eMedicine Specialties > Plastic Surgery > Chest

Empyema and Bronchopleural Fistula

Author: Jeffrey J Rentz, MD, Fellow in Surgical Research, Wound Healing and Tissue Engineering Lab, Brigham and Women's Hospital
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
Contributor Information and Disclosures

Updated: Jun 15, 2006

Introduction

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 Procedure

Early 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.

Problem

Empyema 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.

Frequency

Empyema 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.

Etiology

Bronchopleural 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.

Pathophysiology

The 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.

Presentation

Clinical 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.

Indications

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 Anatomy

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.

Contraindications

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.

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