Treating Empyema:  Changing the algorithm for better patient care

This fear of thoracotomies dwarfs the very real risks of prolonged illness and debility.  

The story of empyema is as old as surgery itself.  Hippocrates himself describes treating empyema with chest tube placement.  However, over the years – the urge to treat this condition with the expediency and urgency it requires, has waned.  With the advent of antibiotics came the idea of a “wait and see” philosophy.  When the alternative was a thoracotomy, this could be forgiven.  In the age of uniportal VATS, it is not.

Current treatment algorithm (with basic variations)

Patient w/ parapneumonic  effusion/ empyema –> antibiotics –> still sick –> more antibiotics –> still sick –> chest tube (or pigtail placement)  –> fibrinolytics then —-> If treatment fails, consult thoracic surgery

The current treatment algorithm, which often starts as several weeks of outpatient antibiotics, (usually initiated for treatment of community acquired pneumonia that develops into a parapneumonic effusion), that engenders an even longer period after subsequent follow up chest x-rays, then CT scan fail to show improvement.

A pneumonia in late September, becomes an effusion in October, then progresses to empyema as various strategies are attempted and fail.  One antibiotic is switched to another, a pigtail is placed in radiology (with partial results), then perhaps, a larger tube, and fibrinolytics.  Then, only then – is the thoracic surgery service consulted.

At this point, the patient has been sick for several days to weeks.   As they remain sick, there is a decline in both nutritional and functional status.  The “spry” and youthful 75-year-old becomes a mostly bedridden and frail elderly patient.  This too, works against the patient and their recovery, as internal medicine physicians and pulmonologists are reluctant to refer this now frail patient due to the perceived rigors of surgery.  This fear of thoracotomies dwarfs the very real risks of prolonged illness and debility.  

For most modern-day practices, thoracotomies for decortication are a thing of the past.  Minimally invasive surgeries such as VATS or uniportal VATS have replaced the large incisions of the 1980’s and reduced, if not eliminated, the incidence of morbidity and mortality related to this procedure.  But our treatment algorithms haven’t kept up with surgical advances.

Proposed treatment algorithm:

Patient sick –> CT scan showing effusion –> thoracic surgery consultation with uniportal VATS for any effusion/empyema

Uniport VATS, (which is basically a glorified tube thoracostomy with anesthesia and a camera) allows for more than drainage of fluid from the pleural cavity. It also allows visualization, for better evacuation of infected material.  Surgeons are able to target areas of loculation; and complete a full decortication, if necessary.   While the use of anesthesia may add a degree of risk for the frailest of patients, it is the anesthetic/ and analgesic effects that allow for optimal patient positioning, and instrument manipulation, allowing for better results that bedside tube thoracostomy alone.

Why then, are we, the thoracic surgery service still only receiving consultations at the 23rd hour?  Why isn’t the literature pushing for a change in perspective, or a change in practice?

Current literature on empyema

Chin, Redden, Hsu and Driel (2017, 2013) published a Cochrane review of multiple randomized control trials comparing outcomes for tube thoracostomy versus VATS.  However, this review, which found in favor of VATS, was primarily based on pediatric studies.

Notably, this Cochrane review (which did not include uniportal VATS), showed decreased mortality and length of stay in the thoracotomy and multi-port VATS groups compared with the tube thoracostomy group.

Another Cochrane study, Cootes et al. (2009), which also demonstrated a decreased length of stay, and decreased duration of chest tube placement with VATS) was withdrawn due to questions about inclusion criteria.

The remainder of the existing studies

The remainder of studies published since the Cochrane database review had similar limitations.  A German study published in 2017 (Segerer et al.) that reviewed 645 children throughout the country that presented with empyema and showed no different in the length of stay.  But only 7% of these children underwent surgical procedures compared to 46.9% that underwent lesser procedures (thoracentesis or chest tube placement).

A more recently published study, Tanbrawarsin et al. (2018) showed a decreased incidence in recurrent bacterial empyema in patients who underwent surgery, but it is difficult to apply these findings to our algorithm, since it was based on just 34 patients, and was not randomized.  Furthermore, all advanced empyema patients received open thoracotomies.  Some patients also underwent thoracoplasties, which is a procedure not commonly used in many parts of the world, including the North America.

Patients deserve better

While the published data appears to remain undecided on the algorithm, it is clear, our patients deserve better.  They deserve an approach that is timely, and effective.  There is significant data that demonstrates that early surgical intervention improves outcomes.  But unless thoracic surgeons present an overwhelming mountain of evidence [at pulmonary and internal medicine conferences] that uniportal VATS is superior to lesser therapies, patients with empyemas will continue to receive lesser therapies, first, before we receive the thoracic surgery consult.

They deserve the opportunity to rapidly return to health and full function.  For that, we need to commit to performing and reporting more research aimed at looking at the most effective treatment for empyema.  We, in thoracic surgery, know that that the answer is not more of the same; increasingly ineffective antibiotic regimens and a long convalesce.  Now, we have to prove it, and publish it, over and over, to get past the persistent belief that risk of surgery outweighs the risk of continued illness.

Now, we need to conduct and publish studies, and reviews that compare nonsurgical treatment with uniportal VATS (excluding the dread thoracotomy) and looking for meaningful end points beyond mortality.  Studies need to look at the length of stay, chest tube duration, morbidities related to either treatment (deconditioning, blood transfusions, DVT, malnutrition, etc. ) as well as both the 30-day recurrence and re-admission rate.

Surgeons, this is your call to action.


References (with links to full text articles when possible)

Cootes et. al. (2009) Surgical versus nonsurgical management of empyema.  Cochrane database.  Paper withdrawn.

Redden, Chin, & Van Driel (2013, 2017).  Surgical versus nonsurgical management of empyema.  Cochrane database.

Segerer, et al. (2017).  Therapy of 645 children with parapneumonic effusion and empyema – a German nationwide surveillance study.  Pediatric Pulmonol 2017 Apr, 52 (4): 540-547.

Shresthra et. al. (2011).  Evolving experience in the management of empyema thoracis.  KUMJ 2011 Jan-Mar 9 (33) 5-7.   In this study, 82% of patients treated with tube thoracostomy eventually needed thoracotomy.  Full text link not available.

Tanbrawasin, A. et al. (2018).  Factors associated with recurrent bacterial empyema thoracis.  Asian J. Surg 2018 Jul, 41(4) 313-320.

There are multiple studies showing early surgical intervention improves outcomes in empyema, but only a single selection was placed within the editorial above.