Tuberculous empyema: Indication / Timing
Tuberculous empyema: Indication / Timing
Tuberculous empyema: Indication / Timing
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<strong>Tuberculous</strong> <strong>empyema</strong>:<strong>Indication</strong>s / <strong>Timing</strong>นพ.ภราดร เจ็ดวรรณะศัลยแพทย์ทรวงอกโรงพยาบาลสุราษฏร์ธานี
IntroductionO 5% of patients with TBdevelop pleural effusionO 2 nd most common site ofextra-pulmonary TB
Pleural tuberculosis1. <strong>Tuberculous</strong> pleuritis2. <strong>Tuberculous</strong> <strong>empyema</strong>3. Late pleural and extra-pleuralcomplication during of collapsetherapy4. TB effusion in HIV/AIDS patientsShield T: General Thoracic surgery 7 th edition<strong>Tuberculous</strong> and fungal infections of pleura
<strong>Tuberculous</strong> pleuritisO During primary TBO Incidence :5% of Pulmonary TBO Serofibrinous fluidO Rupture of subpleural caseousfoci into pleural space
<strong>Tuberculous</strong> pleuritisO ClinicalO Low–grade fever, weakness, weight loss, nightsweat, nonproductive cough, pleuritis chest painO InvestigationO Chest X-ray: pleural effusion ± parenchymallesionO CT scan: assess pleural thickening and fluidbuildup
<strong>Tuberculous</strong> pleuritis
<strong>Tuberculous</strong> pleuritisO DiagnosisO Pleural fluidO AFB stainO Pleural fluid cultureO ADAO Pleural biopsyO Concomitant parenchymal disease 1/3 of cases
<strong>Tuberculous</strong> pleuritisO DiagnosisO Pleural fluid positive for M.TuberculosisO Pleural biopsy: <strong>Tuberculous</strong> granuloma,caseous granuloma
<strong>Tuberculous</strong> pleuritisO Spontaneous re-sorptionO ManagementO Anti-tuberculous + Close observationO DrainageO DecorticationO VATS
<strong>Tuberculous</strong> pleuritis:DecorticationO Thoracocentasis fails to yield fluid or to alterradiographic appearance.O Thick pleural peelO Trapped lungO Pleural fluid ≥ 1/3 hemithoraxO <strong>Timing</strong> :O After 2 to 4 months of drug therapy (Shields:General thoracic surgery 7 th ed)O At least 6 weeks ( Khaled MA. 2000)
<strong>Tuberculous</strong> pleuritis
<strong>Tuberculous</strong> <strong>empyema</strong>O Pleural reactivation of TBO Purulent effusionO Sequelae of pulmonary TBO Clinical : low-grade fever, dyspnea, ± chest painO Abundant sputum – bronchopleural fistula
<strong>Tuberculous</strong> <strong>empyema</strong>O DiagnosisO Purulent pleural fluidO AFB stain and gram stain orcultureO Chest X-rayO Air-fluid level suggestbronchopleural fistula
<strong>Tuberculous</strong> <strong>empyema</strong>O ManagementO Adequate drainageO Chest drainO Open pleural windowO Convert sputum cultures with medical treatmentbefore resectionO Definitive treatment
Definitive treatmentO DecorticationO Lung parenchymal resectionO Extra-pleura pneumonectomyO Open window thoracostomy
DecorticationO symptomatic extra-parenchymal restrictivedisease secondary to fibrothoraxO thoracentesis, tube drainage, or thoracoscopyhave failed to drain the pleural space andexpand the lungO <strong>Indication</strong>O The pleural peel has been present for more than 4-6 weeksO Lung symptoms are disablingO There is radiological evidence of a trapped lung
Additional parenchymalresectionO MDR-TBO HemoptysisO AspergillomaO Cystic bronchiectasis/infectionAvoid pneumonectomy wheneverpossible
Extra-pleura pneumonectomyO Symptomatic severe destroyed lungO Bronchopleural fistulaO Hemoptysis
Appropriate timing of surgicalinterventionO After 2 to 4 months of drug therapy(Shields: General thoracic surgery 7 th ed)O At least 6 weeks ( Khaled MA. 2000)
Definitive treatment1) Is underlying lung expandable ?2) Is parenchymal resection required ?3) Is the patient high risk for surgery ?
Treatment plan for chronicmycobacterial <strong>empyema</strong>
Treatment plan for chronicmycobacterial <strong>empyema</strong>
Chronic <strong>Tuberculous</strong>Empyema
Pleural calcification
Post-op problem afterdecorticationO Pleural space problemO Prolong air leak
Pleural space problemO Muscle flapO PlombageO ThoracoplastyO Open pleural window
Open pleural window
ReferencesO Shield T: General Thoracic surgery 7editionO Khaled MA. Management of tuberculous<strong>empyema</strong>.Eur J Thorac Surg 17 (2000)251-254