Empyema occurs at all ages and has a reported mortality rate ranging from 16% to 58%.1 To obtain a satisfactory therapeutic outcome, complete drainage is mandated. There is yet no consensus on the appropriate treatment option for the drainage of an empyema even with the advent of fibrinolytic enzymes and video-assisted thoracoscopic surgery (VATS). The literature is replete with studies describing variable and inconsistent results. We report a case of successful computed tomography (CT)-guided percutaneous pigtail catheter drainage with adjunctive daily normal saline irrigation of a loculated empyema.
A 55-year-old Hispanic male with hypertension, chronic obstructive pulmonary disease, depression, and chronic lumbago presented to the emergency department with a 2-day history of malaise, generalized body aches, worsening low back pain, dyspnea, profuse night sweats, and weight loss of about 10 kg over the preceding year. He denied fever, chills, chest pain, or cough.
His past medical history was significant for pneumonia 1 year before presentation and gunshot injury to the lower back. Pertinent social history included active intravenous cocaine use and cigarette smoking. He did not have any known allergies and his medications were fluoxetine and ibuprofen.
General examination revealed an ill-appearing male in pain and respiratory distress. Blood pressure was 140/90 mm Hg, pulse rate 109/min, respiratory rate 20/min, and temperature 99.8°F. Room air oxygen saturation by pulse oximetry was 91%. Systemic examination was remarkable for reduced air entry over the left upper lung field, upper thoracic spine point tenderness, needle track marks, and digital clubbing.
Initial laboratory findings were: leukocyte count, 29.2×109/L; hemoglobin, 13 g/L; hematocrit, 40%; normal basic metabolic profile; normal liver function tests except for serum albumin of 2.3 g/dL; normal coagulation profile; normal cardiac markers; serum lactic acid, 1.2 mmoles/L; and erythrocyte sedimentation rate, 92 mm/h. Arterial blood gases on 3 L/min supplemental oxygen by nasal cannula were pH 7.44, PaCO2 34, PaO2 66, and saturation percentage 95. Admission electrocardiogram was normal.
Chest radiographs revealed a left apical pleural-based density (Fig. 1). Chest CT scan showed 2 left apical pleural-based densities at the level of T1 to T2 vertebrae: the lateral one with intralesional low attenuation areas measures 5.6×3.6×4.5 cm whereas the medial paravertebral density measures 3.9×2.1×4.5 cm. Also seen was a right apical parenchymal density (Fig. 2).
The patient was admitted for hypoxemia, sepsis, and a large left pleural-based mass likely to be empyema. Broad-spectrum antibiotics were started. On hospital day 2, he had a blood culture positive for methicillin-sensitive Staphylococcus aureus. A diagnosis of endocarditis was entertained given his history of intravenous drug abuse, S. aureus bacteremia and the right apical lesion. Transthoracic echocardiography revealed normal ejection fraction and no valvular vegetations. Antibiotic therapy was streamlined to intravenous nafcillin, but he continued to have intermittent fevers. Whole body gallium scan showed increased uptake in the upper thoracic spinal areas.
On hospital day 8, CT-guided transthoracic needle aspiration of the loculated pleural-based lesion yielded 70 mL of pus and a 10F pigtail catheter was placed within the loculated empyema (Fig. 3). Subsequently, culture of the aspirate grew methicillin-sensitive S. aureus. Daily intrapleural irrigation with 100 mL of normal saline through the pigtail catheter was performed. Fever and leukocytosis resolved. Repeat CT scan showed resolution of the fluid collections (Fig. 4), and the catheter was removed on hospital day 19. The patient was discharged the next day on 6 weeks of antibiotic therapy and with appropriate follow-up appointments. On each of his 2 pulmonary clinic follow-up visits, the patient reported no complaints and had an unremarkable physical examination. A chest CT scan 3 months postdischarge demonstrated no evidence of residual or recurrent lesions. In addition to clinical and radiologic resolution, he had also given up his drug and smoking habits.
Management of empyema centers on the basic principles of appropriate antibiotic therapy and effective pleural space drainage. The optimal drainage modality has been widely debated. Proponents of stiff tube thoracostomy, pigtail catheter drainage, drainage plus fibrinolytic therapy, VATS debridement, and open thoracotomy each champion the efficacy of their approach. It is apparent that the most effective drainage modality depends on the stage of empyema with due consideration given to patient's comorbid conditions and tolerability of the procedure. The location, size, and Hounsfield density of the collection are also important variables to be considered in selecting an effective method of evacuation. The benefits of a particular drainage method should also be weighed against the attendant procedural risks.
The evolution of an empyema is through exudative, fibrinopurulent, and organizing stages. During the exudative stage, the protein-rich pleural fluid remains free flowing; whereas the fibrinopurulent stage is characterized by increased fluid viscosity and nascent fibroblastic activity with an adhesive meshwork coating the visceral pleura. Loculations may occur. This stage is usually characterized by disease chronicity of several days to a few weeks. The final organizing stage, occurring over several weeks, is marked by enhanced fibroblastic activity causing scarring of the pleural space with adherence of the visceral pleura to the parietal pleura that may lead to lung entrapment.
In addition to a comprehensive history, studies have shown that preprocedural ultrasonography and CAT scan stage empyema give insight into the likelihood of success of a given drainage modality. The preprocedural ultrasound appearance can be classified into anechoic, complex nonseptated, or complex septated.2 Alternatively, CAT scan can determine the size, location, loculation, and consistency of an empyema.
Inaccessible collections are commonly managed surgically. Some data support the use of the VATS approach in the management of the fibrinopurulent phase of empyema, and the use of open thoracotomy in the organized phase.3 However, satisfactory outcomes using these modalities vary widely. Complications may include conversion of a VATS procedure to an open thoracotomy with attendant surgical morbidity, creation of a bronchopleural fistula, diaphragmatic injury, and progressive pulmonary sepsis.
Other series support the use of less invasive approaches such as image-guided pigtail catheter drainage alone or along with fibrinolytic therapy as the initial drainage modality.4–6 Favorable results with fewer or no complications have been reported with these methods. Associated complications include pneumothorax, subcutaneous emphysema, catheter occlusion, fractured catheter, and infection. There have been cases of failures in which more invasive approaches were required.
The use of intrapleural fibrinolytics such as streptokinase or urokinase has also yielded varying results.7–9 A few small randomized controlled trials comparing fibrinolytics versus a normal saline control did not demonstrate significant advantage of fibrinolytic usage.7 Cost and the potential for adverse reactions such as high fever with streptokinase should be considered before the administration of fibrinolytics.
Our patient presented in the early fibrinopurulent stage of empyema, underwent percutaneous CT-guided pigtail catheter drainage with daily normal saline intrapleural irrigation. He had complete resolution of his pleural space infection with no complications. The presence of loculations in our patient did not negatively impact on a satisfactory outcome and should not be a contraindication to percutaneous pigtail catheter drainage. Multiple loculations may require multiple catheters for adequate drainage.10 The presence of thick fibrous peel of chronic empyema is not a contraindication to initial percutaneous pigtail catheter drainage and has been used with some success after failure of stiff tube thoracostomy.10 Image-guided approaches using CT, sonography, or fluoroscopy ensures proper catheter placement, and is successful in a high percentage of cases.6,10,11
Percutaneous drainage offers a safe and effective evacuation modality for loculated empyemas. We believe that image-guided percutaneous insertion of a pigtail catheter should be considered as the initial method of drainage for most empyemas. Daily normal saline intrapleural irrigation can facilitate the evacuation of an empyema, and may obviate surgical intervention. The success of image-guided pigtail catheter drainage depends on proper patient selection, operator skills, and daily monitoring of the catheter for adequate drainage.
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Keywords:© 2008 Lippincott Williams & Wilkins, Inc.
empyema; CT-guided percutaneous pigtail catheter drainage; daily normal saline intrapleural irrigation