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Complications of nosocomial pneumonia in the surgical patient
Complications of Nosocomial Pneumonia in the Surgical Patient Stephen Rowe, MD, William G. Cheadle, MD, Louisville, Kentucky
Nosocomial pneumonia is a leading cause of morbidity and mortality in the surgical and trauma patient. Inadequate treatment can lead to the complications of acute respiratory distress syndrome (ARDS), empyema, and lung abscess. The prevention and treatment of these complications revolve around several key principles. Complete treatment of pneumonia requires appropriate antimicrobial therapy, as well as mechanical pulmonary hygiene and proper airway management. Despite advances in treatment of pneumonia, complications arise necessitating treatment. This article reviews the treatment of ARDS, empyema, and lung abscesses. In particular, the many options for treatment of empyema are discussed in detail. Additionally, the treatment of pulmonary contusion and hemopneumothorax in the trauma patient is discussed. The understanding of sound treatment principles in the critically ill postsurgical patient helps prevent complicated or recurrent pneumonia and allows the surgeon to intervene effectively when such complications occur. Am J Surg. 2000;179 (Suppl 2A):63S– 68S. © 2000 by Excerpta Medica, Inc.
From the Department of Surgery, University of Louisville School of Medicine, the Trauma Program in Surgery, University of Louisville Hospital, and Veterans Affairs Medical Center, Louisville, Kentucky, USA. Correspondence should be addressed to William G. Cheadle, MD, Department of Surgery, School of Medicine, University of Louisville, Louisville, Kentucky 40292.
© 2000 by Excerpta Medica, Inc. All rights reserved.
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osocomial pneumonia is an important cause of morbidity and mortality in the surgical patient. It is the leading cause of death among all nosocomial infections, with a reported mortality ranging from 20% to 50%.1 In a recent monograph on pneumonia in the surgical patient, it was said that “pneumonia may well be the most common cause of death among surgical patients during the last three decades.”2 Pneumonia is clearly an important determinant in the outcome of the postsurgical and trauma patient. Persistent pneumonia can lead to several complications (Table I), including acute respiratory distress syndrome, recurrence, empyema, lung abscess, and even necrotizing pneumonia (pulmonary gangrene). The prevention of these later complications revolves around initial adequate therapy. This article will review the principles important in the treatment of pneumonia and will cover in detail the evaluation and treatment of the parapneumonic effusion and empyema. In particular, the special problems of the trauma patient with regard to pulmonary contusion and hemopneumothorax will be discussed. Lastly, the recognition and treatment of lung abscesses and necrotizing pneumonia will be reviewed.
PREVENTION OF COMPLICATIONS The avoidance of recurrence or complications of pneumonia necessitates adequate initial treatment. The basic principles in the treatment of pneumonia include correct diagnosis, proper usage of antibiotics, and adjunctive therapies that improve drainage and encourage complete expansion of the lung. True recurrent pneumonias resulting from the same microbe are rare and more likely represent incomplete resolution or failure of initial treatment. Appropriate antimicrobial chemotherapy of pneumonia and adequate mechanical treatment are the cornerstones in preventing recurrence and complications. Despite the surfeit of information published on the diagnosis of pneumonia, there remains no gold standard. Positive sputum Gram stain and culture in a patient with fever, leukocytosis, and infiltrate generally prompt the diagnosis and treatment of pneumonia in the surgical patient. Knowledge of microorganisms and their antibiotic sensitivity profiles endemic to the institution, and in particular the critical care units, assists in making rational empiric choices. Spain et al3 recently identified Haemophilus, Staphylococcus aureus, Streptococcus, Enterobacter, Pseudomonas, and Escherichia coli as the most common organisms isolated from surgical intensive care unit (ICU) patients with pneumonia.3 Further, Pseudomonas and methicillin-resistant S. aureus (MRSA) seem to predominate in late and recurrent infections. Multiple studies comparing antibiotic efficacy have yielded varying results. Joshi et al4 reported an advantage to piperacillin/tazobactam over ceftazidime in hospitalacquired pneumonia, but concern has been raised regarding 0002-9610/00/$–see front matter PII S0002-9610(00)00323-8
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the comparability of the two treatment groups. Multiple studies in the 1980s comparing -lactam antibiotics with aminoglycosides found improved efficacy with the  lactams.5 More recent trials comparing monotherapy with combination therapy have also yielded mixed results.5,6 In general, clinical outcome is similarly efficacious, given appropriate antimicrobial therapy. Complete resolution of pneumonia and prevention of recurrence after treatment requires additional measures to provide pulmonary hygiene and allow complete expansion of the lung. In the conscious postoperative or trauma patient, adequate analgesia is absolutely essential. The value of epidural anesthesia in the management of chest trauma is well described.7 Additionally, the use of patientcontrolled analgesia or long-acting oral narcotics is extremely useful in pain control to encourage the patient to ambulate if possible, breathe deeply, and therefore prevent segmental atelectasis. Appropriate analgesia clearly improves the patient’s ability to participate in pulmonary physiotherapy. Management of airway secretions is essential. Routine closed-system suctioning by the nursing and respiratory therapy staff is key in achieving adequate drainage. Several studies have demonstrated the efficacy of periodic bronchoscopy in clearing the airways and improving gas exchange as well as radiographic evidence of lobar atelectasis. Additionally, Shennib and Ghassan8 describe a method by which atelectatic lung can be reexpanded by room air insufflation through the bronchoscope. In this way collapsed segments can be specifically treated. Other less invasive means of improving alveolar expansion have been advocated. Chest physiotherapy is extremely effective, and some studies have suggested equal efficacy to bronchoscopic suctioning. Postural drainage and the use of rotational beds have been extensively studied.9 Pape et al10 found kinetic positioning to be a helpful adjunct in preventing pulmonary complications in the multiply injured trauma patient. Multiple other studies have reported improved outcome with the use of rotational beds, particularly in the neurologically impaired patient. In the mechanically ventilated patient with pneumonia, choice of airway may also affect clinical course. It has been proposed that early tracheostomy after major injury improves the ability to handle pulmonary secretions and provides for better oral hygiene.11 Rodriguez et al12 reported decreased time of ventilatory dependence and subsequent decreased pneumonia with the use of early tracheostomy in the trauma patient. Additionally, prolonged orotracheal intubation may affect the swallowing reflex and lead to recurrent aspiration pneumonias after extubation. The topic remains controversial, however, as repeat studies by Sugerman et al13 failed to demonstrate a significant advantage of early tracheostomy. The American College of Chest Physicians recommends that patients requiring ventilatory support for more than 21 days undergo tracheostomy, and those requiring 10 or fewer days of support could be safely maintained with translaryngeal intubation.
ACUTE RESPIRATORY DISTRESS SYNDROME Acute respiratory distress syndrome (ARDS), described by Ashbaugh in 1967,14 may be both a complication of as 64S
well as a contributing factor to pneumonia in the ICU and trauma patient. The criteria for ARDS include acute respiratory failure, radiographic demonstration of bilateral pulmonary interstitial infiltrates, a PaO2:FiO2 ratio of 0.20, pulmonary compliance less than 30, and a pulmonary capillary wedge pressure less than 18 mm Hg. ARDS is complicated by the development of pneumonia in as many as 73% of patients by postmortem histology.15 Studies in which ARDS patients with pneumonia underwent bronchoscopic sampling revealed MRSA, Pseudomonas aeruginosa, and Enterobacteriacae as the frequent pathogens. ARDS can also be a sequella of pneumonia.16 Croce et al17 studied 178 patients with posttraumatic ARDS and reported two distinct patient populations. The early population followed hemorrhagic shock and occurred within 48 hours of admission. In the late population, 80% of the patients developed pneumonia before the clinical onset of ARDS. Bacterial infection of the alveolar airspace and destruction of the alveolar wall/capillary basement membrane often coexist in the disease entity known as acute lung injury and subsequent pulmonary failure. It is often difficult to sort out the degree of involvement of these two processes in the critically ill surgical patient, but intuitively, the presence of acute lung injury likely predisposes to the development and persistence of pneumonia.
EMPYEMA Despite advancements in antibiotic therapy and knowledge of adjunctive treatments, such complications as empyema, lung abscess, and lung necrosis continue to occur. The evaluation and treatment of the parapneumonic effusion and empyema is complex. Hippocrates, around 460 BC, made the diagnosis of empyema by auscultation of the chest together with symptoms of fever and nonproductive cough.18 He noted the natural history of empyema stating, “in pleuritic afflictions, when the disease is not purged off in 14 days, it usually results in empyema.” He further described the treatment by incision and drainage with packing of the wound. Le Clerk in France and Sharp in England described successful operative drainage in the 1700s. In the early 1800s several physicians, including Stokes, Trousseau, Hughes, and Cock, advocated the treatment by repeat thoracentesis. In 1876, Hewitt described treatment of empyema by closed pleural drainage. As knowledge of the disease and its natural history progressed, the problem of a thickened pleural peel and subsequent trapping of the lung was noted. A French surgeon, Delorme, proposed decortication in 1892, and the first successful decortication was performed by Fowler 1 year later. By the 1920s, most thoracic surgery was done under positive pressure ventilation, and delayed operation to prevent pneumothorax was an important recommendation of the empyema commission after World War I. Thoracotomy for empyema drainage developed into a lifesaving operation during World War II. Computed tomographic (CT) scanning, developed in the 1970s, assisted greatly with the diagnosis. The development of less invasive treatments, including thoracoscopy and closed drainage with fibrinolytic agents, continues to change the paradigm by which empyemas are managed. Parapneumonic effusions occur in 36% to 57% of pneumonias. If empyema develops, mortality rates as high as 19% in the overall population and
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TABLE I Complications of Pneumonia ● Persistence ● Recurrence ● Lung abscess ● ARDS (decreased compliance, hypoxia, hepatization) ● Parapneumonic (pleural) effusion ● Empyema ● Pulmonary gangrene ● Multiple organ failure ARDS ⫽ acute respiratory distress syndrome.
TABLE II Stages of Empyema 1. Stage I (first few days): Fluid is free flowing, pH ⬎7.3, glucose ⬎60 mg/dL, LDH ⬍500 IU 2. Stage II (1–2 wk): Fibrinopurulent fluid, pH ⬍7.2, glucose ⬍40 mg/dL, LDH ⬎1,000 IU 3. Stage III (After 2 wk): Organized phase, thickened pleural peel, pH ⬍7.1 LDH ⫽ lactate dehydrogenase.
TABLE III Classification of Pleural Effusion Disease Fluid Protein Glucose pH LDH
Transudate
Exudate
Heart, liver, renal failure Clear, straw colored Low Same as serum Same as serum ⬍200 IU
Infection, malignancy Turbid High Often low Low ⬎200 IU
LDH ⫽ lactate dehydrogenase Adapted from Ann Intern Med.33
reaching 40% in the debilitated, immunocompromised population have been reported.19 The natural history of empyemas has been well described. Parapneumonic effusions develop as a result of increased capillary permeability associated with inflammation. This collection is initially sterile but can become seeded by spread from contiguous infections. The stages of empyema are listed in Table II and are important to guide treatment plans.20 Several modalities are useful in the imaging of empyema. Posterior–anterior and lateral radiographs are the initial study of choice for visualizing fluid. The addition of a lateral decubitus view allows differentiation of free-flowing versus loculated collections. The CT scan can provide information regarding the size and character of the fluid collection, the thickness of the pleural peel, and determine the extent of loculations. Imaging information can also be obtained by ultrasound, which has the advantages of being portable, inexpensive, and rapid. Furthermore, fluid characteristics can be used to differentiate transudate from exudates.21 As surgeons have become more facile with this technique, its use, particularly in the ICU, will likely become more common.
Large or symptomatic fluid collections in conjunction with pneumonia should be sampled by thoracentesis. Such complications as pneumothorax and hemothorax are rare and can be further minimized by ultrasonographic guidance. The fluid should be sent for cell count, Gram stain, glucose, protein, LDH, and pH, as well as culture. The resulting information can be used to stage and classify the effusion or empyema (Tables II and III). At times, the gross appearance of the fluid may provide a diagnosis; caseous-appearing discharge occurs in tuberculosis, “anchovy paste” effusion in amebic empyema, and sulfur granules in actinomycosis. Once the diagnosis of empyema has been made, there are a number of available treatment regimens. The initial important decision is to determine whether the collection requires drainage. There is good evidence that collections smaller than 10 mm on a lateral decubitus x-ray will resorb without drainage. There is general consensus that thoracentesis results suggesting a stage II empyema and radiographic evidence of septation indicates the need for drainage. The choices for drainage include serial thoracentesis, tube thoracostomy with or without fibrinolytic therapy,
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video-assisted thoracoscopic debridement, and open surgical debridement and decortication. Serial thoracentesis, as originally advocated in the early 1800s for treatment of empyema, has a reported success rate of 11% to 25%.19 A recent study comparing daily thoracentesis plus intrapleural antibiotic instillation on a medical ward versus chest tube placement on a surgical ward suggested better outcomes and decreased complications with the serial thoracentesis.22 However, the study failed to take into account the differences between the two patient groups, and the authors caution against drawing conclusions until randomized trials are performed. Tube thoracostomy has a reported success of 35% to 39% in treating empyemas. Particularly in the early stages of empyema, chest tube placement in conjunction with systemic antibiotics can result in cure. Huang et al23 studied 121 patients with empyema, retrospectively looking for factors that would predict failure of tube thoracostomy. Fifty-three percent of the patients were successfully treated by chest tube alone. The study identified evidence of loculation and a white blood cell count of 6,400 or greater in the pleural fluid as independent factors predicting failure of tube drainage. The authors suggest that patients who fail closed drainage and have the above criteria should undergo early surgical intervention. The addition of intrapleural fibrinolytic agents to tube thoracostomy was first attempted by Tillet in 1949.24 Streptokinase was the original agent studied, but more recently urokinase has been used as well. Both work by activating plasminogen, which is converted to plasmin and subsequently degrades fibrin and clot. Although the two agents are equally efficacious, urokinase has the advantage of being less allergenic. Streptokinase is administered by instilling 250,000 IU in 100 mL of sterile saline through a chest tube and clamping for 4 to 6 hours, and may be repeated daily. Reported success rates using fibrinolytics with tube drainage range from 77% to 93%. Two randomized studies comparing streptokinase and urokinase versus intrapleural normal saline reported successful resolution with therapy of 100% and 86%, respectively.25,26 Additionally, in both the pediatric and adult population this procedure is safe and has few contraindications. In our trauma patients at University of Louisville Hospital, we have found this procedure to be no more effective than drainage alone, and many patients still require decortication or resection. When these measures fail to resolve empyema, surgical drainage and possible decortication is indicated. Earlier thoracoscopic debridements in the 1980s used nonvideo technology and met with success rates around 60%. More recent series using videoscopic-assisted techniques (VATS) report success rates of 80% to 85% when performed in the fibrinopurulent (stage II) phase of empyema.27 The patient is placed in the lateral decubitus position as for a thoracotomy and two or three trocars are placed for instrumentation. The initial trocar is placed along the site of the thoracotomy incision, should an open procedure become necessary. The debridement of the peel and reexpansion of the lung is carried out during single lung ventilation, and two chest tubes are placed under direct visualization. Typically, these may be removed within 3 days. In a recent randomized study, Wait et al 66S
demonstrated a shorter hospital stay and better efficacy comparing VATS versus fibrinolytic therapy plus closed drainage in fibrinopurulent empyema.28 Finally, VATS is extremely useful in the evacuation of retained hemothorax in the trauma patient. When performed within 10 to 14 days, VATS is usually successful in evacuating retained clot and, more important, in preventing a difficult decortication of organized adherent clot later in the clinical course. Failure of less invasive methods of drainage necessitates formal open drainage. Progression of empyema to the organizing phase (stage III) usually predicts failure of any technique short of open thoracotomy. During the organizing phase, the parietal peel can thicken to ⬎2 cm, with severe resultant deleterious effects on pulmonary function. Decortication is an effective technique, both to control the infection and to improve pulmonary function. Swoboda et al29 demonstrated an increase in perfusion of 22% to 38% after decortication. Pulmonary function continues to improve for as long as 3 years postoperatively. The principles of an adequate operation were laid out by Burford et al30: 1) the membrane overlying the visceral pleura must be removed, as well as all the fibrin and clot in the pleural space; 2) good exposure is essential; 3) the initial step is to develop a cleavage plane between the peel and the visceral pleura; 4) blunt dissection is used to remove the peel; 5) the lung must be cleaned circumferentially and decortication of the diaphragm, including the costophrenic sulcus, should be performed; 6) better results are obtained if a greater area of lung is decorticated; 7) any bronchopleural fistula must be closed; and 8) hemostasis is essential. The parietal pleura should remain undissected if stripping begins to cause excessive bleeding. Postoperatively, pain control and physiotherapy are essential to encourage complete ventilation and to manage secretions. Open decortication remains the standard by which less invasive procedures are measured. In addition to appropriate drainage of the empyema, proper use of antibiotics is essential. Pneumococci and staphylocci are the most common organisms cultured in most series. However, there is a recent trend toward gramnegative bacteria, particularly in the trauma patient, with E. coli, Pseudomonas, and Enterobacteriacae being predominant. The choice of antibiotics should reflect the most likely organism or preferably be based on culture of the pleural fluid. A recent review of the medical management of empyemas reported aztreonam, penicillins, cephalosporins, clindamycin, and fluoroquinolones as effective agents in penetrating the empyema cavity.19 Aminoglycosides do not penetrate well into the empyema and may be inactivated in the purulent mileu.
LUNG ABSCESS A less common but severe complication of pneumonia is the development of lung abscess. By far, aspiration pneumonia is the most common event leading to the development of pulmonary abscess. Anaerobes were isolated from lung abscesses in 78% in several recent studies, with species Bacteroides, peptostreptococci, and Prevotella being predominant. The diagnosis of lung abscess is best confirmed by CT scanning if there is clinical suspicion or evidence on the chest x-ray. Antibiotic therapy is the cornerstone of
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management, and efforts should be made to obtain cultures to direct appropriate treatment. The advent of penicillin marked the change from surgical to medical treatment of lung abscess in the mid 1940s. This was associated with the first and only reported decrease in mortality, which remains at 10% to 38% today. In addition to antimicrobial therapy, adequate drainage and ventilation are essential. Postural drainage, suctioning, physiotherapy, and even incentive spirometry are all important in facilitating clearance of infection. Hirshberg et al31 identified several factors that predict poor outcome in patients with lung abscesses. These include large abscess size, right lower lobe involvement, and infection with S. aureus, P. aeruginosa, and Klebsiella pneumoniae. Patients who had these factors fell into the 15% to 20% that failed medical management. Failure of antimicrobial therapy, unrelenting sepsis, and massive hemoptysis are indications for invasive treatment. Surgical drainage with rib resection has been reported. More recently, radiographically guided catheter drainage has attracted interest. Several recent studies reported clinical improvement within 48 hours in the majority of patients undergoing catheter drainage. Lobectomy, the standard procedure before the development of antibiotics, is now rarely performed and is reserved for those who are failing or worsening, despite optimal medical management. Despite the advancements in treatment, the mortality of lung abscess has remained essentially stable over the last four decades. We have found that lung abscess in the surgical or trauma patient usually develops while on antibiotics, and treatment often requires lobectomy, because the surrounding lung is fibrotic and drainage is not effective.
NECROTIZING PNEUMONIA This severe complication results from devitalization of the lung secondary to progressive infection. Causative agents are frequently Klebsiella and Pneumococcus. This disease is marked by severe sepsis and necessitates prompt drainage. Refaely and Weissberg32 describe a two-stage treatment in which the pleural space is initially drained by fenestration. After allowing the infection to clear, the gangrenous tissue is resected approximately 1 week later. This minimizes the risk of mediastinitis associated with dissecting out the hilar structures in a contaminated field. There were no deaths in the small series reported.
CONCLUSIONS The avoidance of complications from pneumonia revolves around sound principles of initial treatment. Despite the advances made this century in the diagnosis and pharmacologic treatment of pneumonia, such complications as empyema, abscesses, and gangrene continue to occur, especially in the critically ill, ventilated patient. Pneumonia is a key contributor to the morbidity and mortality of the surgical patient, and familiarity with the diagnosis and treatment of its complications is fundamental for the practicing surgeon.
REFERENCES 1. Greenway C, Embil J, Orr P, et al. Nosocomial pneumonia on general medical and surgical wards in a tertiary care hospital. Infect Control Hosp Epidemiol. 1997;18:749 –756. 2. Polk HC Jr, Heinzelmann M, Mercer-Jones MA, et al. Pneumonia in the surgical patient. Curr Probl Surg. 1997;34:117–200.
3. Spain D, Wilson M, Boaz P, et al. Haemophilus pneumonia is a common cause of early pneumonia dysfunction following trauma. Arch Surg. 1995;130:1228 –1232. 4. Joshi M, Bernstein J, Solomkin J, et al. Piperacillin/tazobactam plus tobramycin versus ceftazidime plus tobramycin for the treatment of patients with nosocomial lower respiratory tract infection. J Antimicrob Chemother. 1999;43:389 –397. 5. Shentag J, Birmingham M, Paladino J, et al. In nosocomial pneumonia, optimizing antibiotics other than aminoglycosides is a more important determinant of successful clinical outcome, and a better means of avoiding resistance. Sem Respir Infect. 1997;12:278 – 293. 6. Polk HC Jr, Livingston D, Fry D, et al. Treatment of pneumonia in mechanically ventilated trauma patients. Arch Surg. 1997;132: 1086 –1092. 7. Luchette F, Radafshar S, Kaiser R, et al. Prospective evaluation of epidural versus intrapleural catheters for analgesia in chest wall trauma. J Trauma. 1994;36:865– 869. 8. Shennib H, Ghassan B. Bronchoscopy in the intensive care unit. Chest Surg Clin North Am. 1996;6:349 –361. 9. Stoutenbeek C, Van Saene H. Nonantibiotic measures in the prevention of ventilator associated pneumonia. Sem Respir Infect. 1997;12:294 –299. 10. Pape HC, Remmers D, Weinberg A, et al. Is early kinetic positioning beneficial for pulmonary function in multiple trauma patients? Injury. 1998;29:219 –225. 11. Lesnik I, Rappaport W, Fulginiti J, et al. The role of early tracheostomy in blunt, multiple organ trauma. Am Surg. 1992;58: 346 –349. 12. Rodriguez JL, Steinberg SM, Luchetti FA, et al. Eary tracheostomy for primary airway management in the surgical critical care setting. Surgery. 1990;108:655– 659. 13. Sugerman H, Wolfe L, Pasquale M, et al. Multicenter, randomized, prospective trial of early tracheostomy. J Trauma. 1997;43: 741–747. 14. Ashbaugh D, Bigelow D, Petty T, et al. Acute respiratory distress in adults. Lancet. 1967;2:320 –323. 15. Chastre J, Trouillet J, Vuagnat A, et al. Nosocomial pneumonia in patients with acute respiratory distress syndrome. Am J Respir Crit Care Med. 1998;157:1165–1172. 16. Meduri U, Reddy R, Stanley T, et al. Pneumonia in acute respiratory distress syndrome. Am J Respir Crit Care Med. 1998;158: 870 – 875. 17. Croce M, Fabian T, Davis K, et al. Early and late acute respiratory distress syndrome: two distinct clinical entities. J Trauma. 1999;46:361–368. 18. Somers J, Faber P. Historical developments in the management of empyema. Chest Surg Clin North Am. 1996;6:403– 417. 19. Teofilo L, Lee-Chiong J, Matthay R. Current diagnostic methods and medical management of thoracic empyemas. Chest Surg Clin North Am. 1996;6:419 – 437. 20. Sahn S. Use of fibrinolytic agents in the management of complicated parapneumonic effusions and empyemas. Thorax. 1998;53:S65–S72. 21. Lee R. Radiologic evaluation and intervention for empyema thoracis. Chest Surg Clin North Am. 1996;6:439 – 459. 22. Storm H, Krasnik M, Bang K, et al. Treatment of pleural empyema secondary to pneumonia: thoracentesis regimen versus tube drainage. Thorax. 1992;47:821– 824. 23. Huang H, Chang H, Chen C, et al. Predicting factors for outcome of tube thoracostomy in complicated parapneumonic effusion or empyema. Chest. 1999;115:751–756. 24. Tillet WS, Sherry S. The effect in patients of streptococcal fibrinolysin and streptococcal deoxyribonuclease on fibrinous, purulent and sanguinous pleural effusions. J Clin Invest. 1949;28:173– 190. 25. Davies R, Zoe C, Fergus V. Randomized controlled trial of
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intrapleural streptokinase in community acquired pleural infection. Thorax. 1997;52:416 – 421. 26. Bouros D, Schiza S, Tzanakis N, et al. Intrapleural urokinase versus normal saline in the treatment of complicated parapneumonic effusions and empyemas. Am J Respir Crit Care Med. 1999;159: 37– 42. 27. Cassina P, Hauser M, Hillejan L, et al. Video assisted thoracoscopy in the treatment of pleural empyema: stage based management and outcome. J Thorac Cardiovasc Surg. 1999;117:234 –238. 28. Wait M, Sharma S, Hohn J, et al. A randomized trial of empyema therapy. Chest. 1997;111:1548 –1551. 29. Swoboda L, Laule K, Blattmann H, Hasse J. Decortication in
chronic pleural empyema: investigation of lung function based on perfusion scintigraphy. Thorac Cardiovasc Surg. 1990;38:359 –361. 30. Burford TH, Parker ER, Samson PC. Early pulmonary decortication in the treatment of posttraumatic empyema. Ann Surg. 1945;122:163–190. 31. Hirshberg B, Sklair-Levi M, Nir-Paz R, et al. Factors predicting mortality of patients with lung abscess. Chest. 1999;115:746 –750. 32. Refaely Y, Weissberg D. Gangrene of the lung: treatment in two stages. Ann Thorac Surg. 1997;64:970 –974. 33. Light R, Macgregor I, Luchsinger P. Pleural effusions: the diagnostic separation of transudates and exudates. Ann Intern Med. 1972;77:507–513.
DISCUSSION
often required later than that. In other words, if you find something you can deal with in that first week, you can often do that with minimal access. If it goes beyond that, then thoracotomy and decortication is the most valuable treatment. David H. Livingston, MD (Newark, New Jersey): Our approach to this has totally changed, especially with the early use of video-assisted thoracoscopy. However, at present we find it useful only when it is done early—the earlier, the better. If you miss that early window, it is not of much value at all later in the course.
Mark A. Malangoni, MD (Cleveland, Ohio): I think we see this somewhat less commonly than Dr. Cheadle has described. We tend to focus on CT scanning only when there is an abnormal chest x-ray and the patient scenario suggests pleural space infection. It seems you are doing more of these studies than we do. Jorge L. Rodriguez, MD (Minneapolis, Minnesota): Our experience is very much like what Dr. Cheadle has described at the University of Louisville. We find videoassisted thorascopic examination especially helpful in the first week, but we think that definitive thoracotomy is
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Nosocomial pneumonia is a leading cause of morbidity and mortality in the surgical and trauma patient. Inadequate treatment can lead to the complications of acute respiratory distress syndrome (ARDS), empyema, and lung abscess. The prevention and treatment of these complications revolve around several key principles. Complete treatment of pneumonia requires appropriate antimicrobial therapy, as well as mechanical pulmonary hygiene and proper airway management. Despite advances in treatment of pneumonia, complications arise necessitating treatment. This article reviews the treatment of ARDS, empyema, and lung abscesses. In particular, the many options for treatment of empyema are discussed in detail. Additionally, the treatment of pulmonary contusion and hemopneumothorax in the trauma patient is discussed. The understanding of sound treatment principles in the critically ill postsurgical patient helps prevent complicated or recurrent pneumonia and allows the surgeon to intervene effectively when such complications occur. Am J Surg. 2000;179 (Suppl 2A):63S– 68S. © 2000 by Excerpta Medica, Inc.
From the Department of Surgery, University of Louisville School of Medicine, the Trauma Program in Surgery, University of Louisville Hospital, and Veterans Affairs Medical Center, Louisville, Kentucky, USA. Correspondence should be addressed to William G. Cheadle, MD, Department of Surgery, School of Medicine, University of Louisville, Louisville, Kentucky 40292.
© 2000 by Excerpta Medica, Inc. All rights reserved.
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osocomial pneumonia is an important cause of morbidity and mortality in the surgical patient. It is the leading cause of death among all nosocomial infections, with a reported mortality ranging from 20% to 50%.1 In a recent monograph on pneumonia in the surgical patient, it was said that “pneumonia may well be the most common cause of death among surgical patients during the last three decades.”2 Pneumonia is clearly an important determinant in the outcome of the postsurgical and trauma patient. Persistent pneumonia can lead to several complications (Table I), including acute respiratory distress syndrome, recurrence, empyema, lung abscess, and even necrotizing pneumonia (pulmonary gangrene). The prevention of these later complications revolves around initial adequate therapy. This article will review the principles important in the treatment of pneumonia and will cover in detail the evaluation and treatment of the parapneumonic effusion and empyema. In particular, the special problems of the trauma patient with regard to pulmonary contusion and hemopneumothorax will be discussed. Lastly, the recognition and treatment of lung abscesses and necrotizing pneumonia will be reviewed.
PREVENTION OF COMPLICATIONS The avoidance of recurrence or complications of pneumonia necessitates adequate initial treatment. The basic principles in the treatment of pneumonia include correct diagnosis, proper usage of antibiotics, and adjunctive therapies that improve drainage and encourage complete expansion of the lung. True recurrent pneumonias resulting from the same microbe are rare and more likely represent incomplete resolution or failure of initial treatment. Appropriate antimicrobial chemotherapy of pneumonia and adequate mechanical treatment are the cornerstones in preventing recurrence and complications. Despite the surfeit of information published on the diagnosis of pneumonia, there remains no gold standard. Positive sputum Gram stain and culture in a patient with fever, leukocytosis, and infiltrate generally prompt the diagnosis and treatment of pneumonia in the surgical patient. Knowledge of microorganisms and their antibiotic sensitivity profiles endemic to the institution, and in particular the critical care units, assists in making rational empiric choices. Spain et al3 recently identified Haemophilus, Staphylococcus aureus, Streptococcus, Enterobacter, Pseudomonas, and Escherichia coli as the most common organisms isolated from surgical intensive care unit (ICU) patients with pneumonia.3 Further, Pseudomonas and methicillin-resistant S. aureus (MRSA) seem to predominate in late and recurrent infections. Multiple studies comparing antibiotic efficacy have yielded varying results. Joshi et al4 reported an advantage to piperacillin/tazobactam over ceftazidime in hospitalacquired pneumonia, but concern has been raised regarding 0002-9610/00/$–see front matter PII S0002-9610(00)00323-8
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the comparability of the two treatment groups. Multiple studies in the 1980s comparing -lactam antibiotics with aminoglycosides found improved efficacy with the  lactams.5 More recent trials comparing monotherapy with combination therapy have also yielded mixed results.5,6 In general, clinical outcome is similarly efficacious, given appropriate antimicrobial therapy. Complete resolution of pneumonia and prevention of recurrence after treatment requires additional measures to provide pulmonary hygiene and allow complete expansion of the lung. In the conscious postoperative or trauma patient, adequate analgesia is absolutely essential. The value of epidural anesthesia in the management of chest trauma is well described.7 Additionally, the use of patientcontrolled analgesia or long-acting oral narcotics is extremely useful in pain control to encourage the patient to ambulate if possible, breathe deeply, and therefore prevent segmental atelectasis. Appropriate analgesia clearly improves the patient’s ability to participate in pulmonary physiotherapy. Management of airway secretions is essential. Routine closed-system suctioning by the nursing and respiratory therapy staff is key in achieving adequate drainage. Several studies have demonstrated the efficacy of periodic bronchoscopy in clearing the airways and improving gas exchange as well as radiographic evidence of lobar atelectasis. Additionally, Shennib and Ghassan8 describe a method by which atelectatic lung can be reexpanded by room air insufflation through the bronchoscope. In this way collapsed segments can be specifically treated. Other less invasive means of improving alveolar expansion have been advocated. Chest physiotherapy is extremely effective, and some studies have suggested equal efficacy to bronchoscopic suctioning. Postural drainage and the use of rotational beds have been extensively studied.9 Pape et al10 found kinetic positioning to be a helpful adjunct in preventing pulmonary complications in the multiply injured trauma patient. Multiple other studies have reported improved outcome with the use of rotational beds, particularly in the neurologically impaired patient. In the mechanically ventilated patient with pneumonia, choice of airway may also affect clinical course. It has been proposed that early tracheostomy after major injury improves the ability to handle pulmonary secretions and provides for better oral hygiene.11 Rodriguez et al12 reported decreased time of ventilatory dependence and subsequent decreased pneumonia with the use of early tracheostomy in the trauma patient. Additionally, prolonged orotracheal intubation may affect the swallowing reflex and lead to recurrent aspiration pneumonias after extubation. The topic remains controversial, however, as repeat studies by Sugerman et al13 failed to demonstrate a significant advantage of early tracheostomy. The American College of Chest Physicians recommends that patients requiring ventilatory support for more than 21 days undergo tracheostomy, and those requiring 10 or fewer days of support could be safely maintained with translaryngeal intubation.
ACUTE RESPIRATORY DISTRESS SYNDROME Acute respiratory distress syndrome (ARDS), described by Ashbaugh in 1967,14 may be both a complication of as 64S
well as a contributing factor to pneumonia in the ICU and trauma patient. The criteria for ARDS include acute respiratory failure, radiographic demonstration of bilateral pulmonary interstitial infiltrates, a PaO2:FiO2 ratio of 0.20, pulmonary compliance less than 30, and a pulmonary capillary wedge pressure less than 18 mm Hg. ARDS is complicated by the development of pneumonia in as many as 73% of patients by postmortem histology.15 Studies in which ARDS patients with pneumonia underwent bronchoscopic sampling revealed MRSA, Pseudomonas aeruginosa, and Enterobacteriacae as the frequent pathogens. ARDS can also be a sequella of pneumonia.16 Croce et al17 studied 178 patients with posttraumatic ARDS and reported two distinct patient populations. The early population followed hemorrhagic shock and occurred within 48 hours of admission. In the late population, 80% of the patients developed pneumonia before the clinical onset of ARDS. Bacterial infection of the alveolar airspace and destruction of the alveolar wall/capillary basement membrane often coexist in the disease entity known as acute lung injury and subsequent pulmonary failure. It is often difficult to sort out the degree of involvement of these two processes in the critically ill surgical patient, but intuitively, the presence of acute lung injury likely predisposes to the development and persistence of pneumonia.
EMPYEMA Despite advancements in antibiotic therapy and knowledge of adjunctive treatments, such complications as empyema, lung abscess, and lung necrosis continue to occur. The evaluation and treatment of the parapneumonic effusion and empyema is complex. Hippocrates, around 460 BC, made the diagnosis of empyema by auscultation of the chest together with symptoms of fever and nonproductive cough.18 He noted the natural history of empyema stating, “in pleuritic afflictions, when the disease is not purged off in 14 days, it usually results in empyema.” He further described the treatment by incision and drainage with packing of the wound. Le Clerk in France and Sharp in England described successful operative drainage in the 1700s. In the early 1800s several physicians, including Stokes, Trousseau, Hughes, and Cock, advocated the treatment by repeat thoracentesis. In 1876, Hewitt described treatment of empyema by closed pleural drainage. As knowledge of the disease and its natural history progressed, the problem of a thickened pleural peel and subsequent trapping of the lung was noted. A French surgeon, Delorme, proposed decortication in 1892, and the first successful decortication was performed by Fowler 1 year later. By the 1920s, most thoracic surgery was done under positive pressure ventilation, and delayed operation to prevent pneumothorax was an important recommendation of the empyema commission after World War I. Thoracotomy for empyema drainage developed into a lifesaving operation during World War II. Computed tomographic (CT) scanning, developed in the 1970s, assisted greatly with the diagnosis. The development of less invasive treatments, including thoracoscopy and closed drainage with fibrinolytic agents, continues to change the paradigm by which empyemas are managed. Parapneumonic effusions occur in 36% to 57% of pneumonias. If empyema develops, mortality rates as high as 19% in the overall population and
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TABLE I Complications of Pneumonia ● Persistence ● Recurrence ● Lung abscess ● ARDS (decreased compliance, hypoxia, hepatization) ● Parapneumonic (pleural) effusion ● Empyema ● Pulmonary gangrene ● Multiple organ failure ARDS ⫽ acute respiratory distress syndrome.
TABLE II Stages of Empyema 1. Stage I (first few days): Fluid is free flowing, pH ⬎7.3, glucose ⬎60 mg/dL, LDH ⬍500 IU 2. Stage II (1–2 wk): Fibrinopurulent fluid, pH ⬍7.2, glucose ⬍40 mg/dL, LDH ⬎1,000 IU 3. Stage III (After 2 wk): Organized phase, thickened pleural peel, pH ⬍7.1 LDH ⫽ lactate dehydrogenase.
TABLE III Classification of Pleural Effusion Disease Fluid Protein Glucose pH LDH
Transudate
Exudate
Heart, liver, renal failure Clear, straw colored Low Same as serum Same as serum ⬍200 IU
Infection, malignancy Turbid High Often low Low ⬎200 IU
LDH ⫽ lactate dehydrogenase Adapted from Ann Intern Med.33
reaching 40% in the debilitated, immunocompromised population have been reported.19 The natural history of empyemas has been well described. Parapneumonic effusions develop as a result of increased capillary permeability associated with inflammation. This collection is initially sterile but can become seeded by spread from contiguous infections. The stages of empyema are listed in Table II and are important to guide treatment plans.20 Several modalities are useful in the imaging of empyema. Posterior–anterior and lateral radiographs are the initial study of choice for visualizing fluid. The addition of a lateral decubitus view allows differentiation of free-flowing versus loculated collections. The CT scan can provide information regarding the size and character of the fluid collection, the thickness of the pleural peel, and determine the extent of loculations. Imaging information can also be obtained by ultrasound, which has the advantages of being portable, inexpensive, and rapid. Furthermore, fluid characteristics can be used to differentiate transudate from exudates.21 As surgeons have become more facile with this technique, its use, particularly in the ICU, will likely become more common.
Large or symptomatic fluid collections in conjunction with pneumonia should be sampled by thoracentesis. Such complications as pneumothorax and hemothorax are rare and can be further minimized by ultrasonographic guidance. The fluid should be sent for cell count, Gram stain, glucose, protein, LDH, and pH, as well as culture. The resulting information can be used to stage and classify the effusion or empyema (Tables II and III). At times, the gross appearance of the fluid may provide a diagnosis; caseous-appearing discharge occurs in tuberculosis, “anchovy paste” effusion in amebic empyema, and sulfur granules in actinomycosis. Once the diagnosis of empyema has been made, there are a number of available treatment regimens. The initial important decision is to determine whether the collection requires drainage. There is good evidence that collections smaller than 10 mm on a lateral decubitus x-ray will resorb without drainage. There is general consensus that thoracentesis results suggesting a stage II empyema and radiographic evidence of septation indicates the need for drainage. The choices for drainage include serial thoracentesis, tube thoracostomy with or without fibrinolytic therapy,
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video-assisted thoracoscopic debridement, and open surgical debridement and decortication. Serial thoracentesis, as originally advocated in the early 1800s for treatment of empyema, has a reported success rate of 11% to 25%.19 A recent study comparing daily thoracentesis plus intrapleural antibiotic instillation on a medical ward versus chest tube placement on a surgical ward suggested better outcomes and decreased complications with the serial thoracentesis.22 However, the study failed to take into account the differences between the two patient groups, and the authors caution against drawing conclusions until randomized trials are performed. Tube thoracostomy has a reported success of 35% to 39% in treating empyemas. Particularly in the early stages of empyema, chest tube placement in conjunction with systemic antibiotics can result in cure. Huang et al23 studied 121 patients with empyema, retrospectively looking for factors that would predict failure of tube thoracostomy. Fifty-three percent of the patients were successfully treated by chest tube alone. The study identified evidence of loculation and a white blood cell count of 6,400 or greater in the pleural fluid as independent factors predicting failure of tube drainage. The authors suggest that patients who fail closed drainage and have the above criteria should undergo early surgical intervention. The addition of intrapleural fibrinolytic agents to tube thoracostomy was first attempted by Tillet in 1949.24 Streptokinase was the original agent studied, but more recently urokinase has been used as well. Both work by activating plasminogen, which is converted to plasmin and subsequently degrades fibrin and clot. Although the two agents are equally efficacious, urokinase has the advantage of being less allergenic. Streptokinase is administered by instilling 250,000 IU in 100 mL of sterile saline through a chest tube and clamping for 4 to 6 hours, and may be repeated daily. Reported success rates using fibrinolytics with tube drainage range from 77% to 93%. Two randomized studies comparing streptokinase and urokinase versus intrapleural normal saline reported successful resolution with therapy of 100% and 86%, respectively.25,26 Additionally, in both the pediatric and adult population this procedure is safe and has few contraindications. In our trauma patients at University of Louisville Hospital, we have found this procedure to be no more effective than drainage alone, and many patients still require decortication or resection. When these measures fail to resolve empyema, surgical drainage and possible decortication is indicated. Earlier thoracoscopic debridements in the 1980s used nonvideo technology and met with success rates around 60%. More recent series using videoscopic-assisted techniques (VATS) report success rates of 80% to 85% when performed in the fibrinopurulent (stage II) phase of empyema.27 The patient is placed in the lateral decubitus position as for a thoracotomy and two or three trocars are placed for instrumentation. The initial trocar is placed along the site of the thoracotomy incision, should an open procedure become necessary. The debridement of the peel and reexpansion of the lung is carried out during single lung ventilation, and two chest tubes are placed under direct visualization. Typically, these may be removed within 3 days. In a recent randomized study, Wait et al 66S
demonstrated a shorter hospital stay and better efficacy comparing VATS versus fibrinolytic therapy plus closed drainage in fibrinopurulent empyema.28 Finally, VATS is extremely useful in the evacuation of retained hemothorax in the trauma patient. When performed within 10 to 14 days, VATS is usually successful in evacuating retained clot and, more important, in preventing a difficult decortication of organized adherent clot later in the clinical course. Failure of less invasive methods of drainage necessitates formal open drainage. Progression of empyema to the organizing phase (stage III) usually predicts failure of any technique short of open thoracotomy. During the organizing phase, the parietal peel can thicken to ⬎2 cm, with severe resultant deleterious effects on pulmonary function. Decortication is an effective technique, both to control the infection and to improve pulmonary function. Swoboda et al29 demonstrated an increase in perfusion of 22% to 38% after decortication. Pulmonary function continues to improve for as long as 3 years postoperatively. The principles of an adequate operation were laid out by Burford et al30: 1) the membrane overlying the visceral pleura must be removed, as well as all the fibrin and clot in the pleural space; 2) good exposure is essential; 3) the initial step is to develop a cleavage plane between the peel and the visceral pleura; 4) blunt dissection is used to remove the peel; 5) the lung must be cleaned circumferentially and decortication of the diaphragm, including the costophrenic sulcus, should be performed; 6) better results are obtained if a greater area of lung is decorticated; 7) any bronchopleural fistula must be closed; and 8) hemostasis is essential. The parietal pleura should remain undissected if stripping begins to cause excessive bleeding. Postoperatively, pain control and physiotherapy are essential to encourage complete ventilation and to manage secretions. Open decortication remains the standard by which less invasive procedures are measured. In addition to appropriate drainage of the empyema, proper use of antibiotics is essential. Pneumococci and staphylocci are the most common organisms cultured in most series. However, there is a recent trend toward gramnegative bacteria, particularly in the trauma patient, with E. coli, Pseudomonas, and Enterobacteriacae being predominant. The choice of antibiotics should reflect the most likely organism or preferably be based on culture of the pleural fluid. A recent review of the medical management of empyemas reported aztreonam, penicillins, cephalosporins, clindamycin, and fluoroquinolones as effective agents in penetrating the empyema cavity.19 Aminoglycosides do not penetrate well into the empyema and may be inactivated in the purulent mileu.
LUNG ABSCESS A less common but severe complication of pneumonia is the development of lung abscess. By far, aspiration pneumonia is the most common event leading to the development of pulmonary abscess. Anaerobes were isolated from lung abscesses in 78% in several recent studies, with species Bacteroides, peptostreptococci, and Prevotella being predominant. The diagnosis of lung abscess is best confirmed by CT scanning if there is clinical suspicion or evidence on the chest x-ray. Antibiotic therapy is the cornerstone of
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management, and efforts should be made to obtain cultures to direct appropriate treatment. The advent of penicillin marked the change from surgical to medical treatment of lung abscess in the mid 1940s. This was associated with the first and only reported decrease in mortality, which remains at 10% to 38% today. In addition to antimicrobial therapy, adequate drainage and ventilation are essential. Postural drainage, suctioning, physiotherapy, and even incentive spirometry are all important in facilitating clearance of infection. Hirshberg et al31 identified several factors that predict poor outcome in patients with lung abscesses. These include large abscess size, right lower lobe involvement, and infection with S. aureus, P. aeruginosa, and Klebsiella pneumoniae. Patients who had these factors fell into the 15% to 20% that failed medical management. Failure of antimicrobial therapy, unrelenting sepsis, and massive hemoptysis are indications for invasive treatment. Surgical drainage with rib resection has been reported. More recently, radiographically guided catheter drainage has attracted interest. Several recent studies reported clinical improvement within 48 hours in the majority of patients undergoing catheter drainage. Lobectomy, the standard procedure before the development of antibiotics, is now rarely performed and is reserved for those who are failing or worsening, despite optimal medical management. Despite the advancements in treatment, the mortality of lung abscess has remained essentially stable over the last four decades. We have found that lung abscess in the surgical or trauma patient usually develops while on antibiotics, and treatment often requires lobectomy, because the surrounding lung is fibrotic and drainage is not effective.
NECROTIZING PNEUMONIA This severe complication results from devitalization of the lung secondary to progressive infection. Causative agents are frequently Klebsiella and Pneumococcus. This disease is marked by severe sepsis and necessitates prompt drainage. Refaely and Weissberg32 describe a two-stage treatment in which the pleural space is initially drained by fenestration. After allowing the infection to clear, the gangrenous tissue is resected approximately 1 week later. This minimizes the risk of mediastinitis associated with dissecting out the hilar structures in a contaminated field. There were no deaths in the small series reported.
CONCLUSIONS The avoidance of complications from pneumonia revolves around sound principles of initial treatment. Despite the advances made this century in the diagnosis and pharmacologic treatment of pneumonia, such complications as empyema, abscesses, and gangrene continue to occur, especially in the critically ill, ventilated patient. Pneumonia is a key contributor to the morbidity and mortality of the surgical patient, and familiarity with the diagnosis and treatment of its complications is fundamental for the practicing surgeon.
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3. Spain D, Wilson M, Boaz P, et al. Haemophilus pneumonia is a common cause of early pneumonia dysfunction following trauma. Arch Surg. 1995;130:1228 –1232. 4. Joshi M, Bernstein J, Solomkin J, et al. Piperacillin/tazobactam plus tobramycin versus ceftazidime plus tobramycin for the treatment of patients with nosocomial lower respiratory tract infection. J Antimicrob Chemother. 1999;43:389 –397. 5. Shentag J, Birmingham M, Paladino J, et al. In nosocomial pneumonia, optimizing antibiotics other than aminoglycosides is a more important determinant of successful clinical outcome, and a better means of avoiding resistance. Sem Respir Infect. 1997;12:278 – 293. 6. Polk HC Jr, Livingston D, Fry D, et al. Treatment of pneumonia in mechanically ventilated trauma patients. Arch Surg. 1997;132: 1086 –1092. 7. Luchette F, Radafshar S, Kaiser R, et al. Prospective evaluation of epidural versus intrapleural catheters for analgesia in chest wall trauma. J Trauma. 1994;36:865– 869. 8. Shennib H, Ghassan B. Bronchoscopy in the intensive care unit. Chest Surg Clin North Am. 1996;6:349 –361. 9. Stoutenbeek C, Van Saene H. Nonantibiotic measures in the prevention of ventilator associated pneumonia. Sem Respir Infect. 1997;12:294 –299. 10. Pape HC, Remmers D, Weinberg A, et al. Is early kinetic positioning beneficial for pulmonary function in multiple trauma patients? Injury. 1998;29:219 –225. 11. Lesnik I, Rappaport W, Fulginiti J, et al. The role of early tracheostomy in blunt, multiple organ trauma. Am Surg. 1992;58: 346 –349. 12. Rodriguez JL, Steinberg SM, Luchetti FA, et al. Eary tracheostomy for primary airway management in the surgical critical care setting. Surgery. 1990;108:655– 659. 13. Sugerman H, Wolfe L, Pasquale M, et al. Multicenter, randomized, prospective trial of early tracheostomy. J Trauma. 1997;43: 741–747. 14. Ashbaugh D, Bigelow D, Petty T, et al. Acute respiratory distress in adults. Lancet. 1967;2:320 –323. 15. Chastre J, Trouillet J, Vuagnat A, et al. Nosocomial pneumonia in patients with acute respiratory distress syndrome. Am J Respir Crit Care Med. 1998;157:1165–1172. 16. Meduri U, Reddy R, Stanley T, et al. Pneumonia in acute respiratory distress syndrome. Am J Respir Crit Care Med. 1998;158: 870 – 875. 17. Croce M, Fabian T, Davis K, et al. Early and late acute respiratory distress syndrome: two distinct clinical entities. J Trauma. 1999;46:361–368. 18. Somers J, Faber P. Historical developments in the management of empyema. Chest Surg Clin North Am. 1996;6:403– 417. 19. Teofilo L, Lee-Chiong J, Matthay R. Current diagnostic methods and medical management of thoracic empyemas. Chest Surg Clin North Am. 1996;6:419 – 437. 20. Sahn S. Use of fibrinolytic agents in the management of complicated parapneumonic effusions and empyemas. Thorax. 1998;53:S65–S72. 21. Lee R. Radiologic evaluation and intervention for empyema thoracis. Chest Surg Clin North Am. 1996;6:439 – 459. 22. Storm H, Krasnik M, Bang K, et al. Treatment of pleural empyema secondary to pneumonia: thoracentesis regimen versus tube drainage. Thorax. 1992;47:821– 824. 23. Huang H, Chang H, Chen C, et al. Predicting factors for outcome of tube thoracostomy in complicated parapneumonic effusion or empyema. Chest. 1999;115:751–756. 24. Tillet WS, Sherry S. The effect in patients of streptococcal fibrinolysin and streptococcal deoxyribonuclease on fibrinous, purulent and sanguinous pleural effusions. J Clin Invest. 1949;28:173– 190. 25. Davies R, Zoe C, Fergus V. Randomized controlled trial of
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intrapleural streptokinase in community acquired pleural infection. Thorax. 1997;52:416 – 421. 26. Bouros D, Schiza S, Tzanakis N, et al. Intrapleural urokinase versus normal saline in the treatment of complicated parapneumonic effusions and empyemas. Am J Respir Crit Care Med. 1999;159: 37– 42. 27. Cassina P, Hauser M, Hillejan L, et al. Video assisted thoracoscopy in the treatment of pleural empyema: stage based management and outcome. J Thorac Cardiovasc Surg. 1999;117:234 –238. 28. Wait M, Sharma S, Hohn J, et al. A randomized trial of empyema therapy. Chest. 1997;111:1548 –1551. 29. Swoboda L, Laule K, Blattmann H, Hasse J. Decortication in
chronic pleural empyema: investigation of lung function based on perfusion scintigraphy. Thorac Cardiovasc Surg. 1990;38:359 –361. 30. Burford TH, Parker ER, Samson PC. Early pulmonary decortication in the treatment of posttraumatic empyema. Ann Surg. 1945;122:163–190. 31. Hirshberg B, Sklair-Levi M, Nir-Paz R, et al. Factors predicting mortality of patients with lung abscess. Chest. 1999;115:746 –750. 32. Refaely Y, Weissberg D. Gangrene of the lung: treatment in two stages. Ann Thorac Surg. 1997;64:970 –974. 33. Light R, Macgregor I, Luchsinger P. Pleural effusions: the diagnostic separation of transudates and exudates. Ann Intern Med. 1972;77:507–513.
DISCUSSION
often required later than that. In other words, if you find something you can deal with in that first week, you can often do that with minimal access. If it goes beyond that, then thoracotomy and decortication is the most valuable treatment. David H. Livingston, MD (Newark, New Jersey): Our approach to this has totally changed, especially with the early use of video-assisted thoracoscopy. However, at present we find it useful only when it is done early—the earlier, the better. If you miss that early window, it is not of much value at all later in the course.
Mark A. Malangoni, MD (Cleveland, Ohio): I think we see this somewhat less commonly than Dr. Cheadle has described. We tend to focus on CT scanning only when there is an abnormal chest x-ray and the patient scenario suggests pleural space infection. It seems you are doing more of these studies than we do. Jorge L. Rodriguez, MD (Minneapolis, Minnesota): Our experience is very much like what Dr. Cheadle has described at the University of Louisville. We find videoassisted thorascopic examination especially helpful in the first week, but we think that definitive thoracotomy is
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