Management of Empyema

The survey posed question related to the following history regarding a 23 year old man with a history of intravenous drug abuse who was admitted to the hospital for management of pneumonia.� During hospitalization and while on antibiotic therapy he developed an ipsilateral moderate-sized pleural effusion and recurrent fevers associated with an elevated white blood cell count.� A thoracentesis yielded cloudy fluid with a pH of 6.9, a glucose of 23, and an LDH of 1200.� A CT scan demonstrated a moderate effusion that was heterogeneous but uniloculated, parietal pleural thickening, some enhancement of the visceral pleura, and a lower lobe pneumonia.�

Referral for initial consultation for this problem was evenly divided between surgeons and pulmonologists, reflecting institutional, individual, and perhaps regional differences in referral patterns and levels of expertise.� The majority of respondents indicated that chest tube placement was the first step in treatment.� A smaller number indicated that initial surgery would be appropriate, or that fibrinolytics would be used in conjunction with chest tube placement.

In two-thirds of institutions pulmonologists would not personally place chest tubes for management of this problem, indicating that, although pulmonologists were consulted initially for management about half the time, they didn?t perform definitive management as often.�

Respondents overwhelmingly indicated that a VATS approach is what they would use for surgical intervention.� Postoperative pleural drainage was generally maintained until the output was low rather than keeping thoracostomy tubes in for a specified period of time.� Most respondents indicated that a postoperative course of antibiotics for 1-2 weeks was most appropriate.

Overall, the results of the survey indicate that there is general agreement about initial management and surgical management of early stage empyema, despite differences in which specialist would be consulted first about this problem.

1. In your institution, who is initially consulted for management of this problem?
	answered question		205
	skipped question		1
		Response Percent	Response Count
Pulmonary medicine specialist		50.2%	103
Thoracic surgeon		48.3%	99
General surgeon		1.0%	2
Other		0.5%	1

2. In your institution, what initial therapy would be recommended for this patient?
	answered question		203
	skipped question		3
		Response Percent	Response Count
Continued antibiotic therapy only		3.9%	8
Therapeutic thoracentesis		12.3%	25
Chest tube placement without instillation of fibrinolytics		47.8%	97
Chest tube placement with instillation of fibrinolytics		15.8%	32
Surgical intervention		20.2%	41

3. In your institution do pulmonary medicine specialists insert chest tubes and instill fibrinolytics when appropriate?
	answered question		203
	skipped question		3
		Response Percent	Response Count
Yes		27.1%	55
No		66.5%	135
I?m not sure		6.4%	13

4. If surgical intervention was the recommended therapy, what approach would you use?
	answered question		204
	skipped question		2
		Response Percent	Response Count
VATS		71.1%	145
Muscle sparing lateral thoracotomy		9.3%	19
Muscle sparing anterolateral thoracotomy		2.5%	5
Standard lateral thoracotomy dividing the latissimus		7.4%	15
Posterolateral thoracotomy		9.8%	20

5. Assuming an operation is performed and appears successful, for how long do you keep the chest drains in place?
	answered question		202
	skipped question		4
		Response Percent	Response Count
Until there is no air leak and the fluid output is reasonable		67.8%	137
Until the fluid output is scant		25.2%	51
I send the patients home with drains in place and remove them gradually over a period of weeks		6.9%	14

6. Assuming an operation is performed and appears successful, for how long would you keep this patient on antibiotics?
	answered question		202
	skipped question		4
		Response Percent	Response Count
Only for the immediate perioperative period		14.4%	29
For 1-2 weeks		61.4%	124
For 4 weeks		15.3%	31
For 6 weeks		8.9%	18

7. In what region do you work?
	answered question		194
	skipped question		12
		Response Percent	Response Count
North America		42.3%	82
Europe		26.3%	51
South America		7.7%	15
Asia		17.0%	33
Africa		6.7%	13
Other (please specify)			16