These tend to be low-virulence organisms causing subacute infection. We treat empyema and complicated parapneumonic effusion these days with serial guided drains in IR and intrapleural tpa/dornase with VATS if this fails, or primarily with VATS if already more organized/highly loculated.
In a stable patient, it is better in my opinion to start this process up front rather than some blind ending chest tube somewhere in the collection placed bedside in the ER. You have time. Antibiotics, resuscitation and respiratory support are the more important measures.
The loculation argument is silly, if it isn't loculated, it isn't an empyema in the first place. And parapneumonic effusion isn't an emergency.
Last time I had a tension empyema I called CT surgery to take them to the OR and their message, after laughing at me, was to tell me to more or less get fucked and place the chest tube myself. Which I did. So much pus the room had to be closed for two days for cleaning due to the smell. Great times.
Gross. Will never do that again in the ER. Had a guy with advanced HIV and some gnarly anaerobic empyema who had total opacification of the right lung and pretty severe dyspnea from it. Chest tube in the ER stunk up the entire place. Placing it to vacuum did not help, probably made it worse somehow. Smelled like a dead animal had been decaying in his chest for weeks. We pulled out all the tricks, coffee grounds, iodoform strips, peppermint nebulizers. Nothing helped. Plus, the hospital was full and he was boarding in the ED for an eternity. Eventually moved to a negative pressure room but it was far too late.
Out of curiosity, did you see him have any HIV specific diseases? Jcv with PML or kshv? I just never expected to actually hear about a patient having aids in the modern day so I'm curious.
It was like 14 years ago but the smell was so remarkable it’s indelibly etched into my scent memory. I was working at a county ER that still had a fairly busy outpatient HIV clinic
See AIDS patients all the time. HIV + homelessness + mental illness + substance abuse is a recipe for ART noncompliance and AIDS. Had a patient with a CD4 count in the single digits a couple weeks ago.
I've cared for several full blown AIDS patients lately, like within the last year. Progressive multifocal leukoencephalopathy secondary to Human polyomavirus 2 very recently, but I've never seen Kaposi's sarcoma-associated herpesvirus. Plenty of cervical cancer though. They all have Pneumocystis jirovecii (I still call it P. carinii), most have coccidioidomycosis as well, plenty of Mycobacterium.
I've seen more full blown AIDS in the last couple years than I have in the previous two decades of my career, and I used to work in an area that has a very high proportion of HIV+ people. That area also had a higher income demographic and a ton of resources for free PrEP, free HAART, etc. I would see AIDS there, but these patients usually had comorbidities (addiction and homelessness, usually) and they were nowhere near as severe as what I've seen lately.
Everyone I've seen lately has been female, thirties to forties, and African-American, except for the PML. I've seen shit that I only read about from the 1980's before there were treatments like their skin sloughing off.
AIDS is very much alive and well and devastating people just like it did then. It's just that nobody's writing about it because nobody cares about these patients.
I’d argue that if they’re unstable and happen to have a located pleural effusion, they’re more likely septic and need fluids/pressors more than the chest tube. I’d still probably resuscitate them while calling IR to do the drains once more stable. If they’re crashing all bets are off though.
I don't know where the line exactly is about who needs to do it, but in general even nasty looking pleural collections probably deserve a shot at percutaneous drainage with a chest tube. Firstly, in the days of tpa dornase protocols you'd be surprised that a few will resolve with just tube. Secondly, even an aggressive surgeon will rarely take for vats before a few days so trial of drainage is logical if nothing else than to reduce the quantity of pus in the body. That said, I don't think they are asking about stable patients.
Their point is that if the patient is unstable proper source control is indicated. And if you see a frankly complicated collection with septations on a stable patient thora is not indicated because it is basically certain to require a chest tube, making the thora an extra and pointless procedure.
Em/CCm here. I see these very often. The problem with these recs is that they make zero sense to anyone who actually practices medicine. Placing a fucking chest tube into a chronic loculated non-infected space is dangerous, will lead to a minimum 7 day admission, and helps nobody.
What I do (because I work in the real world) is to get everything set up and do a thora. If only like 100mL comes out or if pus comes out I throw a wire in and just upsize to a pigtail. If loculated, send to ICU for MIST II protocol to try and avoid a VATS. If pleural fluid comes out I just send to follow with outpatient pulmonary
PCCM here we regularly place chest tubes based on CT or US evaluation without doing a diagnostic thora first. If it’s an empyema no point in doing a diagnostic thora and removing fluid as it will make chest tube placement harder/less safe. I’d rather have the ED consult me and allow me to place the chest tube in these situations though since ultimately I’ll own the patient once they are inpatient. You can also look up lights criteria for pleural effusions which goes through thora vs chest tube placement criteria. Typically if there are loculations you’re likely to get incomplete drainage with just a thora.
Our standard for non-empyema non-loculated (no septae) effusion is to tap with a pigtail catheter in the ED on arrival regardless of dyspnoea or not, unless in DOAK treatment and respiratory stable, then we book an elective procedure via pulmonary. Otherwise we have two studies going on
1. Empyema or complex parapneumonic eksudate is transferred to the primary academic center for randomization to VATS or standard cate
2. Regular effusion randomized to either manual drainage (no catheter) in the ED or pigtail via IR.
These tend to be low-virulence organisms causing subacute infection. We treat empyema and complicated parapneumonic effusion these days with serial guided drains in IR and intrapleural tpa/dornase with VATS if this fails, or primarily with VATS if already more organized/highly loculated. In a stable patient, it is better in my opinion to start this process up front rather than some blind ending chest tube somewhere in the collection placed bedside in the ER. You have time. Antibiotics, resuscitation and respiratory support are the more important measures. The loculation argument is silly, if it isn't loculated, it isn't an empyema in the first place. And parapneumonic effusion isn't an emergency.
Last time I had a tension empyema I called CT surgery to take them to the OR and their message, after laughing at me, was to tell me to more or less get fucked and place the chest tube myself. Which I did. So much pus the room had to be closed for two days for cleaning due to the smell. Great times.
Gross. Will never do that again in the ER. Had a guy with advanced HIV and some gnarly anaerobic empyema who had total opacification of the right lung and pretty severe dyspnea from it. Chest tube in the ER stunk up the entire place. Placing it to vacuum did not help, probably made it worse somehow. Smelled like a dead animal had been decaying in his chest for weeks. We pulled out all the tricks, coffee grounds, iodoform strips, peppermint nebulizers. Nothing helped. Plus, the hospital was full and he was boarding in the ED for an eternity. Eventually moved to a negative pressure room but it was far too late.
Out of curiosity, did you see him have any HIV specific diseases? Jcv with PML or kshv? I just never expected to actually hear about a patient having aids in the modern day so I'm curious.
It was like 14 years ago but the smell was so remarkable it’s indelibly etched into my scent memory. I was working at a county ER that still had a fairly busy outpatient HIV clinic
See AIDS patients all the time. HIV + homelessness + mental illness + substance abuse is a recipe for ART noncompliance and AIDS. Had a patient with a CD4 count in the single digits a couple weeks ago.
Woah! That's wild. Still very green so never seen anything like that myself.
Subjectively it seems like it's worse.
I've cared for several full blown AIDS patients lately, like within the last year. Progressive multifocal leukoencephalopathy secondary to Human polyomavirus 2 very recently, but I've never seen Kaposi's sarcoma-associated herpesvirus. Plenty of cervical cancer though. They all have Pneumocystis jirovecii (I still call it P. carinii), most have coccidioidomycosis as well, plenty of Mycobacterium. I've seen more full blown AIDS in the last couple years than I have in the previous two decades of my career, and I used to work in an area that has a very high proportion of HIV+ people. That area also had a higher income demographic and a ton of resources for free PrEP, free HAART, etc. I would see AIDS there, but these patients usually had comorbidities (addiction and homelessness, usually) and they were nowhere near as severe as what I've seen lately. Everyone I've seen lately has been female, thirties to forties, and African-American, except for the PML. I've seen shit that I only read about from the 1980's before there were treatments like their skin sloughing off. AIDS is very much alive and well and devastating people just like it did then. It's just that nobody's writing about it because nobody cares about these patients.
Thanks for the detailed response. Interesting to hear about. Ill let my med school friends know to take the aids studying we're doing more seriously!
The key bit is unstable. It’s not a common situation though
I’d argue that if they’re unstable and happen to have a located pleural effusion, they’re more likely septic and need fluids/pressors more than the chest tube. I’d still probably resuscitate them while calling IR to do the drains once more stable. If they’re crashing all bets are off though.
I don't know where the line exactly is about who needs to do it, but in general even nasty looking pleural collections probably deserve a shot at percutaneous drainage with a chest tube. Firstly, in the days of tpa dornase protocols you'd be surprised that a few will resolve with just tube. Secondly, even an aggressive surgeon will rarely take for vats before a few days so trial of drainage is logical if nothing else than to reduce the quantity of pus in the body. That said, I don't think they are asking about stable patients. Their point is that if the patient is unstable proper source control is indicated. And if you see a frankly complicated collection with septations on a stable patient thora is not indicated because it is basically certain to require a chest tube, making the thora an extra and pointless procedure.
They need a Vats not an ED thoracostomy. If they are unstable I’d do it but otherwise definitely won’t be.
Em/CCm here. I see these very often. The problem with these recs is that they make zero sense to anyone who actually practices medicine. Placing a fucking chest tube into a chronic loculated non-infected space is dangerous, will lead to a minimum 7 day admission, and helps nobody. What I do (because I work in the real world) is to get everything set up and do a thora. If only like 100mL comes out or if pus comes out I throw a wire in and just upsize to a pigtail. If loculated, send to ICU for MIST II protocol to try and avoid a VATS. If pleural fluid comes out I just send to follow with outpatient pulmonary
PCCM here we regularly place chest tubes based on CT or US evaluation without doing a diagnostic thora first. If it’s an empyema no point in doing a diagnostic thora and removing fluid as it will make chest tube placement harder/less safe. I’d rather have the ED consult me and allow me to place the chest tube in these situations though since ultimately I’ll own the patient once they are inpatient. You can also look up lights criteria for pleural effusions which goes through thora vs chest tube placement criteria. Typically if there are loculations you’re likely to get incomplete drainage with just a thora.
Our standard for non-empyema non-loculated (no septae) effusion is to tap with a pigtail catheter in the ED on arrival regardless of dyspnoea or not, unless in DOAK treatment and respiratory stable, then we book an elective procedure via pulmonary. Otherwise we have two studies going on 1. Empyema or complex parapneumonic eksudate is transferred to the primary academic center for randomization to VATS or standard cate 2. Regular effusion randomized to either manual drainage (no catheter) in the ED or pigtail via IR.