Pleural empyema natural history, complications and prognosis
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Prince Tano Djan, BSc, MBChB [2]
Overview
If left untreated 40% of complicated pneumonia results in effusion with 60% resulting in the formation of empyema.[1] Empyema may result in the following complications; empyema necessitans,[2] imparired perfusion and ventilation of lungs as a result of pleural thickening and reduced lung function, necrotizing fasciitis of the chest wall,[3] bronchopulmonary fistula or alveolar-pleural fistula,[3][4] The prognosis of empyema after treatment is good however, the risk of permanent lung damage and mortality increase when empyema complicates pneumonia.[5][6] Advanced age and comorbidity are strong prognostic factors. Thirty-day mortality rate ranges from 1.2% in patients aged 15 to 39 years to 20.2% in those aged ≥ 80 years. Mortality also varies substantially according to level of comorbidity.[5]
Natural History
If left untreated 40% of complicated pneumonia results in effusion with 60% resulting in the formation of empyema.[1]
Complications
Cpmlications of empyema include:
- Empyema necessitans[2]
- Imparired perfusion and ventilation of lungs as a result of pleural thickening and reduced lung function.
- Necrotizing fasciitis of the chest wall[3]
- Bronchopulmonary fistula or alveolar-pleural fistula[3][4]
Prognosis
Majority of people fully recover from empyema after treatment. However the risk of permanent lung damage and mortality increase when empyema complicates pneumonia.[5][6] “If an empyema does not rupture, death will occur” – Hippocrates. Advanced age and comorbidity are strong prognostic factors, and empyema remains a serious condition requiring a long hospital stay. Thirty-day mortality rate ranges from 1.2% in patients aged 15 to 39 years to 20.2% in those aged ≥ 80 years with age-adjusted adjusted 30-day mortality rate of 0.69. Mortality also varies substantially according to level of comorbidity.[5]
The prognosis risk of empyema may be stratified using the RAPID score as shown below:[7][8]
| Parameter | Measure | Score |
|---|---|---|
| Urea, mM | <5 | 0 |
| 5-8 | 1 | |
| >8 | 2 | |
| Age, years | <50 | 0 |
| 50-70 | 1 | |
| >70 | 2 | |
| Purulence of pleural fluid | ||
| Purulent | 0 | |
| Nonpurulent | 1 | |
| Infection source | ||
| Community acquired | 0 | |
| Hospital acquired | 1 | |
| Dietary factors | ||
| Albumin g/l | ≥ 27 | 0 |
| <27 | 1 |
Interpretation of score:
Low risk: 0-2
Medium risk: 3-4
High risk: 5-7
The following co-morbid factors have been found to be associated with high-risk scores:[7]
- Gram-negative rod infections
- Heart disease
- Diabetes
- Cancer
- Lung disease
- Increased length of hospital stay
References
- ↑ 1.0 1.1 Perez VP, Caierão J, Fischer GB, Dias CA, d'Azevedo PA (2016). "Pleural effusion with negative culture: a challenge for pneumococcal diagnosis in children". Diagn Microbiol Infect Dis. 86 (2): 200–4. doi:10.1016/j.diagmicrobio.2016.07.022. PMID 27527890.
- ↑ 2.0 2.1 Ahmed SI, Gripaldo RE, Alao OA (2007). "Empyema necessitans in the setting of pneumonia and parapneumonic effusion". Am J Med Sci. 333 (2): 106–8. PMID 17301589.
- ↑ 3.0 3.1 3.2 3.3 Nishihara T, Hayama M, Okamoto N, Tanaka A, Nishida T, Shiroyama T; et al. (2016). "Endoscopic Bronchial Occlusion with Silicon Spigots for the Treatment of an Alveolar-pleural Fistula during Anti-tuberculosis Therapy for Tuberculous Empyema". Intern Med. 55 (15): 2055–9. doi:10.2169/internalmedicine.55.6672. PMID 27477414.
- ↑ 4.0 4.1 Deschamps C, Bernard A, Nichols FC, Allen MS, Miller DL, Trastek VF; et al. (2001). "Empyema and bronchopleural fistula after pneumonectomy: factors affecting incidence". Ann Thorac Surg. 72 (1): 243–7, discussion 248. PMID 11465187.
- ↑ 5.0 5.1 5.2 5.3 Søgaard M, Nielsen RB, Nørgaard M, Kornum JB, Schønheyder HC, Thomsen RW (2014). "Incidence, length of stay, and prognosis of hospitalized patients with pleural empyema: a 15-year Danish nationwide cohort study". Chest. 145 (1): 189–92. doi:10.1378/chest.13-1912. PMID 24394842.
- ↑ 6.0 6.1 Smith JA, Mullerworth MH, Westlake GW, Tatoulis J (1991). "Empyema thoracis: 14-year experience in a teaching center". Ann Thorac Surg. 51 (1): 39–42. PMID 1985571.
- ↑ 7.0 7.1 White HD, Henry C, Stock EM, Arroliga AC, Ghamande S (2015). "Predicting Long-Term Outcomes in Pleural Infections. RAPID Score for Risk Stratification". Ann Am Thorac Soc. 12 (9): 1310–6. doi:10.1513/AnnalsATS.201505-272OC. PMID 26193196.
- ↑ Rahman NM, Kahan BC, Miller RF, Gleeson FV, Nunn AJ, Maskell NA (2014). "A clinical score (RAPID) to identify those at risk for poor outcome at presentation in patients with pleural infection". Chest. 145 (4): 848–55. doi:10.1378/chest.13-1558. PMID 24264558.