BTS guidelines for the management of pleural infection
- C W H Davies1,
- F V Gleeson2,
- R J O Davies3,
- on behalf of the BTS Pleural Disease Group, a subgroup of the BTS Standards of Care Committee
- 1Department of Respiratory Medicine, Battle and Royal Berkshire Hospitals, Oxford Road, Reading RG30 1AG, UK
- 2Department of Radiology, Churchill Hospital Site, Oxford Radcliffe Hospital, Headington, Oxford OX3 7LJ, UK
- 3Oxford Centre for Respiratory Medicine, Churchill Hospital Site, Oxford Radcliffe Hospital, Headington, Oxford OX3 7LJ, UK
- Correspondence to:
Dr R J O Davies, Oxford Centre for Respiratory Medicine, Churchill Hospital Site, Oxford Radcliffe Hospital, Headington, Oxford OX3 7LJ, UK;
robert.davies{at}ndm.ox.ac.uk
There is great variation worldwide in the management of patients with pleural infection, and approaches differ between physicians.1–14 In the UK up to 40% of empyema patients come to surgery due to failed catheter drainage4 and, overall, 20% of patients with empyema die.4 The process of rapid evaluation and therapeutic intervention appears to reduce morbidity and mortality, as well as health care costs.
This paper presents the results of a peer reviewed systematic literature review, combined with expert opinion, of the preferred management of pleural infection. The clinical guidelines generated from this process are shown in fig 1. The guidelines are aimed predominantly at physicians involved in general and respiratory medicine, and specifically do not cover in detail the complex areas of surgical management or the management of post pneumonectomy empyema.
Flow diagram describing the management of pleural infection.
1 HISTORICAL PERSPECTIVE, PATHOPHYSIOLOGY AND BACTERIOLOGY OF PLEURAL INFECTION
This section provides background information for reference, interest, and to set the management guidelines in context.
1.1 Historical perspective
Pleural infection was first described by Hippocrates in 500bc. Open thoracic drainage was the only treatment for this disorder until the 19th century when closed chest tube drainage was first described but not adopted.15 This technique became widely practised during an influenza epidemic in 1917–19 when open surgical drainage was associated with a mortality rate of up to 70%.16 This high mortality was probably due to respiratory failure produced by the large open pneumothorax left by open drainage.16 This was particularly true of Streptococcus haemolyticus infections which produce streptokinase and probably reduce adhesion formation.16 A military commission investigated this high mortality rate and produced recommendations that remain the basis for treatment today. They advocated adequate pus drainage with a closed chest tube, avoidance of early open drainage, obliteration of the pleural space, and proper nutritional …
