You are in: eMedicine Specialties > Plastic Surgery > CHEST Empyema and Bronchopleural FistulaArticle Last Updated: Jun 15, 2006AUTHOR AND EDITOR INFORMATIONSection 1 of 12
  Author: Jeffrey J Rentz, MD, Fellow in Surgical Research, Wound Healing and Tissue Engineering Lab, Brigham and Women's Hospital Jeffrey J Rentz is a member of the following medical societies: American College of Surgeons Coauthor(s): William G Austen Jr, MD, Assistant Professor, Department of Surgery, Harvard Medical School; Consulting Staff, Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital; Suresh Koneru, MD, Clinical Assistant Professor, Department of Plastic and Reconstructive Surgery, University of Texas Health Science Center at San Antonio Editors: Dennis P Orgill, MD, PhD, Associate Professor, Harvard Medical School; Director, Burn Center, Brigham and Women's Hospital; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Jaime R Garza, MD, DDS, FACS, Consulting Staff, Private Practice; Nicolas (Nick) G Slenkovich, MD, Practice Director, Colorado Plastic Surgery Center at Swedish Medical Center; Jorge I de la Torre, MD, FACS, Professor of Surgery and Physical Medicine and Rehabilitation, Residency Program Director, Division of Plastic Surgery, University of Alabama at Birmingham; Director, Center for Advanced Surgical Aesthetics Author and Editor Disclosure Synonyms and related keywords: empyema, bronchopleural fistula, fistula, thoracic cavity, intrathoracic sepsis pleural infection INTRODUCTIONSection 2 of 12
  Empyema thoracis has many causes, but the most common causes in order of magnitude are pulmonary infection and previous surgical resection of lung. These two etiologies represent 70-80% of empyemas in most series. Those patients with empyema treated by plastic surgeons commonly have undergone previous surgical resection and have developed a bronchopleural fistula. History of the ProcedureEarly treatment of empyema involved open drainage. In 1935, Eloesser described a skin flap procedure that creates a permanent fistula to drain the pleural space; however, his experience was not apparently reported until 1969. In 1938, Carter described the use of muscle flaps in the closure of chronic empyema cavities. His rationale was based on the acceptance of muscle flap coverage of osteomyelitic defects. ProblemEmpyema thoracis is a collection of pus within the pleural space. Since the thoracic cavity is rigid, obliterating dead space in the thoracic cavity is more difficult than in soft tissue. For example, fluid naturally fills any vacancies made by abscesses or lung resection. If the fluid becomes seeded with bacteria, either hematogenously or through direct contact, it initiates an inflammatory response that eventually leads to organization of a fibrous peel and trapped lung parenchyma. Bronchopleural fistulas occur following pulmonary resections because of failure of the bronchial stump to heal and may lead to empyema when not quickly recognized and treated. In addition, bronchopleural fistulas put the contralateral lung at risk of being seeded with bacteria from the infected hemithorax. FrequencyEmpyema most commonly occurs following pulmonary infection and in approximately 1-3% of lung abscesses. Streptococcus species are responsible for most empyema secondary to community-acquired pneumonia. However, hospital-acquired cases have a broader bacteriology, including methicillin-resistant Staphylococcus aureus, Pseudomonas species, and Escherichia coli. The second most common cause is previous surgical procedures, including surgery of the lungs, esophagus, or mediastinum. Empyema occurs in 2-12% of patients following these procedures. EtiologyBronchopleural fistulas result following failure of the bronchial stump to heal. This failure to heal may be from improper initial closure, inadequate blood supply, infection at the bronchial stump, or residual malignant tumor at the bronchial stump. PathophysiologyThe American Thoracic Society has classified empyema into 3 phases based on the natural history of the disease. The first phase is the exudative phase and involves the release of sterile pleural fluid into the pleural space in response to inflammation of the pleura. At this stage, the pleura and related lung are mobile. The second phase has been termed the fibrinopurulent or transitional phase. During this stage, the pleural fluid becomes more turbid and fibrin develops on the pleural surfaces. At this time, pleural fluid becomes viscous. The fibrin peel loculates the fluid collection and gradually limits expansion of the underlying lung. The final phase is the organizing or chronic phase, during which time the peel begins to organize with ingrowth of capillaries and fibroblasts. The lung has now become completely trapped within the peel and cannot expand to fill the empyema cavity. ClinicalClinical presentation depends on the underlying cause of the empyema. Most patients report dyspnea with little exertion, and they usually have a low-grade fever early in the course. Later on, patients may experience pleuritic chest pain and a feeling of heaviness on the affected side of the chest. They may also experience purulent sputum. On physical examination, breath sounds are decreased on the involved side of the chest. In addition, the affected hemithorax may be less mobile than the unaffected hemithorax. Chest radiographs are the appropriate first study and usually show opacifications and may show air-fluid levels. CT scans are invaluable to elucidate loculation and to direct appropriate drainage of the area. INDICATIONSSection 3 of 12
The first priority in managing a major pleural space infection is to protect the healthy lung parenchyma. If the patient is coughing copious sputum or blood, he or she may require intubation. Keep the affected side in a dependent position as much as possible to prevent contamination of the other lung. Patients may be hemodynamically labile early in the management phase. Many of these patients have significant comorbidities and are malnourished. It can take weeks or months to treat significant infections. Treatment options have expanded greatly in recent years. Empiric antibiotics are usually started before culture results have returned. The key to treating the infection is to eliminate the dead space. Placement a of tube thoracostomy into the infected cavity and aspiration of fluid for cultures are initial procedures. This may require multiple tubes or image-guided tube placement. The hemithorax should be imaged again to assess for removal of fluid. Fibrinolytic therapy is often successful in fibrinopurulent or early organized cavities. Following stabilization, if a bronchopleural fistula is present, perform the repair with flap coverage. If hemodynamic stabilization is protracted then open drainage, originally described by Clagett in 1972, may be instituted. Clagett's procedure has many modifications, but all involve draining the empyema externally and the instillation of antibiotic solution. Antibiotic solution may be instilled via one tube and drained through a tube placed in the cavity. Other options include partial rib resection and packing of the cavity with sodium hypochlorite solution. In addition, the previously placed tube thoracostomy may be used to instill sodium hypochlorite solution. Some surgeons irrigate the pleural cavity continuously with saline or antibiotic solutions. Following sterilization of the cavity and stabilization of the patient, muscle flap reconstruction of the cavity may be performed. RELEVANT ANATOMYSection 4 of 12
In planning the reconstruction of an empyema cavity or bronchopleural fistula, consider previous operations and the structures divided. For example, a lateral thoracotomy usually involves division of the latissimus dorsi muscle. Usually, the patient presenting to the plastic surgeon with a diagnosis of empyema or bronchopleural fistula has already undergone at least one lateral thoracotomy. In addition, various drainage attempts may have been made, thereby compromising the reconstructive options. Consider simple options first. Thorough decortication can be tedious, but it serves 2 purposes. It recruits more functional lung and it obliterates more dead space. Intercostal muscle flaps, pleura, or pericardial tissues are readily available and adequately protect leaking bronchi or lung parenchyma. Unfortunately, they are often used or are too small to totally obliterate the space. They can cover a lobar bronchus as an extra layer of protection. The latissimus dorsi muscle has the ideal bulk, pedicle length, and arc of rotation to fill most thoracic defects. Unfortunately, it is divided in most open thoracic procedures. Rotation of this muscle is based on the thoracodorsal artery; in patients who have not undergone division of the muscle, it usually provides enough muscle bulk to obliterate an empyema cavity. The muscle may be used as a turn-over flap or advanced directly into the wound and can be brought through the incision or through a small rib resection of the sixth or seventh ribs to facilitate longer reach. The second most common muscle used to fill an empyema cavity is the serratus anterior. This muscle has the advantage of being thin enough to fill a small space and can be passed through a lateral thoracotomy incision. The lateral thoracic artery supplies blood flow to this muscle. This muscle also can be brought into the chest with the latissimus dorsi muscle on a common pedicle. Another possible muscle flap is the pectoralis major that can be used as either a turn-over flap or placed directly in the wound. The pectoralis has a dual blood supply from both the internal mammary artery and the thoracoacromial artery. Intrathoracic placement of the pectoralis major requires creation of a window by partial rib resection of the second or third ribs to afford maximal length. This muscle may have been divided as well if an anterior approach had been used. If the empyema space is not large or a well-vascularized reinforcement of a bronchopleural fistula is required, the omentum can be used. The advantages of using omentum include its long reach, excellent vasculature, and it is relatively distant from the infectious process. Previous abdominal sepsis or surgery may make harvesting adequate omentum difficult but usually a sufficient amount of tissue can be mobilized through an anterior opening in the diaphragm. The omentum may be harvested laparoscopically eliminating the need for laparotomy. Another regional muscle flap available for reconstruction is the rectus abdominis based on the superior epigastric artery. If all of these regional flaps are not adequate then free tissue transfer may be required. Prior to attempting obliteration of the pleural space, it is essential to plan the flaps to be used based on previous operations and ensure adequate bulk to obliterate the space. A thorough understanding of the thoracic anatomy and flap options is essential. The highest priority is to control the source of contamination. If the hole in the bronchus or the lung abscess can be covered but the void in the thoracic cavity cannot be completely filled, then the wound can be left open to granulate. This is a time-consuming process, but it may be the safest alternative for the patient. CONTRAINDICATIONSSection 5 of 12
Transection of any of the regional flaps during previous operations may limit the reconstructive options. However, in many cases, the muscles are only partially injured and sufficient portions may be salvaged for reconstruction. WORKUPSection 6 of 12
Imaging Studies
TREATMENTSection 7 of 12
Medical TherapyMedical therapy alone may benefit acute empyema following drainage of a pneumonic abscess yet is not effective in the treatment of empyema because of bronchopleural fistula or chronic empyema. The empyema cavity must be aggressively drained early and appropriate antibiotic therapy initiated for successful medical therapy. If the empyema cavity cannot be adequately drained by tube thoracostomy, open drainage in preparation for flap surgery will be required. Surgical TherapyTreatment of a bronchopleural fistula depends on several factors. Acute fistulae (1-7 d postoperatively) should be repaired and drained promptly. Care must be taken to protect the contralateral lung from contamination. The fistula should be debrided of necrotic or inflammatory material. If able, repair should be performed with monofilament suture or stapled anastomosis. Often, repair becomes too technically difficult due to the degree of inflammation present. Repair may be reinforced with a local flap of pleura, pericardium, or mediastinal fatty tissue. In addition, a muscle or omental flap sutured over the fistula with monofilament suture may be used to reinforce the repair. Treatment of chronic fistulae requires a staged approach. During the first stage, drain the empyema and allow the underlying lung to expand maximally. Drainage may be performed by tube thoracostomy, thoracoscopy, or open thoracostomy. The next stage involves debridement or decortication of the empyema cavity and placement of vascularized tissue to cover the infected area as well as obliteration of dead space. Debridement of all epithelialized and granulating surfaces must be performed. This decortication may become quite tedious and may be accompanied by heavy blood loss. Prior to flap reconstruction of the thoracic cavity, adequately drain the cavity and ensure it is free of gross infection. Several flap options are available when treating an empyema cavity following bronchopleural fistula as outlined above. Evaluate the simplest and closest flaps, such as the pleura or intercostal muscle flap, first. One option is omental flap coverage, usually based on the right gastroepiploic artery. The omentum can be harvested laparoscopically or via laparotomy and passed through the diaphragm into the chest cavity. This flap provides well-vascularized tissue to cover the bronchus or esophagus yet does not usually contain enough bulk to fill the dead space of the empyema cavity. Other flap options are the serratus anterior or the latissimus dorsi muscles based on the thoracodorsal vessels. These muscles have the advantage of being easily accessible at the site of the thoracotomy wound. The latissimus also is advantageous, as it is a large-volume muscle that can fill the residual cavity. Passage into the chest may necessitate partial resection of the sixth or seventh ribs. The disadvantage of either of these muscles is that they may have been transected at thoracotomy. More distant muscle flap options include the rectus abdominis based on the superior epigastric vessels and the pectoralis major based on the thoracoacromial vessels. Both of these muscles are large enough the fill the empyema cavity and usually are preserved at thoracotomy. Free tissue transfer using contralateral latissimus, pectoralis, or de-epithelialized transverse rectus abdominus myocutaneous (TRAM) flap also has been described for use when local flaps are not available. It is imperative that all residual space be filled with muscle or omentum to decrease the risk of recurrent empyema. If the entire cavity cannot be filled, it may be partially obliterated by removing portions of overlying ribs. The chest cavity also should be thoroughly drained postoperatively via chest tubes. Multiple large bore (32-36 Fr) tubes are often required. Patients prefer softer tubes, since they may remain in place for weeks. One of the tubes should sit on the diaphragm and go into the posterior sulcus to collect dependent drainage. After a week, the tubes can be gradually removed by 2 centimeters at a time and resecured. The inflammation in the pleural space is vigorous and usually prevents the lung from collapsing in several days, but prudence requires follow-up with chest radiography. Preoperative DetailsPreoperative evaluation should involve a thorough history and physical examination. A chest radiograph usually is adequate to visualize the process. However, a CT scan of the chest is reasonable to assess for drainage catheters and to plan an operative strategy. Assess nutritional status preoperatively and correct deficiencies prior to definitive flap reconstruction. Intraoperative DetailsIntraoperatively, fill the cavity with water and have the anesthesiologist manually inflate the lungs to a pressure of 35-40 cm water. This may identify the fistula. Make attempts to seal this fistula. Debride devitalized or marginal tissue. Stapled closures or hand-sewn closures with monofilament suture should be done; base the choice on the surgeon's preference and comfort. Biologic sealants may be helpful. Aggressive debridement and decortication of all epithelialized and granulating surfaces should be undertaken. Ensure all of the empyema cavity has been filled with vascularized tissue prior to closing the chest and drain all cavities postoperatively. Consider that the tubes will likely remain in place for a long time and that they will be backed out gradually every other day when they come out. Take care to drain the most dependent areas in the supine and upright positions. Postoperative DetailsAdequately drain all cavities postoperatively for at least 7-10 days. If a patient is using a ventilator, keep the pressures as low as possible and extubate the patient as quickly as it is safe to do so. As mentioned above, the tubes may be removed gradually once the lung is stuck against the parietal pleura. Maintain appropriate antibiotics based on intraoperative and preoperative cultures. Patients commonly decompensate after the initial drainage procedure. Be prepared for this situation, and keep it under consideration when deciding when to proceed with definitive closure. The patient should be followed closely as recurrence of the bronchopleural fistula or empyema cavity is possible. In the event of a recurrence, the basic principles of drainage, coverage, and obliteration of the cavity should be reinstituted. COMPLICATIONSSection 8 of 12
Observe patients closely postoperatively as recurrence of the fistula and empyema is possible. Many patients deteriorate in the first day or two after debridement and drainage. If the cavity is well-drained and the antibiotics are appropriate, patients readily improve within a few days. If they continue to worsen, consider a repeat CT scan to look for more undrained infection. The most common complication in the most series is persistence of the cavity. If residual cavity is present it may be eliminated with further muscle flap coverage. OUTCOME AND PROGNOSISSection 9 of 12
The underlying disease process generally limits the prognosis for patients with empyema because of bronchopleural fistula. Empyema management delays chemotherapy and radiation therapy in cancer patients. Oncologic surgery is usually not undertaken in patients with short life expectancy, but it and empyema or bronchopleural fistula can significantly reduce quality of life for patients for many months. Often, patients who develop empyemas have many comorbidities and limited potential to heal. Empyemas are seen in community-acquired pneumonia in children. Although these patients may heal well and make a full recovery, complex wound care is more difficult and the impact of residual physical limitations is more severe. FUTURE AND CONTROVERSIESSection 10 of 12
In the future, tissue adhesives may play a more prominent role in the sealing of fistulae. Numerous case series involving fibrin sealants are reported in the literature. The most recent trend is to use bronchoscopic stents and sealants to limit contamination in combination with external drainage of the space. In addition, as more surgeons gain expertise in microvascular techniques, free tissue transfer may become the preferred method of flap transfer. Distal flaps are less likely than regional flaps to have been compromised by previous surgeries. Distal flaps that can be harvested simultaneous to recipient vessel preparation may prove to be ideal for obliterating the space. MULTIMEDIASection 11 of 12
REFERENCESSection 12 of 12
Empyema and Bronchopleural Fistula excerpt Article Last Updated: Jun 15, 2006 | |||||||||||||||||||||||||||||||||
