complex fibrinopurulent parapneumonic empyema thoracis, a primary treatment strategy of VATS is associated with a higher efficacy, shorter hospital duration, and less cost than a treatment strategy that utilizes catheter-directed fibrinolytic therapy.
october 30th
U.O. di Pneumologia - Endoscopia Toracica U.O. di Pneumologia - Endoscopia Toracica
Case Report G.P.A. 51 years old
U.O. di Pneumologia - Endoscopia Toracica U.O. di Pneumologia - Endoscopia Toracica
Case Report G.P.A. 51 years old
october 31st
november 5th: Thoracoscopy
U.O. di Pneumologia - Endoscopia Toracica U.O. di Pneumologia - Endoscopia Toracica
Case Report G.P.A. 51 years old
november 23th
U.O. di Pneumologia - Endoscopia Toracica U.O. di Pneumologia - Endoscopia Toracica
Case Report G.P.A. 51 years old
Conclusion
Although thoracoscopy has proved useful in the treatment ofinfected pleural space, in particular in multiloculated empyema where it allows recovery avoiding thoracotomy, even today its employment has not been justified by large controlled trials. Moreover there are no prospective, controlled studies on the role of medical thoracoscopy inparapneumonic effusions and empyema.
Medical thoracoscopy, as a drainage procedure intermedate between tube thoracostomy and VATS, is significantly lower in cost and can avoid surgical thoracoscopy under general anaesthesia. It is essential that it is performed early on in the course of empyema and it is particularly advisable for frail patients at high surgical risk.
U.O. di Pneumologia - Endoscopia Toracica U.O. di Pneumologia - Endoscopia Toracica
Conclusion
Although thoracoscopy has proved useful in the treatment ofinfected pleural space, in particular in multiloculated empyema where it allows recovery avoiding thoracotomy, even today its employment has not been justified by large controlled trials. Moreover there are no prospective, controlled studies on the role of medical thoracoscopy inparapneumonic effusions and empyema.
Medical thoracoscopy, as a drainage procedure intermedate between tube thoracostomy and VATS, is significantly lower in cost and can avoid surgical thoracoscopy under general anaesthesia. It is essential that it is performed early on in the course of empyema and it is particularly advisable for frail patients at high surgical risk.