Clinical Management of Tuberculosis Dato Dr Hj Abdul Razak Muttalif MBBS, MSc, M.Med, AM, FCCP Consultant Chest Physician & Head Department of Respiratory Medicine Hospital Pulau Pinang
Diagnosis of Tuberculosis
Pulmonary Tuberculosis Symptoms & Signs Investigations
Sputum AFBs X 3, AFB C&S (egg based media, BACTEC)
Chest X-rays Mantoux test
Duration of symptoms from first visit 70 60 50 40 Percent
30 20 10 0
Days
Weeks
Months
Years
Razak,Norhafizah,Norlidar,Norhashimah. C.C.HKT
2.Microbiology
Sputum AFB/AFB C+S Most cost effective method Categorization for treatment
AFB +ve AFB -ve
3. Serology Mantoux Test Antibody/antigen PCR
More than 10mm is positive
2TU in 0.1 ml, read after 72 hours
In children more than 15 mm
4.CXR Upper lobe opacity Cavity ( 1 cavity= 1 million bacilli) Miliary Effusion
Radiological classification Minimal
Slight lesion without cavitations, confined to a small part of one or both lungs. Total extent of lesions should not exceed the volume of lung which lies above the second chostosternal junction and the spine of the fourth vertebra
Radiological classification Moderately advanced
One or both lungs may be involved. Total extent of lesion should not exceed the following:
i) Not exceeding total volume of one lung ii)Dense lesions not exceeding one third lung volume Iii)Total diameter of cavity less than 4cm
Radiological classification Far advanced
Lesions more extensive than moderately advanced
Extra pulmonary TB (TB outside the lung parenchyma)
Tuberculous lymphadenitis by LN biopsy sent for DS, C&S, cytology TB effusion by pleurocentesis, pleural biopsy GUT by radiological, urine C&S TB bones/joints by x-rays, HPE Miliary TB by CXR,liver biopsy TB meningitis CSF microscopy, biochemestry C&S, PCR for TB
Tuberculosis Classification Pulmonary tuberculosis
Smear positive Smear negative
Extrapulmonary tuberculosis Pulmonary with Extrapulmonary
tuberculosis
Pulmonary Tuberculosis Smear positive
Two sputum DS positive One sputum positive with CXR changes of TB One sputum positive with culture positive
Smear negative
Three DS negative with CXR abnormalities and decision to treat as TB Initial sputum DS negative but culture positive
Extra Pulmonary TB Extra-pulmonary TB
TB of organs other than lung parenchyma Based on culture, histology or strong clinical evidence and a decision to treat
Pulmonary with extra-pulmonary
Tuberculosis involving lung parenchyma as well as any other part of the body
Extrapulmonary TB classification of severity Severe
Meningitis, miliary, pericarditis, peritonitis, bilateral or extensive pleural effusion, spinal, intestinal, genito-urinary
Less severe
Lymph node, unilateral pleural effusion, bone (excluding spine), peripheral joint, skin
Definition of terms New case Relapse case Chronic case Cure Treatment failure Treatment after interruption Transferred in case
Definition New case Newer had TB treatment or has take treatment for less than 4 weeks in the past Relapse case
Sputum positive relapse Declared cured of any form of TB in the past by a doctor has become sputum smear positive Sputum negative relapse As above, developed active disease based on bacteriological, histological clinical and radiological assessment
Definition Chronic case
A patient who remained or becomes smear positive again after completing a fully supervised re-treatment regimen
Cure
A smear positive patient has negative sputum at the end of treatment and another negative sputum one month or more prior to completion of treatment
Definition Treatment failure A patient while on treatment becomes again smear positive 5 months or later after commencing treatment A patient who was initially negative became positive after second month of treatment Treatment after interruption
A patient who interrupts treatment for 2 months or more then returns with smear positive or negative but still active TB based on clinical or radiological assessment
Definition Transferred in case
A patient transferred from another centre for continuation of treatment. The new centre undertakes the responsibility of treatment Not considered a transfer if a patient just come to centre for treatment only
Tuberculosis in children Infection from adults via coughing and
droplets From milk and food Through skin
Changes after infection in children Primary complex Pleural effusion Acute cavitation of focus Ring shadow Lymph node at root of lung Blood spread
Liver, bones, brain kidneys
?TB in children Failed to gain weight Wheezing, cough, fever, LOA, LOW Pleural effusion Ascites Joint swelling, spinal lump Lymph node, discharging sinus Headache, irritability
FAMILY HISTORY OF TB!!!!
“Two Diseases - one Patient”
Tuberculosis T helper lymphocytes Protective Immunity
Th1
Immunopathology and disease
Stress Glucocorticoids Th1
+
Tissue damage Macrophage activation
The immune response
Th2
Altered cytokines in HIV/TB patients Normal
Tb
TB/HIV
Advanced HIV
CD4
759
569
201
130
INF
7.5
10
2.2
0.1
IL-12
0.6
12.5
4
2.2
424
735
370
232
IL-10 TNF
231
TH1 cytokines---IL-12,INF Inhibitory cytokines IL-10
21
S.swaminathan et al 2002
Effect of TB on HIV TB causes release of TNF and
stimulates multiplication of virus inside T cells TB helps in destruction of CD4 cells Helps release of new virions from HIV infected cells
Effect of HIV on TB Decrease macrophage activating
lymphokines Increase in number of CD8 cells Increase tissue destruction T4 lymphopenia HIV promotes T4 destruction and CD4 cells impairment
Effect of HIV on TB
HIV Status
Lifetime risk of developing TB
Negative
5-10%
Positive
50%
Chest Imaging (in HIV +ve case) Not used for screening Limited to symptomatic Variety of manifestations Normal CXR in 15%,CT scan used only
for further diagnostic procedures Gallium scan for PCP
CXR findings in HIV patients (1) Normal
PCP, MTB, Histoplasma, Kaposi
Focal infiltrates
PCP, MTB, bacterial, Cryptococcus,aspergillus
Diffuse infiltrates
PCP, MTB, bacterial Cryptococcus, histoplasma
CXR finding (2) Nodular PCP, Cryptococcus, Histoplasma, Norcardia, CMV, Toxo Cavitary
Bacterial, PCP, MTB, Aspergilluss
Lymphadenopathy PCP, MTB, Cryptococcus, Kaposi, lymphoma Pleural effussion
Bacterial, PCP, MTB, lymphoma
Pneumothorax PCP, MTB
Pneumococcal
Staphylococcal
Lung abscess
Acceleration of TB in HIV patients Among 30 residents from a housing facility for HIV infected persons, 11 patients had active TB and were noted to have the same restricted fragment length polymorphisms (RFLPs) 4 others had positive TST 6 of the 28 staff members had positive TST Conclusion: Newly acquired TB infection in HIV infected patients can spread readily and progress rapidly to active disease. Heightened surveillance for TB in facilities as this is needed Charles et al. NEJM 1992;326:231-5
PTB mini epidemic in a church Gospel Choir Five cases of TB, one index and three
secondary All three had same DNA fingerprinting All three were tenors (not sopranos) Singing, location of ventilation and exposure time were contributing factors
Bonita et al Chest 1998; 113: 234-37
PTB in early and late HIV infection
Features of PTB
Stage of HIV infection Early
Late
Clinical picture
Often resembles post primary PTB
Often resembles primary PTB
Sputum smear
Often positive
Often negative
CXR
Often cavities
Often infiltrates with no cavities
CD4 count and CXR 35 subjects, 26 had CD4 <200cells/L 21 of these subjects had atypical CXR Atypical CXR
Diffuse lower lobar opacities Pleural effusion Mediastinal lymphadenopathy Interstitial nodes Normal x-ray Kelper et al. Chest;107:74-80
CXR in HIV patients 225 Haitians tested for HIV 67 positive and 158 negative Intrathoracic adenopathy more common then
parenchymal infiltrates (p<0.05) 80% of patients with AIDS has CXR consistent with primary TB (p<0.05)
R Long et al Chest; 99: 123-127
Pulmonary nodules in HIV patients* Diagnosis
Number
Bacterial
88
PCP
26
Lymphoma
25
Tuberculosis
23
Kaposi
16
NTM
15
Aspergillus
9
Lung Ca
4
CMV
2
* 242 HIV patients who had CT chest
Robert et al Chest 2000; 117:1023-1030
CD4 count and lung nodule CD4 cell count Diagnosis
0-49
50-99
100-199 >200
Pneumonia
17
1
8
4
TB
4
5
4
1
PCP
2
0
0
1
Aspergillus
3
0
0
0
Kaposi
9
1
1
0
87 HIV patients with lung nodules
Robert et al Chest 2000; 117:1023-1030
Undiagnosed TB in patients with HIV infection (Dept of Med, U of Souther Califonia Medical Center) Flora et al
11 patients with HIV TB undiagnosed 9/11 had pulmonary complaints 8/11 had x-ray suggestive of TB Non of these patients had TST AFBs in only 3 patients and bronchoscopy in
only 4 PCP was the main presumptive diagnosis Three had post mortem diagnosis of TB and 7 had evidence of disseminated TB
Chest 1990 Vol 98 1056-1059
Significance of abnormal CXR findings in patients with HIV infection and respiratory symptoms 44 patients were eligible 86% had CD4 count <200cells/uL Nodular disease was commonest (57%) Adenopathy (17%) Most common diagnosis was TB followed by
NTM Only 18% with TB had diagnosis by sputum
Jeffrey A Gold et al. Chest 2002;121:1472-1477
Other Investigations
Variables
CXR
Nodules
22
Adenopathy
7
Infiltrate
5
Cavity
4
Mass
4
Effusion
2
27% 38%
11% 3% 5%
8%
8%
Diagnosis
Percent
Infectious
52 (MTB 26, NTM 23)
Neoplasia
19 (KS 12, NSSCa 2, HL 2 )
Lymphoproliferative
7
Others
7
Unknown
14
Scope TTNA Surgery Thoracentesis FNA Clinical Sputum
Bronchoscopy
Treatment of Tuberculosis
Aims of treatment To reduce morbidity To prevent mortality To prevent relapse of tuberculosis To decrease transmission To prevent the emergence of MDR TB
Treatment of TB Responsibility is to the public health, not
patient Patient centered Each patient management plan should be individualised DOTS
First line drugs Isoniazid (H) Rifampicin ( R ) Pyrazinamide (Z) Streptomycin (S) Ethambutol (E)
Treatment categories
Category I New case
Category II
Relapse
Category III
Chronic case
Treatment failure
Sputum positive, MO boleh treat
Treatment after interruptio n
Refer to physician/che st
Treatment regimens Intensive or initial phase
Three or four drugs given daily for rapid sputum conversion and amelioration of clinical symptoms
Maintenance or continuation phase
Two or three drugs given intermittently for sterilizing effect and to eliminate remaining bacilli and reduce chance of relapse
Category I (New case) Intensive phase
2SHRZ or 2EHRZ or 2HRZ two months of daily doses
Continuation phase
4H2R2 or 4S2H2R2 or 4HR or 4H3R3 or 4S3H3R3 durations extended for severe form of TB or extrapulmonary TB
Category II (Relapse, Treatment failure, Treatment after interruption)
Send MTB C&S (rapid culture if
available) Do not initiate standard treatment Refer to chest physician or physician in charge of chest clinic Subsequent drug regimen based on sensitivity results and clinical response
Category III (Chronic case) Send MTB C&S (Rapid culture if
available) Refer to chest physician or physician in charge of chest clinic
Anti TB drugs Daily dosage
Biweekly dosage
mg/kg
max
mg/kg
max
Isoniazid H
5-8
300
15-20
1200
Rifampicin R
10-15
600
15-20
600
Streptomycin S
15-20
1000
15-20
1000
Ethambutol E
15-25
1200
50
2000
Pyrazinamide Z
20-40
1500
50
3000
Multi- drugs(first line) Intracellular
Extracellular
Cavity
RIF
+
+
+
INH
+
+
_
PZA
+
_
_
SMC
_
+
_
Flow Chart for 6 months regimen 1. 0 mo (0 w)
2. 2 mo (8w) 3. 2 mo (8w)
4. 2m (8w)
5. 6mo(24w)
Baseline Ix:FBC,LFT,RP,HIV,R BSSpt AFBs DS, AFB culture
2SHRZ/2EHR Z
4SHR2 Continue Rx
4HR2
Spt AFB DS, spt culture if smear positive,CXR
Continue RxSpt AFB DS, CXR
Completion of 6 mo Rx
Follow up
Spt AFB DS, CXR
Spt AFB, CXR
Practical Aspects All anti TB drugs given together, do not
split dosing Vigilant for drug interactions Empty stomach? After food? AntiTB drugs should not be stopped or minor side effects especially RIF
NOTIFICATION!!! !!
Patient Monitoring Treatment response
All patients with positive sputum have repeat sputum smears every two months
Patient compliance by DOTS Hospitalisation
Gravely ill, acute disseminated TB,TB of vital organs,MDRTB,frequent defaulters,complications, severe side effects, homelessness
Contact tracing!!! Family members Workplace Close contacts Inmates Institution
Drug toxicity monitoring and management
Monitoring for drug toxicity All patients should have baseline Ix Monitored clinically for adverse reaction Routine blood Ix for asymptomatic
patients not required If symptoms suggesting drug toxicity, perform appropriate Ix
Drug Toxicity Minor side effects GI intolerance Arthralgia Mild rash Serious side effects
Hepatitis Severe skin rash Thrombocytopenia Shock Renal failure, eight cranial nerve damage Visual impairement
Drug interactions Isoniazid
Raises the level of phenytoin,carbamazepine Absorption of INH impaired by allumonium hydroxide
Rifampicin
Need to increase dosages of PIs,steroids, OCP,OHA, anti-coagulants, phenytoin, cimetidine, theophylline and digitalis
Outcome analysis Cure Smear negative on two occasions at completion of treatment Treatment completed Completed treatment without proof of cure Treatment failure Remains positive of becomes positive again at five months of treatment Died Dies for any reason during course of treatment Treatment interrupted Treatment interrupted for two months or more
TB in Children Diagnosis is difficult Features:
Recent contact, symptoms and signs, unresolving pneumonia, positive mantoux, hilar nodes, segmental collapse, pleural effusion, LN calcification
Gastric lavage for DS and culture Bronchoscopy if necessary
Anti-TB in children Intensive phase
HRZ for 2 months (syrup preparation)
Maintenance phase
Daily RH is preferred Biweekly RH fully supervised
Avoid ethambutol and streptomycin
TB meningitis Total duration is 12 months Steroids in acute stage Observe for late complications like
hydrocephalus
TB in pregnancy and lactation Standard treatment and dosage Avoid streptomycin Breast feeding best avoided for 2 weeks
in a mother who is a new smear positive case BCG and INH prophylaxis given if needed
TB and OCP Rifampicin interacts with OCP Decreases protective efficacy against
pregnancy Use a higher dose of oestrogen or other form of contraception
TB and liver impairment Established chronic liver disease
i) 2SHRE/7H2R2 ii) 2SHE/10HE Iii)2SH/12S2H2
Acute hepatitis (viral hepatitis)
Hepatitis unrelated to TB or TB treatment, defer treatment until hepatitis is resolved if treatment is necessary, 3SE/6HR
TB and renal impairment Streptomycin and ethambutol avoided If need to be given, monitor renal function
closely 2HRZ/6HR is safest regimen
TB and HIV Initial therapy
INH, RFP, PZA , ETM
Long term
IHN and RFP for 7 months biweekly or for 6 months after culture is negative
Antiretroviral Drugs Nucleoside reverse transcriptase inhibitors (NRTI)
Zidovudine (AZT) Didanosine (ddI) Zalcitabine (ddC) Stavudine (d4T)
Non-nucleoside reverse transcriptase inhibitors (NNRTI)
Efavirenz (Stocrin) Nevirapine (Viramune)
Protease Inhibitors (PI)
Indinavir Ritonavir Saquinavir
Managing HIV/TB co-infection HAART decreased death by 60-90% In absence of HAART higher mortality
due to OIs HAART /anti-TB has overlapping toxicity, drug interaction, non-adherence, paradoxical reactions Recommended to delay HAART until first two months of TB treatment
Anti TB and HAART PIs and NNRTIs inhibit or induce
cytochrome P450 (CYP450) Rifampicin induce CYP450 and decrease levels of anti-retrovirals NRTIs (AZT,ddI,ddC,d4T,3TC) are not metabolised by CYP450 Concurrent use of NRTIs and rifampicin is not contraindicated and does not require dose adjustment
TB treatment in HIV patient In patients with no HIV treatment, usual
regimen In patients with HIV treatment, omit rifampicin and rifabutin or add streptomycin
Two options for TB Rx INH + RBT + PZA +
INH + PZA + ETH +
ETH for two months then INH + RBT for 4 months Do not use ritonavir, delavirdine, dose of PI adjusted
SM for 2 months then INH + PZA + SM for 7 months PIs can be used at usual dose
RBT=rifabutin
New options Rifampicin can be used in 3 situations:
I) NNRTI (efavirenz) + 2 NRTIs II) Ritonavir + one or two NRTIs III)Use of two Pis (ritonavir + saquinavir)
Use of non rifampicin included regimen
with longer duration
Pharmacologic interactions between rifampicin and efavirenz Coltres et al 24 HIV positive patients randomised into 3 groups: 1. Rifater + E(600mg qd) + 2NRTIs (D8-D14) 2. Rifater + E(800mg qd) + 2NRTIs (D8-D14) 3. Rifater + E(800mg qd) + 2NRTIs (D1-D14)
Result: 30% decrease in E level in group 1. No change in rifampicin levels Conclusion: Rifampicin and efavirenz can be used concomittently with a higher dose of efavirenz. Advise use of FDCs
8th Conference in Retroviruses and OIs February 2001, Chicago
Paradoxical worsening of TB in HIV infected persons (Johns Hopkins) HAART results in partial restoration of
cell mediated immunity 36% of patients who receive anti-TB and HAART compared to TB treatment alone Low CD4 counts higher risk Occurred 4-10 weeks after initiating treatment Increased risk of TB relapse Karen A Wendel et al. Chest 2001;120:193-197
Drug malabsorption and resistant TB in HIV patients (Kalpana Patel, Hartford Hospital) Drug
Optimum Level
Patient One
Patient Two
INH
3-5
0.80
0.92
RIF
8-24
0
0
PZA
20-60
24.9
34.81
ETH
2-6
0.40
0.86
Cipro
4-6
0.47
1.3
Serum levels measured after 2 hours of oral administration in ug/ml
Drug malabsorption may contribute to MDRTB
Fixed Dose Combinations (FDC) Rifinah/Rimactazid/Rifamate (RFP and
INH) Rifater (RFP, INH and PZA) Myrin (ETM, RFP and INH) Myrin P (ETM, RFP, INH and PZA)
FDC Advantages
Decreases MDRTB An effective regimen No medication errors Patient compliance
Disadvantages
Bioavailability, use only FDC approved Cost Dosage adjustment
DOTS
Directly Observed Treatment, Short-course (DOTS) Government commitment to a NTCP Case detection by sputum microscopy A standardised short course treatment
under direct observation A regular uninterrupted supply of quality anti TB drugs A monitoring and reporting system to evaluate treatment outcome
Advantages of DOTS Cure rates of up to 95% Integrated with primary health care Microscopy is cheap and reliable Trained health care workers or community volunteers
can supervise No hospitalisation or isolation Prevents MDRTB Reording system ensures cure Cost effective
Combined chemotherapy strategy in TB control DOTS No specific chemotherapy
T B
Drug susceptible TB Specific chemotherapy
Time
Defaulter tracing and retrieval Defaulter
Missed 25% of treatment doses in one month
Retrieve by phone call, letter on same
day Home visit if not turn up by 3rd day
Prevention of TB among Health Care Workers (HCW) Transmission of TB to HCWs depends
on:
Number of patients with active TB The infectiousness of the index case The ventilation rate of the worker The duration of exposure The air-exchange rate in the interior space
TB and HCW Administrative controls
Developing and implementing effective protocols for rapid identification, isolation and treatment Effective work practices by education, training and counseling
Engineering control
Prevent spread and reduce concentration of infectious droplet nuclei (exhaust fan, unidirectional flow, ultraviolet germicidal irradiation, biological safety cabinets classII)
Personal respirator protection
Surveillance of HCWs for TB All HCW have CXY on employment Those working in high risk area, have
CXR every two years Workers with symptoms should be evaluated for TB Infected HCW given long leave
Latent TB Infection (LTBI) 2 billion people worldwide have LTBI Most cases of active TB arise from LTBI Improved diagnosis and treatment of
LTBI is a major route of preventing and decreasing incidence and mortality from TB Direct TST to population at risk Offer simple short course regimens (2 months of RIF and PZA) 6th Annual IUATLD Conference Chicago 2001
Drugs for preventing TB in HIV infected persons Seven trials were reviewed Preventive therapy compared with placebo Lower incidence of active TB (46%) in preventive group Incidence of TB reduced in people with positive TST
compared with negative TST Death were less frequent in those with positive TST and taking preventive medicine Any regimen (INH alone, INH +RIF or INH + RIF+PZA) has similar protective effects Preventive therapy is effective in reducing death and active TB in positive TST group
Wilkinson D, Cochrane Review Abstracts
Targeting persistence One third of worlds population infected
(1.8 billion) 8 million with the latent disease develop reactivation 30% only fully treated in the world 5-20% reactivate after treatment Stanford researchers identified genes involved in latency
Persistence and latency 48 genes involved Ability of bacteria to respond to low
oxygen levels and increased nitric oxide The genes transform the physiological state, biochemical pathways and structure of organism Drug strategy for latency
Surgery in Tuberculosis
Surgery in Tuberculosis Pneumothorax Empyema MDRTB
Pneumothorax Treatment Observation & bed rest Aspiration Chest tube drainage Pleurodesis Surgery
Pneumothorax Treatment Observation Small (<20%), asymtomatic, good health Rate of air resorption = 1.25% or 50-70ml/day O’Rourke and Yee Chest 96:1302 1989 - 5% (2/40) mortality - tension pneumothorax - 22.5% - subsequent chest drain Prolonged observation (>14 days) Entrapped lung with chronic pneumothorax -
Chest tube or aspiration if not re-expanded after one week
Pneumothorax Treatment Aspiration Success rate = 50% Recurrence rate = 20-50%
Pneumothorax Treatment Tube Thoracostomy Moderate – large pneumothorax Rapid re-expansion of the lung Air leak usually stops within 48 hours Allow chemical pleurodesis to be
performed. Eg talc, tetracycline, bleomycin
Pneumothorax Treatment Recurrence Observation
30% Aspiration 20-50% Chest tube drainage 20-30% Pleurodesis (tetracycline) 25% Pleurodesis (talc) 7% Surgery
2%
Pneumothorax Indications for Surgery First episode Tension pneumothorax Bilateral pneumothoraces Haemo-pneumothorax <5% Non re-expansion of the lung Prolonged air leak (>3-4 days) – 3-5% Occupational hazard (flight personnel, divers, frequent flyers) Associated single large bullae Live in isolated remote area with no medical facilities
Second episode Ipsi-lateral recurrence Contra-lateral recurrence
Pneumothorax Treatment Surgical Approach Thoracotomy Conventional Limited muscle sparing VATS (Video assisted thoracoscopic surgery) Three small incisions Allow bilateral procedures
EMPYEMA THORACIS Indication for Surgery
Empyema Thoracis Paget 1896 “….unhealed empyema is, as a rule, the direct result of patient’s neglect, or of the surgeon’s delay, or of inadequate and useless surgery. ”
Empyema Thoracis Sir William Osler 1892 “ It is sad to think of the number lives which are sacrificed annually by the failure to recognize that empyema should be treated as an ordinary abscess by free incision” Open drainage with rib resetion recommended
Empyema Thoracis Evarts Graham – Am J Med Sci 1918 Open drainage – 30% mortality
Empyema Thoracis The Empyema Commission – Evarts Graham 1925 Recommended closed tube drainage
5-10% mortality
American Thoracic Society Pathological Stages Acute 1: Exudative, pleural swelling 2: Fibrinopurulent, with heavy fibrin deposits Chronic 3: Organization with in growth of fibroblasts and deposition of collagen (4-6 weeks)
Empyema Thoracis Complications Pulmonary fibrosis and contraction of chest wall Spontaneous Drainage
1. empyema necessitatis 2. brochopleural fistula 3. osteomyelitis 4. pericarditis 5. mediastinal abscess
Management Acute Empyema Nutrition, physiotherapy, underlying
medical condition Anti TB treatment is vital Drainage
Management Acute Empyema Drainage – cornerstone 1. evacuation of pus 2. apposition of pleural surfaces and obliteration of pleural space Must be performed as early as possible
Acute Empyema Pleural Drainage Conservative 1. Closed tube drainage 2. Intra-pleural fibrinolytics (streptokinase or urokinase) Surgical 1. Video assisted thoracoscopy 2. Thoracotomy – limited, muscle sparing, full Refer early
Acute Empyema Pleural Drainage
Minimum size 32F recommended Works best before formation of loculi Principle All infected fluid and pus must be drained
Empyema Thoracis Indications for Surgery Evidence of significant residual effusion on CXR
despite chest drain insertion Non-reexpansion of the lung after evacuation of empyema Multiple loculated collections demonstrated on ulrasound or CT Chronic empyema with trapped lung Complications
Empyema Thoracis Pleural Drainage CT or ultrasound guided pigtail catheter drainage in multi-loculated pleural empyema: a recommended procedure?. Maier A Respirology. 5(2):119-24, 2000 Jun.
RESULTS: Image-guided drainage failed in all (14/14) patients. Septic symptoms disappeared within 24-48 h after surgery with decortication.
Empyema Thoracis Intrapleural fibrinolytics 38-100% Success in Resolution of empyema 69% (18/26) of patients. Temes RT. Chest. 110(1):102-6, 1996 Jul. 77% (10/13 patients) Robinson Ann Thor Surg 1994;57:803 Cochrane Database of Systematic Reviews [computer file]. (3):CD002312, 2000
- Results not consistent across studies to recommend routine use
Empyema Thoracis Intrapleural fibrinolytics Controlled trial of intrapleural streptokinase in the treatment of pleural
empyema and complicated parapneumonic effusions. Chin NK. Lim TK. Chest. 111(2):275-9, 1997 Feb.
RESULTS: The incidence of surgical decortication was 17% and mortality
was 15%.
There were no significant differences between the two treatment groups in
terms of the need for surgical intervention, or mortality rates.
Twenty-nine patients were treated with Drain only 23 received, in addition, repeated daily SK, 250,000 U in saline solution (mean, 5.3 days).
Empyema Thoracis Operative Drainage Mortality rate
drain alone 24%
vs SK+ early OP = 3%
The average duration of hospital stay in the SK+early OP
group was significantly shorter than in the Drain and IPSK groups.
Lim TK. Chin NK. National University Hospital, Singapore Empirical treatment with fibrinolysis and early surgery reduces the duration of hospitalization in pleural sepsis. European Respiratory Journal. 13(3):514-8, 1999 Mar.
1) Drain (n=29, chest catheter drainage); 2) IP-SK (n=23, adjunctive intrapleural fibrinolysis with 250,000 U x day(-1) SK) 3) SK+early OP (n=30, early surgical drainage was offered to patients who failed to respond promptly following initial drainage plus SK).
Empyema Thoracis Video Assisted Thoracoscopy VATS Fibrino-purulent stage with loculated collections
Success rate 71% (48/67) Striffeler H. Gugger M. Annals of Thoracic Surgery. 65(2):319-23, 1998 Feb.
68% (30/44) Lawrence DR. Ohri SK Annals of Thoracic Surgery. 64(5):1448-50, 1997 Nov.
28% (2/7) children Steinbrecher HA. Najmaldin AS.Journal of Pediatric Surgery. 33(5):708-10, 1998 May
Chronic Empyema Options 1. Thoracotomy and decortication 2. Rib resection & open drainage 3. Space sterilization 4. Muscle or omentum transposition 5. Thoracoplasty 6. Total pleuro-pneumonectomy
Empyema Thoracis Thoracotomy Significant complications in children who had
delayed thoracotomy. Early thoracotomy hasten patient recovery regardless of the stage of disease.
Recommend aggressive early operative approach to empyema thoracis Shankar KR. Acta Paediatrica. 89(4):417-20, 2000 Apr Renner H. Gabor S. European Journal of Cardio-Thoracic Surgery. 14(2):117-22, 1998 Aug.
.
Empyema Thoracis Conclusions (1) Acute empyema is easily treated Chronic empyema has high morbidity
and mortality Chronic empyema is avoidable
Empyema Thoracis Conclusions (2) Early chest drain insertion Early surgical referral
Aggressive = Quick Recovery Conservative x8 mortality Lim TK. Chin NK. European Respiratory Journal. 13(3):514-8, 1999 Mar.
Empyema Thoracis “Early recognition of complicated empyema and institution of surgical interventions as primary therapy rather than as a last resort will likely result in improved survival and shortened hospital stay” Ferguson MK: The Healing Hand. Chest 97:4, 1990
Chest Drain
Chest Drain Closed Water seal System Gotthard Bülau 1891 –Hamburg,
Germany
Indications for Chest Tube Pneumothorax Haemothorax Empyema Pleural effusion Chylothorax Post-op – Thoracic & cardiac
Chest Tubes 6Fr (paediatric) to 40Fr Pure pneumothorax – minimum 24Fr Haemothorax, effusion and empyema –
minimum 28Fr recommended Drains with multiple side holes preferred
Insertion site 3rd to 5th intercostal space in the anterior axillary
or mid-axillary line behind the pectoralis muscle Advantages No muscles other the intercostals Scars less visible More comfortable
Avoid the front (muscles and breast) and the
back ( painful)
Insertion technique Aseptic technique Local anesthesia with lignocaine 3mg/kg
from skin down to pleura Aspirate air or fluid to confirm location
Insertion technique 2cm incision just above the rib Blunt dissection with artery forceps over
the superior border of the rib into the pleural space Finger palpation to confirm entry into the pleural space; absence of adhesions and loculated space Introduce the drain to apex or basal space
Anchor the drain with a simple skin stitch
( number 1 or 0 size) Another simple stitch for later skin closure after removal of drain Confirm the drain is swining well / bubbling or draining CXR to check position / lung re-
expansion / drainage
Insertion technique Should be painless if done properly (infiltrate
lignocaine widely and the right space) Avoid trocar ( can puncture lung, heart, spleen,
liver, oesophagus, aorta and diaphragm) Avoid purse-string ( ugly puckered scar) Simple dressing
Tube Management Monitoring Early and daily CXR Air leak and fluid drainage Maintain tube patency (swinging) Ensure air–tightness of closed system
Tube Removal Complete lung re-expansion >48 hours No air –leak Drainage <100ml / 24 hour Clamping of tube not necessary, probably in
cases with intermittent air leak
Removed at and inspiration or when
peforminga Valsava maneuver Check CXR
One way Drainage System
One way Drainage System Advantages Cheap Simple Problems Higher resistance with fluid accumulation Foaming
Suction Device
Indications for Suction Failure of lung to re-expand with good
size patent chest drain To promote drainage of blood and fluid Contra-indications Massive bleeding Pneumonectomy