Tuberculous empyema: Indication / Timing

Tuberculous empyema:Indications / Timingนพ.ภราดร เจ็ดวรรณะศัลยแพทย์ทรวงอกโรงพยาบาลสุราษฏร์ธานี

IntroductionO 5% of patients with TBdevelop pleural effusionO 2 nd most common site ofextra-pulmonary TB

Pleural tuberculosis1. Tuberculous pleuritis2. Tuberculous empyema3. Late pleural and extra-pleuralcomplication during of collapsetherapy4. TB effusion in HIV/AIDS patientsShield T: General Thoracic surgery 7 th editionTuberculous and fungal infections of pleura

Tuberculous pleuritisO During primary TBO Incidence :5% of Pulmonary TBO Serofibrinous fluidO Rupture of subpleural caseousfoci into pleural space

Tuberculous 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

Tuberculous pleuritis

Tuberculous pleuritisO DiagnosisO Pleural fluidO AFB stainO Pleural fluid cultureO ADAO Pleural biopsyO Concomitant parenchymal disease 1/3 of cases

Tuberculous pleuritisO DiagnosisO Pleural fluid positive for M.TuberculosisO Pleural biopsy: Tuberculous granuloma,caseous granuloma

Tuberculous pleuritisO Spontaneous re-sorptionO ManagementO Anti-tuberculous + Close observationO DrainageO DecorticationO VATS

Tuberculous pleuritis:DecorticationO Thoracocentasis fails to yield fluid or to alterradiographic appearance.O Thick pleural peelO Trapped lungO Pleural fluid ≥ 1/3 hemithoraxO Timing :O After 2 to 4 months of drug therapy (Shields:General thoracic surgery 7 th ed)O At least 6 weeks ( Khaled MA. 2000)

Tuberculous pleuritis

Tuberculous empyemaO Pleural reactivation of TBO Purulent effusionO Sequelae of pulmonary TBO Clinical : low-grade fever, dyspnea, ± chest painO Abundant sputum – bronchopleural fistula

Tuberculous empyemaO DiagnosisO Purulent pleural fluidO AFB stain and gram stain orcultureO Chest X-rayO Air-fluid level suggestbronchopleural fistula

Tuberculous empyemaO 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 IndicationO 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 empyema

Treatment plan for chronicmycobacterial empyema

Chronic TuberculousEmpyema

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 tuberculousempyema.Eur J Thorac Surg 17 (2000)251-254