Clinical Management

of Tuberculosis

Dato Dr Hj Abdul Razak Muttalif

MBBS, MSc, M.Med, AM, FCCP
Consultant Chest Physician & Head Department of
Respiratory Medicine
Hospital Pulau Pinang
Diagnosis of Tuberculosis
Pulmonary Tuberculosis

 Symptoms & Signs

 Investigations
 Sputum AFBs X 3, AFB C&S (egg based
media, BACTEC)
 Chest X-rays
 Mantoux test
Duration of symptoms from
first visit
70

60

50

40

30 Percent

20

10
0
Days Weeks Months Years

Razak,Norhafizah,Norlidar,Norhashimah. C.C.HKT
 2.Microbiology
 Sputum AFB/AFB C+S
 Most cost effective
method
 Categorization for
treatment
 AFB +ve
 AFB -ve
3. Serology

 Mantoux Test
 Antibody/antigen
 PCR

More than 10mm is

positive
2TU in 0.1 ml, read after
72 hours
In children more than 15


mm
4.CXR
 Upper lobe opacity
 Cavity ( 1 cavity= 1 million bacilli)
 Miliary
 Effusion
Radiological classification
 Minimal
 Slight lesion without cavitations, confined to a small part of
one or both lungs. Total extent of lesions should not
exceed the volume of lung which lies above the second
chostosternal junction and the spine of the fourth vertebra
Radiological classification
 Moderately advanced
 One or both lungs may be involved. Total extent of lesion
should not exceed the following:
 i) Not exceeding total volume of one lung
 ii)Dense lesions not exceeding one third lung volume

 Iii)Total diameter of cavity less than 4cm

Radiological classification
 Far advanced
 Lesions more extensive than moderately advanced
 Extra pulmonary TB (TB outside the lung
parenchyma)

 Tuberculous lymphadenitis by LN biopsy sent for DS, C&S, cytology

 TB effusion by pleurocentesis, pleural biopsy
 GUT by radiological, urine C&S
 TB bones/joints by x-rays, HPE
 Miliary TB by CXR,liver biopsy
 TB meningitis CSF microscopy, biochemestry C&S, PCR for TB
Tuberculosis Classification

 Pulmonary tuberculosis
 Smear positive
 Smear negative
 Extrapulmonary tuberculosis
 Pulmonary with Extrapulmonary
tuberculosis
Pulmonary Tuberculosis
 Smear positive
 Two sputum DS positive
 One sputum positive with CXR changes of TB
 One sputum positive with culture positive
 Smear negative
 Three DS negative with CXR abnormalities and
decision to treat as TB
 Initial sputum DS negative but culture positive
Extra Pulmonary TB

 Extra-pulmonary TB
 TB of organs other than lung parenchyma
 Based on culture, histology or strong
clinical evidence and a decision to treat
 Pulmonary with extra-pulmonary
 Tuberculosis involving lung parenchyma as
well as any other part of the body
Extrapulmonary TB
classification of severity
 Severe
 Meningitis, miliary, pericarditis, peritonitis,
bilateral or extensive pleural effusion,
spinal, intestinal, genito-urinary
 Less severe
 Lymph node, unilateral pleural effusion,
bone (excluding spine), peripheral joint,
skin
Definition of terms

 New case
 Relapse case
 Chronic case
 Cure
 Treatment failure
 Treatment after interruption
 Transferred in case
Definition
 New case
 Newer had TB treatment or has take treatment for
less than 4 weeks in the past
 Relapse case
 Sputum positive relapse
 Declared cured of any form of TB in the past by a
doctor has become sputum smear positive
 Sputum negative relapse
 As above, developed active disease based on
bacteriological, histological clinical and
radiological assessment
Definition
 Chronic case
 A patient who remained or becomes smear
positive again after completing a fully
supervised re-treatment regimen
 Cure
 A smear positive patient has negative
sputum at the end of treatment and
another negative sputum one month or
more prior to completion of treatment
Definition
 Treatment failure
 A patient while on treatment becomes again smear
positive 5 months or later after commencing
treatment
 A patient who was initially negative became
positive after second month of treatment
 Treatment after interruption
 A patient who interrupts treatment for 2 months or
more then returns with smear positive or negative
but still active TB based on clinical or radiological
assessment
Definition

 Transferred in case
 A patient transferred from another centre
for continuation of treatment. The new
centre undertakes the responsibility of
treatment
 Not considered a transfer if a patient just
come to centre for treatment only
Tuberculosis in children

 Infection from adults via coughing and

droplets
 From milk and food
 Through skin
Changes after infection in
children
 Primary complex
 Pleural effusion
 Acute cavitation of focus
 Ring shadow
 Lymph node at root of lung
 Blood spread
 Liver, bones, brain kidneys
?TB in children

 Failed to gain weight

 Wheezing, cough, fever, LOA, LOW
 Pleural effusion
 Ascites
 Joint swelling, spinal lump
 Lymph node, discharging sinus
 Headache, irritability

FAMILY HISTORY OF TB!!!!

“Two Diseases - one
Patient”
 Tuberculosis

T helper lymphocytes
Protective Immunopathology
Immunity and disease
Stress
Glucocorticoids
Th1 Th1 Th2
+

Tissue
damage
Macrophage
activation

The immune response

 Altered cytokines in HIV/TB
patients
Normal Tb TB/HIV Advanced
HIV
CD4 759 569 201 130

INF 7.5 10 2.2 0.1

IL-12 0.6 12.5 4 2.2

IL-10 424 735

TNF 231 370 232 21

TH1 cytokines---IL-12,INF
S.swaminathan et al 2002
Inhibitory cytokines IL-10
Effect of TB on HIV

 TB causes release of TNF and

stimulates multiplication of virus inside T
cells
 TB helps in destruction of CD4 cells
 Helps release of new virions from HIV
infected cells
Effect of HIV on TB

 Decrease macrophage activating

lymphokines
 Increase in number of CD8 cells
 Increase tissue destruction
 T4 lymphopenia
 HIV promotes T4 destruction and CD4
cells impairment
Effect of HIV on TB

HIV Status Lifetime risk of

developing TB
Negative 5-10%

Positive 50%
Chest Imaging (in HIV +ve
case)
 Not used for screening
 Limited to symptomatic
 Variety of manifestations
 Normal CXR in 15%,CT scan used only
for further diagnostic procedures
 Gallium scan for PCP
CXR findings in HIV patients
(1)
 Normal
 PCP, MTB, Histoplasma, Kaposi
 Focal infiltrates
 PCP, MTB, bacterial,
Cryptococcus,aspergillus
 Diffuse infiltrates
 PCP, MTB, bacterial Cryptococcus,
histoplasma
 CXR finding (2)

 Nodular
 PCP, Cryptococcus, Histoplasma, Norcardia, CMV, Toxo

 Cavitary
 Bacterial, PCP, MTB, Aspergilluss
 Lymphadenopathy
 PCP, MTB, Cryptococcus, Kaposi, lymphoma

 Pleural effussion
 Bacterial, PCP, MTB, lymphoma
 Pneumothorax
 PCP, MTB
Pneumococcal Staphylococcal Lung abscess
 Acceleration of TB in HIV patients

Among 30 residents from a housing facility for HIV infected

persons, 11 patients had active TB and were noted to have the
same restricted fragment length polymorphisms (RFLPs)
4 others had positive TST
6 of the 28 staff members had positive TST
Conclusion: Newly acquired TB infection in HIV infected
patients can spread readily and progress rapidly to active
disease. Heightened surveillance for TB in facilities as this is
needed

Charles et al. NEJM 1992;326:231-5

PTB mini epidemic in a church
Gospel Choir

 Five cases of TB, one index and three

secondary
 All three had same DNA fingerprinting
 All three were tenors (not sopranos)
 Singing, location of ventilation and
exposure time were contributing factors

Bonita et al Chest 1998; 113: 234-37

PTB in early and late HIV infection

Features of Stage of HIV

PTB infection
Early Late

Clinical picture Often resembles Often resembles

post primary PTB primary PTB

Sputum smear Often positive Often negative

CXR Often cavities Often infiltrates with

no cavities
CD4 count and CXR
 35 subjects, 26 had CD4 <200cells/L
 21 of these subjects had atypical CXR
 Atypical CXR
 Diffuse lower lobar opacities
 Pleural effusion
 Mediastinal lymphadenopathy
 Interstitial nodes
 Normal x-ray

Kelper et al. Chest;107:74-80

 CXR in HIV patients
 225 Haitians tested for HIV
 67 positive and 158 negative
 Intrathoracic adenopathy more common then
parenchymal infiltrates (p<0.05)
 80% of patients with AIDS has CXR consistent with
primary TB (p<0.05)

R Long et al Chest; 99: 123-127

 Pulmonary nodules in HIV patients*

Diagnosis Number
Bacterial 88
PCP 26
Lymphoma 25
Tuberculosis 23
Kaposi 16
NTM 15
Aspergillus 9
Lung Ca 4
CMV 2

* 242 HIV patients who had CT chest Robert et al Chest 2000; 117:1023-1030
 CD4 count and lung nodule
CD4 cell count
Diagnosis 0-49 50-99 100-199 >200
Pneumonia 17 1 8 4
TB 4 5 4 1
PCP 2 0 0 1
Aspergillus 3 0 0 0
Kaposi 9 1 1 0

87 HIV patients with lung nodules

Robert et al Chest 2000; 117:1023-1030
Undiagnosed TB in patients with HIV
infection (Dept of Med, U of Souther Califonia Medical
Center) Flora et al

 11 patients with HIV TB undiagnosed

 9/11 had pulmonary complaints
 8/11 had x-ray suggestive of TB
 Non of these patients had TST
 AFBs in only 3 patients and bronchoscopy in
only 4
 PCP was the main presumptive diagnosis
 Three had post mortem diagnosis of TB and 7
had evidence of disseminated TB

Chest 1990 Vol 98 1056-1059

Significance of abnormal CXR findings in
patients with HIV infection and respiratory
symptoms

 44 patients were eligible

 86% had CD4 count <200cells/uL
 Nodular disease was commonest (57%)
 Adenopathy (17%)
 Most common diagnosis was TB followed by
NTM
 Only 18% with TB had diagnosis by sputum

Jeffrey A Gold et al. Chest 2002;121:1472-1477

Other Investigations
 Variables CXR Scope
27%
Nodules 22 TTNA
38%
Adenopathy 7 Surgery
Thoracentesis
Infiltrate 5 FNA
Cavity 4 11% Clinical
Mass 4 3% Sputum
8%
8%
Effusion 2 5%

Diagnosis Percent
Infectious 52 (MTB 26, NTM 23)
Neoplasia 19 (KS 12, NSSCa 2, HL 2 )
Lymphoproliferative 7
Others 7
Unknown 14
Bronchoscopy
Treatment of Tuberculosis
 Aims of treatment

 To reduce morbidity
 To prevent mortality
 To prevent relapse of tuberculosis
 To decrease transmission
 To prevent the emergence of MDR TB
Treatment of TB

 Responsibility is to the public health, not

patient
 Patient centered
 Each patient management plan should
be individualised
 DOTS
First line drugs

 Isoniazid (H)
 Rifampicin ( R )
 Pyrazinamide (Z)
 Streptomycin (S)
 Ethambutol (E)
 Treatment categories

Category Category II Category

I III

New case Chronic case

Relapse
Treatment
failure
Sputum Treatment
after Refer to
positive, MO
interruptio physician/che
boleh treat n st
Treatment regimens

 Intensive or initial phase

 Three or four drugs given daily for rapid
sputum conversion and amelioration of
clinical symptoms
 Maintenance or continuation phase
 Two or three drugs given intermittently for
sterilizing effect and to eliminate remaining
bacilli and reduce chance of relapse
Category I (New case)

 Intensive phase
 2SHRZ or 2EHRZ or 2HRZ two months of
daily doses
 Continuation phase
 4H2R2 or 4S2H2R2 or 4HR or 4H3R3 or
4S3H3R3 durations extended for severe
form of TB or extrapulmonary TB
Category II (Relapse, Treatment failure,
Treatment after interruption)

 Send MTB C&S (rapid culture if

available)
 Do not initiate standard treatment
 Refer to chest physician or physician in
charge of chest clinic
 Subsequent drug regimen based on
sensitivity results and clinical response
Category III (Chronic case)

 Send MTB C&S (Rapid culture if

available)
 Refer to chest physician or physician in
charge of chest clinic
 Anti TB drugs
Daily dosage Biweekly dosage

mg/kg max mg/kg max

Isoniazid H 5-8 300 15-20 1200

Rifampicin R 10-15 600 15-20 600

Streptomycin S 15-20 1000 15-20 1000

Ethambutol E 15-25 1200 50 2000

Pyrazinamide Z 20-40 1500 50 3000

Multi- drugs(first line)

Intracellular Extracellular Cavity

RIF + + +
INH + + _
PZA + _ _
SMC _ + _
 Flow Chart for 6 months regimen

2SHRZ/2EHR Baseline
1. 0 mo (0 w) Z Ix:FBC,LFT,RP,HIV,R
BSSpt AFBs DS, AFB
culture

Spt AFB DS, spt

2. 2 mo 4SHR2 4HR2 culture if smear
(8w) positive,CXR

3. 2 mo (8w) Continue Rx Continue RxSpt AFB DS, CXR

4. 2m (8w) Completion of 6 mo Rx Spt AFB DS, CXR

Follow up Spt AFB, CXR

5. 6mo(24w)
Practical Aspects

 All anti TB drugs given together, do not

split dosing
 Vigilant for drug interactions
 Empty stomach? After food?
 AntiTB drugs should not be stopped or
minor side effects especially RIF
NOTIFICATION!!!
!!
Patient Monitoring
 Treatment response
 All patients with positive sputum have
repeat sputum smears every two months
 Patient compliance by DOTS
 Hospitalisation
 Gravely ill, acute disseminated TB,TB of
vital organs,MDRTB,frequent
defaulters,complications, severe side
effects, homelessness
Contact tracing!!!
 Family members
 Workplace
 Close contacts
 Inmates
 Institution
Drug toxicity monitoring and
management
Monitoring for drug toxicity

 All patients should have baseline Ix

 Monitored clinically for adverse reaction
 Routine blood Ix for asymptomatic
patients not required
 If symptoms suggesting drug toxicity,
perform appropriate Ix
Drug Toxicity
 Minor side effects
 GI intolerance
 Arthralgia
 Mild rash

 Serious side effects

 Hepatitis
 Severe skin rash
 Thrombocytopenia
 Shock
 Renal failure, eight cranial nerve damage
 Visual impairement
Drug interactions
 Isoniazid
 Raises the level of
phenytoin,carbamazepine
 Absorption of INH impaired by allumonium
hydroxide
 Rifampicin
 Need to increase dosages of PIs,steroids,
OCP,OHA, anti-coagulants, phenytoin,
cimetidine, theophylline and digitalis
Outcome analysis
 Cure
 Smear negative on two occasions at completion of
treatment
 Treatment completed
 Completed treatment without proof of cure
 Treatment failure
 Remains positive of becomes positive again at five
months of treatment
 Died
 Dies for any reason during course of treatment
 Treatment interrupted
 Treatment interrupted for two months or more
TB in Children
 Diagnosis is difficult
 Features:
 Recent contact, symptoms and signs,
unresolving pneumonia, positive mantoux,
hilar nodes, segmental collapse, pleural
effusion, LN calcification
 Gastric lavage for DS and culture
 Bronchoscopy if necessary
Anti-TB in children

 Intensive phase
 HRZ for 2 months (syrup preparation)
 Maintenance phase
 Daily RH is preferred
 Biweekly RH fully supervised
 Avoid ethambutol and streptomycin
TB meningitis

 Total duration is 12 months

 Steroids in acute stage
 Observe for late complications like
hydrocephalus
TB in pregnancy and lactation

 Standard treatment and dosage

 Avoid streptomycin
 Breast feeding best avoided for 2 weeks
in a mother who is a new smear positive
case
 BCG and INH prophylaxis given if
needed
TB and OCP

 Rifampicin interacts with OCP

 Decreases protective efficacy against
pregnancy
 Use a higher dose of oestrogen or other
form of contraception
TB and liver impairment

 Established chronic liver disease

 i) 2SHRE/7H2R2
 ii) 2SHE/10HE
 Iii)2SH/12S2H2
 Acute hepatitis (viral hepatitis)
 Hepatitis unrelated to TB or TB treatment,
defer treatment until hepatitis is resolved if
treatment is necessary, 3SE/6HR
TB and renal impairment
 Streptomycin and ethambutol avoided
 If need to be given, monitor renal function
closely
 2HRZ/6HR is safest regimen
TB and HIV

 Initial therapy
 INH, RFP, PZA , ETM
 Long term
 IHN and RFP for 7 months biweekly or for
6 months after culture is negative
 Antiretroviral Drugs
 Nucleoside reverse transcriptase inhibitors (NRTI)
 Zidovudine (AZT)
 Didanosine (ddI)
 Zalcitabine (ddC)
 Stavudine (d4T)
 Non-nucleoside reverse transcriptase inhibitors (NNRTI)
 Efavirenz (Stocrin)
 Nevirapine (Viramune)
 Protease Inhibitors (PI)
 Indinavir
 Ritonavir
 Saquinavir
Managing HIV/TB co-infection

 HAART decreased death by 60-90%

 In absence of HAART higher mortality
due to OIs
 HAART /anti-TB has overlapping toxicity,
drug interaction, non-adherence,
paradoxical reactions
 Recommended to delay HAART until
first two months of TB treatment
 Anti TB and HAART
 PIs and NNRTIs inhibit or induce
cytochrome P450 (CYP450)
 Rifampicin induce CYP450 and
decrease levels of anti-retrovirals
 NRTIs (AZT,ddI,ddC,d4T,3TC) are not
metabolised by CYP450
 Concurrent use of NRTIs and rifampicin
is not contraindicated and does not
require dose adjustment
TB treatment in HIV patient
 In patients with no HIV treatment, usual
regimen
 In patients with HIV treatment, omit
rifampicin and rifabutin or add
streptomycin
 Two options for TB Rx

 INH + RBT + PZA +  INH + PZA + ETH +

ETH for two months SM for 2 months
then then
 INH + RBT for 4  INH + PZA + SM for
months 7 months
 Do not use ritonavir,  PIs can be used at
delavirdine, dose of usual dose
PI adjusted

RBT=rifabutin
 New options
 Rifampicin can be used in 3 situations:
 I) NNRTI (efavirenz) + 2 NRTIs
 II) Ritonavir + one or two NRTIs
 III)Use of two Pis (ritonavir + saquinavir)
 Use of non rifampicin included regimen
with longer duration
 Pharmacologic interactions between rifampicin and
efavirenz Coltres et al

24 HIV positive patients randomised into 3 groups:

1. Rifater + E(600mg qd) + 2NRTIs (D8-D14)
2. Rifater + E(800mg qd) + 2NRTIs (D8-D14)
3. Rifater + E(800mg qd) + 2NRTIs (D1-D14)

Result: 30% decrease in E level in group 1. No change in rifampicin levels

Conclusion: Rifampicin and efavirenz can be used concomittently with a
higher dose of efavirenz. Advise use of FDCs

8th Conference in Retroviruses and OIs

February 2001, Chicago
Paradoxical worsening of TB in HIV infected
persons (Johns Hopkins)

 HAART results in partial restoration of

cell mediated immunity
 36% of patients who receive anti-TB and
HAART compared to TB treatment alone
 Low CD4 counts higher risk
 Occurred 4-10 weeks after initiating
treatment
 Increased risk of TB relapse

Karen A Wendel et al. Chest 2001;120:193-197

 Drug malabsorption and resistant TB in HIV
patients (Kalpana Patel, Hartford Hospital)
Drug Optimum Patient Patient
Level One Two
INH 3-5 0.80 0.92
RIF 8-24 0 0
PZA 20-60 24.9 34.81
ETH 2-6 0.40 0.86
Cipro 4-6 0.47 1.3

Serum levels measured after 2 hours of oral administration in ug/ml

Drug malabsorption may contribute to MDRTB

Fixed Dose Combinations (FDC)

 Rifinah/Rimactazid/Rifamate (RFP and

INH)
 Rifater (RFP, INH and PZA)
 Myrin (ETM, RFP and INH)
 Myrin P (ETM, RFP, INH and PZA)
FDC
 Advantages
 Decreases MDRTB
 An effective regimen
 No medication errors
 Patient compliance
 Disadvantages
 Bioavailability, use only FDC approved
 Cost
 Dosage adjustment
DOTS
Directly Observed Treatment,
Short-course (DOTS)
 Government commitment to a NTCP
 Case detection by sputum microscopy
 A standardised short course treatment
under direct observation
 A regular uninterrupted supply of quality
anti TB drugs
 A monitoring and reporting system to
evaluate treatment outcome
 Advantages of DOTS
 Cure rates of up to 95%
 Integrated with primary health care
 Microscopy is cheap and reliable
 Trained health care workers or community volunteers
can supervise
 No hospitalisation or isolation
 Prevents MDRTB
 Reording system ensures cure
 Cost effective
 Combined chemotherapy strategy in TB
control

DOTS

No specific
chemotherapy
T
B

Drug susceptible TB

Specific
chemotherapy
Time
Defaulter tracing and
retrieval
 Defaulter
 Missed 25% of treatment doses in one
month
 Retrieve by phone call, letter on same
day
 Home visit if not turn up by 3rd day
Prevention of TB among Health
Care Workers (HCW)
 Transmission of TB to HCWs depends
on:
 Number of patients with active TB
 The infectiousness of the index case
 The ventilation rate of the worker
 The duration of exposure
 The air-exchange rate in the interior space
TB and HCW
 Administrative controls
 Developing and implementing effective protocols
for rapid identification, isolation and treatment
 Effective work practices by education, training and
counseling
 Engineering control
 Prevent spread and reduce concentration of
infectious droplet nuclei (exhaust fan, unidirectional
flow, ultraviolet germicidal irradiation, biological
safety cabinets classII)
 Personal respirator protection
Surveillance of HCWs for TB

 All HCW have CXY on employment

 Those working in high risk area, have
CXR every two years
 Workers with symptoms should be
evaluated for TB
 Infected HCW given long leave
Latent TB Infection (LTBI)
 2 billion people worldwide have LTBI
 Most cases of active TB arise from LTBI
 Improved diagnosis and treatment of
LTBI is a major route of preventing and
decreasing incidence and mortality from
TB
 Direct TST to population at risk
 Offer simple short course regimens (2
months of RIF and PZA)
6th Annual IUATLD Conference Chicago 2001
 Drugs for preventing TB in HIV infected persons

 Seven trials were reviewed

 Preventive therapy compared with placebo
 Lower incidence of active TB (46%) in preventive group
 Incidence of TB reduced in people with positive TST
compared with negative TST
 Death were less frequent in those with positive TST and
taking preventive medicine
 Any regimen (INH alone, INH +RIF or INH + RIF+PZA)
has similar protective effects
 Preventive therapy is effective in reducing death and
active TB in positive TST group

Wilkinson D, Cochrane Review Abstracts

Targeting persistence

 One third of worlds population infected

(1.8 billion)
 8 million with the latent disease develop
reactivation
 30% only fully treated in the world
 5-20% reactivate after treatment
 Stanford researchers identified genes
involved in latency
Persistence and latency

 48 genes involved
 Ability of bacteria to respond to low
oxygen levels and increased nitric oxide
 The genes transform the physiological
state, biochemical pathways and
structure of organism
 Drug strategy for latency
Surgery in
Tuberculosis
Surgery in Tuberculosis

 Pneumothorax
 Empyema
 MDRTB
Pneumothorax

Treatment
 Observation & bed rest
 Aspiration
 Chest tube drainage
 Pleurodesis
 Surgery
 Pneumothorax Treatment
Observation

Small (<20%), asymtomatic, good health

Rate of air resorption = 1.25% or 50-70ml/day

O’Rourke and Yee Chest 96:1302 1989

- 5% (2/40) mortality - tension pneumothorax
- 22.5% - subsequent chest drain

- Prolonged observation (>14 days)

Entrapped lung with chronic pneumothorax

Chest tube or aspiration if not re-expanded after one week

Pneumothorax Treatment
Aspiration
 Success rate = 50%

 Recurrence rate = 20-50%

Pneumothorax Treatment
Tube Thoracostomy
 Moderate – large pneumothorax
 Rapid re-expansion of the lung
 Air leak usually stops within 48 hours

 Allow chemical pleurodesis to be

performed. Eg talc, tetracycline,
bleomycin
Pneumothorax Treatment
Recurrence
 Observation 30%
 Aspiration 20-50%
 Chest tube drainage 20-30%
 Pleurodesis (tetracycline) 25%
 Pleurodesis (talc) 7%

 Surgery 2%
Pneumothorax
Indications for Surgery
First episode
 Tension pneumothorax
 Bilateral pneumothoraces
 Haemo-pneumothorax <5%

 Non re-expansion of the lung

 Prolonged air leak (>3-4 days) – 3-5%

 Occupational hazard (flight personnel, divers, frequent flyers)

 Associated single large bullae
 Live in isolated remote area with no medical facilities

Second episode
 Ipsi-lateral recurrence
 Contra-lateral recurrence
Pneumothorax Treatment
Surgical Approach
Thoracotomy
 Conventional
 Limited muscle sparing

VATS (Video assisted thoracoscopic

surgery)
 Three small incisions
 Allow bilateral procedures
EMPYEMA THORACIS
Indication for Surgery
Empyema Thoracis

Paget 1896
 “….unhealed empyema is, as a rule, the
direct result of patient’s neglect, or of the
surgeon’s delay, or of inadequate and
useless surgery. ”
Empyema Thoracis

Sir William Osler 1892

“ It is sad to think of the number lives which
are sacrificed annually by the failure to
recognize that empyema should be
treated as an ordinary abscess by free
incision”

Open drainage with rib resetion

recommended
Empyema Thoracis

Evarts Graham – Am J Med Sci 1918

Open drainage – 30% mortality

Empyema Thoracis

The Empyema Commission

– Evarts Graham 1925

 Recommended closed tube drainage

5-10% mortality
American Thoracic Society
Pathological Stages
Acute
1: Exudative, pleural swelling
2: Fibrinopurulent, with heavy fibrin
deposits

Chronic
3: Organization with in growth of fibroblasts
and deposition of collagen (4-6 weeks)
Empyema Thoracis

Complications
 Pulmonary fibrosis and contraction of chest wall
 Spontaneous Drainage
1. empyema necessitatis
2. brochopleural fistula
3. osteomyelitis
4. pericarditis
5. mediastinal abscess
Management
Acute Empyema
 Nutrition, physiotherapy, underlying
medical condition

 Anti TB treatment is vital

 Drainage
Management
Acute Empyema
Drainage – cornerstone
1. evacuation of pus
2. apposition of pleural surfaces and
obliteration of pleural space

Must be performed as early as possible

Acute Empyema
Pleural Drainage

Conservative
1. Closed tube drainage
2. Intra-pleural fibrinolytics (streptokinase or
urokinase)

Surgical
1. Video assisted thoracoscopy
2. Thoracotomy – limited, muscle sparing, full

Refer early
Acute Empyema
Pleural Drainage

Minimum size 32F recommended

 Works best before formation of loculi

Principle
All infected fluid and pus must be drained
Empyema Thoracis
Indications for Surgery

 Evidence of significant residual effusion on CXR

despite chest drain insertion
 Non-reexpansion of the lung after evacuation of
empyema
 Multiple loculated collections demonstrated on
ulrasound or CT
 Chronic empyema with trapped lung
 Complications
Empyema Thoracis
Pleural Drainage
CT or ultrasound guided pigtail catheter drainage
in multi-loculated pleural empyema: a
recommended procedure?.
Maier A Respirology. 5(2):119-24, 2000 Jun.

RESULTS:
 Image-guided drainage failed in all (14/14)
patients.
 Septic symptoms disappeared within 24-48 h
after surgery with decortication.
Empyema Thoracis
Intrapleural fibrinolytics

38-100% Success in Resolution of empyema

 69% (18/26) of patients. Temes RT. Chest. 110(1):102-6, 1996 Jul.
 77% (10/13 patients) Robinson Ann Thor Surg 1994;57:803

Cochrane Database of Systematic Reviews [computer file].

(3):CD002312, 2000
- Results not consistent across studies to
recommend routine use
 Empyema Thoracis
Intrapleural fibrinolytics
 Controlled trial of intrapleural streptokinase in the treatment of pleural
empyema and complicated parapneumonic effusions.
Chin NK. Lim TK. Chest. 111(2):275-9, 1997 Feb.

 RESULTS: The incidence of surgical decortication was 17% and mortality

was 15%.

 There were no significant differences between the two treatment groups in

terms of the need for surgical intervention, or mortality rates.

 Twenty-nine patients were treated with Drain only

 23 received, in addition, repeated daily SK, 250,000 U in saline solution (mean, 5.3 days).
Empyema Thoracis
Operative Drainage
 Mortality rate
drain alone 24% vs SK+ early OP = 3%

 The average duration of hospital stay in the SK+early OP

group was significantly shorter than in the Drain and IP-
SK groups.

Lim TK. Chin NK. National University Hospital, Singapore

Empirical treatment with fibrinolysis and early surgery reduces the duration of hospitalization in
pleural sepsis.
 European Respiratory Journal. 13(3):514-8, 1999 Mar.
 1) Drain (n=29, chest catheter drainage);
 2) IP-SK (n=23, adjunctive intrapleural fibrinolysis with 250,000 U x day(-1) SK)
 3) SK+early OP (n=30, early surgical drainage was offered to patients who failed to respond promptly following initial
drainage plus SK).
 Empyema Thoracis
Video Assisted Thoracoscopy
VATS
 Fibrino-purulent stage with loculated collections

Success rate
 71% (48/67)
Striffeler H. Gugger M. Annals of Thoracic Surgery. 65(2):319-23, 1998 Feb.

 68% (30/44)
Lawrence DR. Ohri SK Annals of Thoracic Surgery. 64(5):1448-50, 1997 Nov.

 28% (2/7) children

Steinbrecher HA. Najmaldin AS.Journal of Pediatric Surgery. 33(5):708-10, 1998
May
Chronic Empyema
Options
1. Thoracotomy and decortication

2. Rib resection & open drainage

3. Space sterilization
4. Muscle or omentum transposition
5. Thoracoplasty
6. Total pleuro-pneumonectomy
Empyema Thoracis
Thoracotomy

 Significant complications in children who had

delayed thoracotomy.
 Early thoracotomy hasten patient recovery
regardless of the stage of disease.

Recommend aggressive early operative approach

to empyema thoracis
Shankar KR. Acta Paediatrica. 89(4):417-20, 2000 Apr
Renner H. Gabor S. European Journal of Cardio-Thoracic Surgery. 14(2):117-22, 1998 Aug.
.
Empyema Thoracis
Conclusions (1)

 Acute empyema is easily treated

 Chronic empyema has high morbidity
and mortality

Chronic empyema is avoidable

Empyema Thoracis
Conclusions (2)
 Early chest drain insertion
 Early surgical referral

Aggressive = Quick Recovery

Conservative x8 mortality
Lim TK. Chin NK. European Respiratory Journal. 13(3):514-8, 1999 Mar.
Empyema Thoracis

“Early recognition of complicated

empyema and institution of surgical
interventions as primary therapy
rather than as a last resort will likely
result in improved survival and
shortened hospital stay”
Ferguson MK: The Healing Hand. Chest 97:4, 1990
Chest Drain
Chest Drain
Closed Water seal System
 Gotthard Bülau 1891 –Hamburg,
Germany
Indications for Chest Tube

 Pneumothorax
 Haemothorax
 Empyema
 Pleural effusion
 Chylothorax
 Post-op – Thoracic & cardiac
Chest Tubes

 6Fr (paediatric) to 40Fr

 Pure pneumothorax – minimum 24Fr
 Haemothorax, effusion and empyema –
minimum 28Fr recommended

 Drains with multiple side holes preferred

Insertion site
 3rd to 5th intercostal space in the anterior axillary
or mid-axillary line behind the pectoralis muscle
 Advantages
 No muscles other the intercostals
 Scars less visible
 More comfortable

 Avoid the front (muscles and breast) and the

back ( painful)
Insertion technique

 Aseptic technique
 Local anesthesia with lignocaine 3mg/kg
from skin down to pleura
 Aspirate air or fluid to confirm location
Insertion technique

 2cm incision just above the rib

 Blunt dissection with artery forceps over
the superior border of the rib into the
pleural space
 Finger palpation to confirm entry into the
pleural space; absence of adhesions
and loculated space
 Introduce the drain to apex or basal
space
 Anchor the drain with a simple skin stitch
( number 1 or 0 size)
 Another simple stitch for later skin
closure after removal of drain
 Confirm the drain is swining well /
bubbling or draining

 CXR to check position / lung re-

expansion / drainage
Insertion technique
 Should be painless if done properly (infiltrate
lignocaine widely and the right space)

 Avoid trocar ( can puncture lung, heart, spleen,

liver, oesophagus, aorta and diaphragm)

 Avoid purse-string ( ugly puckered scar)

 Simple dressing
Tube Management

Monitoring
 Early and daily CXR
 Air leak and fluid drainage

 Maintain tube patency (swinging)

 Ensure air–tightness of closed system
Tube Removal
 Complete lung re-expansion >48 hours
 No air –leak
 Drainage <100ml / 24 hour

 Clamping of tube not necessary, probably in

cases with intermittent air leak

 Removed at and inspiration or when

peforminga Valsava maneuver
 Check CXR
One way Drainage System
One way Drainage System

Advantages
 Cheap
 Simple

Problems
 Higher resistance
with fluid
accumulation
 Foaming
Suction Device
Indications for Suction

 Failure of lung to re-expand with good

size patent chest drain
 To promote drainage of blood and fluid

Contra-indications
 Massive bleeding
 Pneumonectomy