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Stage-directed therapy of pleural empyema

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Abstract

Purpose

Intensivists and surgeons are often confronted with critically ill patients suffering from pleural empyema. Due to it’ s multifactorial pathogenesis and etiology, medicals should be sensitized to recognize the different stages of the disease. Besides a whole bundle of different established classification systems, the progress of pleural effusions can be subdivided into the early exudative, the intermediate fibropurulent and the late organized phase according to the classification of the American Thoracic Society.

Results

Rapid diagnosis of pleura empyema is essential for patients’ survival. Due to the importance of stage-adapted therapeutic decisions, different classification systems were established. Depending on the stage of pleural empyema, both antimicrobial and interventional approaches are indicated. For organized empyema, minimally invasive and open thoracic surgery are gold standard. Surgery is based on the three therapeutic columns: removal of pleural fluid, debridement and decortication. In general, therapy must be intended stage-directed following multidisciplinary concepts including surgeons, intensivists, anesthesiologists, physiotherapists and antibiotic stewards. Despite an established therapeutic algorithm is presented in this review, there is still a lack of randomized, prospective studies to evaluate potential benefits of minimally invasive (versus open) surgery for end-stage empyema or of catheter-directed intrathoracic fibrinolysis (versus minimally invasive surgery) for intermediate-stage pleural empyema. Any delay in adequate therapy results in an increased morbidity and mortality.

Conclusion

The aim of this article is to review current treatment standards for different phases of adult thoracic empyema from an interdisciplinary point of view.

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Abbreviations

ACCP:

American College of Chest Physicians

ATS:

American Thoracic Society

BTS:

British Thoracic Society

COPD:

Chronic obstructive pulmonary disease

CT:

Computed tomography

EACTS:

European Association for Cardio-Thoracic Surgery

LDH:

Lactate dehydrogenase

MIST 1/2:

First/Second Multicenter Intrapleural Sepsis Trial

t-PA:

Tissue plasminogen activator

VAC:

Vacuum-assisted closure

VATS:

Video-assisted thoracoscopic surgery

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Authors and Affiliations

  1. Department of General and Thoracic Surgery, University Hospital of Giessen, Rudolf-Buchheim-Strasse 7, 35392, Giessen, Germany

    Martin Reichert, Biruta Witte, Winfried Padberg & Andreas Hecker

  2. Department of Pulmonology and Intensive Care Medicine, Medical Clinic II, University Hospital of Giessen, 35392, Giessen, Germany

    Matthias Hecker

  3. Department of Thoracic Surgery, Klinikum Bogenhausen, Englschalkinger Strasse 77, 81925, Munich, Germany

    Johannes Bodner

  4. Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Innsbruck Medical University, 6020, Innsbruck, Austria

    Johannes Bodner

  5. Department of Anesthesiology, University Hospital of Heidelberg, 69120, Heidelberg, Germany

    Markus A Weigand

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  1. Martin Reichert
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Reichert, M., Hecker, M., Witte, B. et al. Stage-directed therapy of pleural empyema. Langenbecks Arch Surg 402, 15–26 (2017). https://doi.org/10.1007/s00423-016-1498-9

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