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Treatment of Empyema
Medical Clinics of North America January, 1938. Chicago Number
CLINIC OF DR. WILLARD VAN HAZEL ST. LUKE'S HOSPITAL
TREATMENT OF EMPYEMA ANY symposium on pneumonia would be incomplete without a discussion of one of its frequent complications; namely, empyema. Too often it manifests itself as an anticlimax, just at a time when the hopes of recovery have been warranted. Or, on the other hand, its signs may merge into those of the primary illness and thus make its detection even more difficult. The value of serum in suitable cases and of oxygen therapy in others appears to be established but it appears that the incidence of a complicating empyema unfortunately has not been reduced by these measures. Ordinarily it does not come within the province of the surgeon to treat pneumonia though he may see it as a postoperative complication or following cases of trauma. Because empyema is a complication rather than a primary disease he does not often observe its development. Though the diagnosis therefore may fall to the one who has been responsible for the care during the pneumonia, it is well to emphasize certain features which are found in proved cases of empyema before drainage. One may become suspicious of the development of an empyema when the fever having subsided rises again. This is more often true in the pneumococcic type forming more slowly and giving evidence of its presence when the signs of the pneumonic process are subsiding. In the streptococcic form it forms simultaneously with the process within the lung. In infants the pneumococcic type may be synpneumonic. During an epidemic of influenza the streptococcic type may predominate though ordinarily the pneumococcic type is more common. In the patient with a large accumulation of pus the physical signs of flatness and absent breath sounds may be sufficient, coupled with the clinical course, to suspect an empyema. A smaller pocket, however, may escape detection because of a minimum of findings. The presence of breath
69
70
WILLARD VAN HAZEL
sounds in children and some adults, over fairly large pockets can easily be misleading. A searching examination may go unrewarded when the accumulation of pus lies along the mediastinum or arises in an interlobar space. An x-ray plate may be the only way of detecting such a collection. However, although an x-ray plate is not necessary for the establishment of a diagnosis in many instances, nevertheless, when such a plate can be secured without too much effort on the part of the patient it should not be omitted. Its greatest value lies in having a record for comparison after drainage to note the progress in the obliteration of the cavity. If for any reason the patient's response to drainage is not what is expected a new x-ray film may show the cause. Two or more distinct pockets are sometimes seen as well as an occasional bilateral involvement. For these reasons the x-ray where available may be invaluable. The absolute diagnosis is made by the aspiration of pus with a needle. This in most instances is readily accomplished. Sometimes, however, particularly in relatively small collections several attempts may be necessary for localization. One should always introduce a needle of moderate caliber at first and be conscious of the fact that injury to the lung can occur. Where several aspirations are carried out at varying intervals or successive days one may be disappointed at not obtaining pus though the same site is chosen. This is more likely to occur where the original aspiration was near the periphery of the pocket so that now with its reduction in size the lung may have reexpanded and become adherent to the chest wall at that site. On the other hand, anyone with experience knows that sometimes no pus is obtained and the explanation is not obvious because an operation reveals pus and one is at a loss to explain why the needle did not reveal it when a reasonably large pocket exists. An examination of purulent material removed should be made routinely. A smear may be sufficient to show chains of streptococci or pneumococci. Cultures likewise can be taken and aerobic and anaerobic media should be used. Anaerobic organisms frequently render the pus foul. A sterile culture should lead one to suspect a tuberculous basis for the empyema. Certain physiologic considerations must be constantly borne
TREAT MENT OF EMPYE MA
71
in mind in the treatm ent of empyema. It has been shown that the mediastinum cannot be regarded as a fixed structure, this being particu larly true in infants and children. If this be true an open pneumothorax may embarrass respiration by a shift of the mediastinal structu res and encroachment on the capacity of the good lung. This will occur where no adhesions exist between the lung and the chest wall. In pneumococcic infections there is laid down considerable fibrin, the development of the empyema is relatively slow and the pus is thick, all tending to favor adhesions between the parieta l and visceral pleura. In the streptococcic infection the opposite is true, the empyema occurs simultaneously with the pneumonia, it develops more rapidly, and there is little fibrin early and the pus is seropurulent. It is in this type that an open pneumothorax may allow the lung to collapse, a shift of the mediastinum may occur and with the toxemia of the pneumonia still present cause too great a load on the respiratory and circulatory mechanisms. This danger is obviated of course if sufficient time is allowed for the pus to become thick, at which time adhesions are usually present, or by the avoidance of an open pneumothorax. There are two objectives in the treatm ent of an empyema. The first is the establishment of adequate drainage, the other is the obliteration of the cavity. If these are successfully accomplished chronicity and recurrence will be avoided. Adequate drainage is usually accomplished by the open or closed method. Equall y good results are obtained by each method provided that the fundamental principles in the treatment of empyema are observed. Of these principles perhaps the most important one is to avoid an open pneumothorax in an early case of streptococcic empyema or in a very sick patient of any age. A useful procedure in any desperately ill patient is the simple aspiration of some of the pus as the initial procedure. Definite improvement often follows making the drainage operation safer when it is carried out. Occasionally in small pockets aspiration may suffice to bring about a good result making drainage unnecessary. However, to use aspiration as a method to establish adequate drainage will lead to many disappointments. If closed drainage is employed slight suction by any available means may exert a favorable influence toward obliteration of the cavity by the expansion of the lung. Too
~LLARD
VAN HAZEL
great a suction may cause the lung to fall against the tube and pockets to form which can give a great deal of trouble. Irrigation of the cavity with saline or chlorine solution helps to control the infection and wash out the fibrin, thus giving greater expansibility to the lung and hastening the obliteration of the cavity. Small bronchial fistulae usually close spontaneously. Where large ones are present the patient usually raises much of the pleural contents through the bronchial tree. This type is probably better treated by open drainage. The fistula can then be watched and treated if it persists. When open drainage is used it must only be done after adhesions of the parietal and visceral pleura exists. The resection of a small piece of one or two ribs will always provide adequate drainage. The failures in this method are not due to the method but to failure to maintain adequate drainage. The wound will soon fall together unless attempt is made to keep it open until the lung expands and thereby obliterates the cavity. Case I.-This x-ray (Fig. 10) is that of a baby three years of age. The haziness at the left base shows some aeration of the lung field immediately above the diaphragm. The suspected area is not very dense. This child had a lobar pneumonia on the left side. The fever had not subsided at any time except for the slight daily fluctuations. The two days before I first saw her, there was a slight cyanosis present, a troublesome cough and constant fever. The child had been ill for two weeks. Aspiration of pus over the duIJ area posteriorIy revealed pus and 60 cc. were removed. Examination of. the pus revealed pneumococci and this case illustrates how the empyema developed without any cessation in the febrile course as usuaIJy seen in pneumococcic empyema in adults. The following day only a small amount of pus could be obtained by use of the needle and there was no improvement in the condition of the patient except slightly less cough. Closed drainage was then instituted by introducing a catheter through a trocar and irrigations with Dakin's solution was carried out every two hours. The cavity which held more than 150 cc. at the time drainage was established reduced in size rapidly and in two weeks no more solution would enter the tube. The reduction was gradual and the two objectives were accomplished, adequate drainage maintained and obliteration of the cavity. It is a gratifying result in a small child by means of closed drainage which did not require any further surgery because no residual cavity remained unobliterated. Case n.-This lady is fifty-five years of age. She had a cold which later became severe enough to cause her to go to bed. High fever followed up to 104 0 F. She was cared for at home where adequate nursing care and an oxygen tent were employed. At the end of ten days she appeared to be better
73
TREATMENT OF EMPYEMA
for several days when her toxemia which had not at any time subsided was increased. She was irrational at times and took very little nourishment by mouth. There was evidence that the consolidation in the right lower lobe was undergoing resolution. No new involvement could be detected on physical examination. She was then moved to a hospital where an x-ray film (Fig. 11) revealed a large circumscribed density on the right side in midfield. The upper lung field was clear as was the costophrenic angle and adjacent area. Localization of this collection by x-ray allowed for even more careful examination of the chest but the findings were similar. Breath sounds were slightly suppressed but present throughout . the right side, and no dulness could be elicited. By the absence of peripheral signs with the positive x-ray findings in the location of the interlobar fissure, an interlobar empyema is suggested.
Fig. 10.
Fig. 11.
This condition is really an abscess and is best treated as such. Aspiration with a needle may reveal pus but this procedure is not without danger because if no adhesions exist a free pleural space may be infected which usually proves a very serious complication in an already very toxic patient. An open operation is therefore indicated in this condition. If a point of tenderness can be found on the chest wall it is strong presumptive evidence of involvement of the pleura at that point and the collection lies most superficial at this point. A midaxillary incision is usually suited for exploration with a needle in any direction. provided the adhesions are found to be present. This was done in this patient, pus aspirated and drainage established. Tubes were inserted to facilitate drainage, the cavity quickly reduced in size with the evacuation of the pus, the fever subsided gradually in a week. The tubes were gradually shortened as the cavity obliterated itself.
74
WILLARD VAN HAZEL
Case IlL-This twenty-year-old girl came to our dispensary two months ago. At that time she had a draining sinus in her right side which had been present for six months. She stated that she had pneumonia followed by empyema which required drainage. However, a careful history revealed that she had a cough, pain in her chest which was aggravated by breathing, fever, nausea and vomiting which required her to go to bed where she remained for one month prior to calling a physician. At this time a diagnosis of empyema was made and a rib resection for drainage was done. There had been little change in her condition in the subsequent six months when she was seen here. She was underweight and anemic with a corresponding loss of strength. Because of her history one must consider a pleurisy with effusion. Because of the cough tuberculosis or empyema with a bronchial fistula should be considered in the diagnosis. The first sputum examination revealed tubercle bacilli. This case brings out many instructive points. A careful history as to onset may be of great help. The typical severe pleurisy with a cough could occur in pneumonia but is certainly suggestive of pleurisy with effusion. Another point is the ever-present value of a sputum examination which if negative may still not rule out tuberculosis. The examination of the pus is another point which in this case might have revealed a sterile pus on culture. This is regarded as tuberculosis and open drainage in such cases is contraindicated because it allows a mixed infection to occur and often times the lung to collapse because of the absence of adhesions in tuberculous infection of the pleura even though having been present for some time. The x-ray showed no parenchymal change but the positive sputum indicated its presence. It was assumed, therefore, that the disease in the lung was a basal lesion obscured by the haziness of the lower lung field by the infection of the pleural space. Consequently a phrenic paralysis was first done which immediately controlled the cough and sputum. The cavity was frequently washed with Dakin's solution and thus kept clean. No great attempt was made to reexpand the underlying lung because the active pulmonary disease required rest. Consequently. after some improvement segments of 3 ribs overlying the cavity were removed and a portion of the thickened pleura was cut away. Microscopically it showed tuberculous granulations. The wound was left open to granulate in from its base. Thus the cavity was obliterated by a partial collapse of the chest wall overlying it which at the same time added its beneficent effect along with the diaphragmatic paralysis to the diseased lung tissue. This girl has lost all signs of her pulmonary disease and as you can see, will soon have a wound which will close from the base thereby obliterating the pleural space and preventing recurrence.
The best results in the treatment of empyema will come from a careful study of each individual case. Strict adherence to fundamentals rather than methods will be well rewarded with a low mortality rate, infrequent recurrence and rare cases of chronicity.
CLINIC OF DR. WILLARD VAN HAZEL ST. LUKE'S HOSPITAL
TREATMENT OF EMPYEMA ANY symposium on pneumonia would be incomplete without a discussion of one of its frequent complications; namely, empyema. Too often it manifests itself as an anticlimax, just at a time when the hopes of recovery have been warranted. Or, on the other hand, its signs may merge into those of the primary illness and thus make its detection even more difficult. The value of serum in suitable cases and of oxygen therapy in others appears to be established but it appears that the incidence of a complicating empyema unfortunately has not been reduced by these measures. Ordinarily it does not come within the province of the surgeon to treat pneumonia though he may see it as a postoperative complication or following cases of trauma. Because empyema is a complication rather than a primary disease he does not often observe its development. Though the diagnosis therefore may fall to the one who has been responsible for the care during the pneumonia, it is well to emphasize certain features which are found in proved cases of empyema before drainage. One may become suspicious of the development of an empyema when the fever having subsided rises again. This is more often true in the pneumococcic type forming more slowly and giving evidence of its presence when the signs of the pneumonic process are subsiding. In the streptococcic form it forms simultaneously with the process within the lung. In infants the pneumococcic type may be synpneumonic. During an epidemic of influenza the streptococcic type may predominate though ordinarily the pneumococcic type is more common. In the patient with a large accumulation of pus the physical signs of flatness and absent breath sounds may be sufficient, coupled with the clinical course, to suspect an empyema. A smaller pocket, however, may escape detection because of a minimum of findings. The presence of breath
69
70
WILLARD VAN HAZEL
sounds in children and some adults, over fairly large pockets can easily be misleading. A searching examination may go unrewarded when the accumulation of pus lies along the mediastinum or arises in an interlobar space. An x-ray plate may be the only way of detecting such a collection. However, although an x-ray plate is not necessary for the establishment of a diagnosis in many instances, nevertheless, when such a plate can be secured without too much effort on the part of the patient it should not be omitted. Its greatest value lies in having a record for comparison after drainage to note the progress in the obliteration of the cavity. If for any reason the patient's response to drainage is not what is expected a new x-ray film may show the cause. Two or more distinct pockets are sometimes seen as well as an occasional bilateral involvement. For these reasons the x-ray where available may be invaluable. The absolute diagnosis is made by the aspiration of pus with a needle. This in most instances is readily accomplished. Sometimes, however, particularly in relatively small collections several attempts may be necessary for localization. One should always introduce a needle of moderate caliber at first and be conscious of the fact that injury to the lung can occur. Where several aspirations are carried out at varying intervals or successive days one may be disappointed at not obtaining pus though the same site is chosen. This is more likely to occur where the original aspiration was near the periphery of the pocket so that now with its reduction in size the lung may have reexpanded and become adherent to the chest wall at that site. On the other hand, anyone with experience knows that sometimes no pus is obtained and the explanation is not obvious because an operation reveals pus and one is at a loss to explain why the needle did not reveal it when a reasonably large pocket exists. An examination of purulent material removed should be made routinely. A smear may be sufficient to show chains of streptococci or pneumococci. Cultures likewise can be taken and aerobic and anaerobic media should be used. Anaerobic organisms frequently render the pus foul. A sterile culture should lead one to suspect a tuberculous basis for the empyema. Certain physiologic considerations must be constantly borne
TREAT MENT OF EMPYE MA
71
in mind in the treatm ent of empyema. It has been shown that the mediastinum cannot be regarded as a fixed structure, this being particu larly true in infants and children. If this be true an open pneumothorax may embarrass respiration by a shift of the mediastinal structu res and encroachment on the capacity of the good lung. This will occur where no adhesions exist between the lung and the chest wall. In pneumococcic infections there is laid down considerable fibrin, the development of the empyema is relatively slow and the pus is thick, all tending to favor adhesions between the parieta l and visceral pleura. In the streptococcic infection the opposite is true, the empyema occurs simultaneously with the pneumonia, it develops more rapidly, and there is little fibrin early and the pus is seropurulent. It is in this type that an open pneumothorax may allow the lung to collapse, a shift of the mediastinum may occur and with the toxemia of the pneumonia still present cause too great a load on the respiratory and circulatory mechanisms. This danger is obviated of course if sufficient time is allowed for the pus to become thick, at which time adhesions are usually present, or by the avoidance of an open pneumothorax. There are two objectives in the treatm ent of an empyema. The first is the establishment of adequate drainage, the other is the obliteration of the cavity. If these are successfully accomplished chronicity and recurrence will be avoided. Adequate drainage is usually accomplished by the open or closed method. Equall y good results are obtained by each method provided that the fundamental principles in the treatment of empyema are observed. Of these principles perhaps the most important one is to avoid an open pneumothorax in an early case of streptococcic empyema or in a very sick patient of any age. A useful procedure in any desperately ill patient is the simple aspiration of some of the pus as the initial procedure. Definite improvement often follows making the drainage operation safer when it is carried out. Occasionally in small pockets aspiration may suffice to bring about a good result making drainage unnecessary. However, to use aspiration as a method to establish adequate drainage will lead to many disappointments. If closed drainage is employed slight suction by any available means may exert a favorable influence toward obliteration of the cavity by the expansion of the lung. Too
~LLARD
VAN HAZEL
great a suction may cause the lung to fall against the tube and pockets to form which can give a great deal of trouble. Irrigation of the cavity with saline or chlorine solution helps to control the infection and wash out the fibrin, thus giving greater expansibility to the lung and hastening the obliteration of the cavity. Small bronchial fistulae usually close spontaneously. Where large ones are present the patient usually raises much of the pleural contents through the bronchial tree. This type is probably better treated by open drainage. The fistula can then be watched and treated if it persists. When open drainage is used it must only be done after adhesions of the parietal and visceral pleura exists. The resection of a small piece of one or two ribs will always provide adequate drainage. The failures in this method are not due to the method but to failure to maintain adequate drainage. The wound will soon fall together unless attempt is made to keep it open until the lung expands and thereby obliterates the cavity. Case I.-This x-ray (Fig. 10) is that of a baby three years of age. The haziness at the left base shows some aeration of the lung field immediately above the diaphragm. The suspected area is not very dense. This child had a lobar pneumonia on the left side. The fever had not subsided at any time except for the slight daily fluctuations. The two days before I first saw her, there was a slight cyanosis present, a troublesome cough and constant fever. The child had been ill for two weeks. Aspiration of pus over the duIJ area posteriorIy revealed pus and 60 cc. were removed. Examination of. the pus revealed pneumococci and this case illustrates how the empyema developed without any cessation in the febrile course as usuaIJy seen in pneumococcic empyema in adults. The following day only a small amount of pus could be obtained by use of the needle and there was no improvement in the condition of the patient except slightly less cough. Closed drainage was then instituted by introducing a catheter through a trocar and irrigations with Dakin's solution was carried out every two hours. The cavity which held more than 150 cc. at the time drainage was established reduced in size rapidly and in two weeks no more solution would enter the tube. The reduction was gradual and the two objectives were accomplished, adequate drainage maintained and obliteration of the cavity. It is a gratifying result in a small child by means of closed drainage which did not require any further surgery because no residual cavity remained unobliterated. Case n.-This lady is fifty-five years of age. She had a cold which later became severe enough to cause her to go to bed. High fever followed up to 104 0 F. She was cared for at home where adequate nursing care and an oxygen tent were employed. At the end of ten days she appeared to be better
73
TREATMENT OF EMPYEMA
for several days when her toxemia which had not at any time subsided was increased. She was irrational at times and took very little nourishment by mouth. There was evidence that the consolidation in the right lower lobe was undergoing resolution. No new involvement could be detected on physical examination. She was then moved to a hospital where an x-ray film (Fig. 11) revealed a large circumscribed density on the right side in midfield. The upper lung field was clear as was the costophrenic angle and adjacent area. Localization of this collection by x-ray allowed for even more careful examination of the chest but the findings were similar. Breath sounds were slightly suppressed but present throughout . the right side, and no dulness could be elicited. By the absence of peripheral signs with the positive x-ray findings in the location of the interlobar fissure, an interlobar empyema is suggested.
Fig. 10.
Fig. 11.
This condition is really an abscess and is best treated as such. Aspiration with a needle may reveal pus but this procedure is not without danger because if no adhesions exist a free pleural space may be infected which usually proves a very serious complication in an already very toxic patient. An open operation is therefore indicated in this condition. If a point of tenderness can be found on the chest wall it is strong presumptive evidence of involvement of the pleura at that point and the collection lies most superficial at this point. A midaxillary incision is usually suited for exploration with a needle in any direction. provided the adhesions are found to be present. This was done in this patient, pus aspirated and drainage established. Tubes were inserted to facilitate drainage, the cavity quickly reduced in size with the evacuation of the pus, the fever subsided gradually in a week. The tubes were gradually shortened as the cavity obliterated itself.
74
WILLARD VAN HAZEL
Case IlL-This twenty-year-old girl came to our dispensary two months ago. At that time she had a draining sinus in her right side which had been present for six months. She stated that she had pneumonia followed by empyema which required drainage. However, a careful history revealed that she had a cough, pain in her chest which was aggravated by breathing, fever, nausea and vomiting which required her to go to bed where she remained for one month prior to calling a physician. At this time a diagnosis of empyema was made and a rib resection for drainage was done. There had been little change in her condition in the subsequent six months when she was seen here. She was underweight and anemic with a corresponding loss of strength. Because of her history one must consider a pleurisy with effusion. Because of the cough tuberculosis or empyema with a bronchial fistula should be considered in the diagnosis. The first sputum examination revealed tubercle bacilli. This case brings out many instructive points. A careful history as to onset may be of great help. The typical severe pleurisy with a cough could occur in pneumonia but is certainly suggestive of pleurisy with effusion. Another point is the ever-present value of a sputum examination which if negative may still not rule out tuberculosis. The examination of the pus is another point which in this case might have revealed a sterile pus on culture. This is regarded as tuberculosis and open drainage in such cases is contraindicated because it allows a mixed infection to occur and often times the lung to collapse because of the absence of adhesions in tuberculous infection of the pleura even though having been present for some time. The x-ray showed no parenchymal change but the positive sputum indicated its presence. It was assumed, therefore, that the disease in the lung was a basal lesion obscured by the haziness of the lower lung field by the infection of the pleural space. Consequently a phrenic paralysis was first done which immediately controlled the cough and sputum. The cavity was frequently washed with Dakin's solution and thus kept clean. No great attempt was made to reexpand the underlying lung because the active pulmonary disease required rest. Consequently. after some improvement segments of 3 ribs overlying the cavity were removed and a portion of the thickened pleura was cut away. Microscopically it showed tuberculous granulations. The wound was left open to granulate in from its base. Thus the cavity was obliterated by a partial collapse of the chest wall overlying it which at the same time added its beneficent effect along with the diaphragmatic paralysis to the diseased lung tissue. This girl has lost all signs of her pulmonary disease and as you can see, will soon have a wound which will close from the base thereby obliterating the pleural space and preventing recurrence.
The best results in the treatment of empyema will come from a careful study of each individual case. Strict adherence to fundamentals rather than methods will be well rewarded with a low mortality rate, infrequent recurrence and rare cases of chronicity.