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Ann Thorac Surg 1998;66:1121-1127
© 1998 The Society of Thoracic Surgeons

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Original articles: general thoracic

Evaluation of treatment modalities for thoracic empyema: a cost-effectiveness analysis¹

^a Section of General Thoracic Surgery, Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Georgia, USA

Address reprint requests to Dr Miller, Section of General Thoracic Surgery, 25 Prescott St, Suite 3420, Atlanta, GA 30345

Presented at the Thirty-fourth Annual Meeting of The Society of Thoracic Surgeons, New Orleans, LA, Jan 26–28, 1998.

Abstract

Background. Empyema thoracis is treated with a multitude of therapeutic options. Optimal therapy and cost-containment requires selection of the most appropriate initial intervention.

Methods. A retrospective review of treatment modalities was performed on 77 patients diagnosed with empyema thoracis from 1990 to 1997 at one institution. Mean age was 59 years (range, 21 to 90 years); 52 were men and 25 were women.

Results. Sixty-five percent (50/77) were parapneumonic and 68% (52/77) were multiloculated. Treatment modalities were as follows: group 1, antibiotics only (n = 4); group 2, primary intervention: image-directed catheter (n = 20) or tube thoracostomy (n = 24); and group 3, secondary intervention: decortication (n = 17), rib resection or muscle interposition (n = 12). Thirty-four percent (9/20 image-directed catheter and 8/24 tube thoracostomy) had failure of initial intervention. Patients undergoing decortication more often had multiloculated empyema thoracis (16 of 17) compared with those undergoing image-directed catheters (8 of 20) or tube thoracotomy (16 of 24). Length of stay was reduced for decortication patients (17 days) compared with those having image-directed catheters (21.8 days), failed image-directed catheters (29.7 days), or tube thoracostomies (19.6 days). Hospital charges per patient between decortication and image-directed catheter ($34,770.79 versus $37,869.41) were comparable, but charges were significantly decreased in decortication patients as compared with failed image-directed catheters ($55,609.32; p < 0.05).

Conclusions. Our series revealed that early decortication has charges similar to those of primary intervention (image-directed catheter or tube thoracostomy) but is more cost-effective than failed image-directed catheter. We advocate the use of early surgical intervention as the most optimal and cost-effective initial modality for the treatment of empyema thoracis.

Since the era of Hippocrates [1], empyema thoracis (ET) has been recognized as a debilitating disease process. Empyema thoracis has a higher frequency and is more devastating in elderly and immunocompromised populations. The most common cause of ET is parapneumonic, whereas thoracic surgical procedure, trauma, esophageal perforation, cystic fibrosis, foreign body, chest wall infections, and subdiaphragmatic abscesses are less common [2, 3]. Therapy for ET requires appropriate antibiotics, drainage of the infected space, and reexpansion of the lung [4]. However, the most appropriate and cost-effective management of ET remains controversial. Initially, most cases are treated by repeat aspiration (thoracentesis), image-directed catheters (IDC), or tube thoracostomy (CT). Traditional surgical approaches include decortication, video-assisted thoracoscopic surgery, rib resection, and open drainage with or without a musculoskeletal flap reconstruction. Despite various treatment options, ET remains associated with mortality ranging from 1% to 19% [5].

The treatment of ET poses a considerable medical expense to society. Of the approximately 1.2 million persons affected by pneumonia in the United States, nearly 5% or 60,000 persons will develop a parapneumonic empyema [6]. Furthermore, with an aging population and an increase of intravenous drug abusers and acquired immunodeficiency syndrome-related pulmonary complications, the incidence in pneumonia is not likely to diminish. In this study, we retrospectively reviewed treatment modalities and hospital charges in patients diagnosed with ET at one institution.

Patients and methods

Patients
A retrospective review was performed on 77 consecutive patients with a discharge diagnosis of ET at Crawford Long Hospital of Emory University between April 1990 and July 1997. Mean age was 59 ± 1.9 years (range, 21 to 90 years); 52 were men and 25 were women. Empyema thoracis was confirmed in all patients by one of the following three criteria: (1) aspiration of grossly purulent pleural fluid during thoracentesis, IDC, CT, or thoracot-omy; (2) biochemical evidence of pleural fluid defined as pH less than 7.10, lactate dehydrogenase level greater than 1,000 IU/L, glucose level less than 40 mg/dL, protein level greater than 2.5 g, and white blood cell count (WBC) greater than 500/mL; or (3) positive pleural fluid microbiology culture or Gram stain revealing organisms.

Patient charts were retrospectively reviewed for patient age, sex, chief complaint, symptoms, past medical history, first and last WBC count, length of hospital and intensive care unit stay, and mortality. Empyemas were classified by origin, microbiology culture results, and type of loculation (simple or complex). Simple or uniloculated empyemas were defined as a single fluid collection, whereas complex or multiloculated empyemas were defined as more than two fluid collections. The number of chest roentgenograms (standard and lateral decubitus) and chest computed tomography were documented. Treatment modalities were divided into three groups: group 1, antibiotics only (n = 4); group 2, primary intervention: IDC (12F to 14F, n = 20) or CT (n = 24); and group 3, secondary intervention: decortication (n = 17), Eloesser flap (n = 8), and muscle interposition (n = 4). Hospital charges for each patient were accrued from time of admission to Crawford Long Hospital and extended to the time of discharge, but did not incorporate outpatient follow-up visits. Charges were obtained from the Crawford Long Hospital financial department. Follow-up was obtained by chart review or telephone interviews.

Statistics
Statistical analysis involved one-way analysis of variance to determine whether group-related differences occurred [7]. If significant interactions were found, Tukey’s post hoc multiple comparisons tests were applied to locate the sources of differences [7]. A p value less than 0.05 was considered significant, and mean ± standard error of the mean are reported [7].

Results

Seventy-seven patients with a discharge diagnosis of ET were treated at Crawford Long Hospital of Emory University from April 1990 to July 1997. The three most common presenting symptoms (Table 1) for all patients included shortness of breath (46 of 77, 60%), chronic fever (41 of 77, 53%), and chest pain (30 of 77, 39%).

The admission and discharge WBC counts were recorded for all patients (Table 4). Patients who were treated with antibiotics alone had a significantly higher admission WBC count than patients treated with successful IDC, decortication, and surgical flap reconstruction. Similarly, discharge WBC count for patients in group 1 was significantly increased as compared with all other treatment groups (Table 4). The number of chest roentgenograms were significantly reduced in patients in group 1 (Table 4). Although there was a significant increase in chest roentgenograms performed for failed IDC (20.7 ± 1.0) as compared with patients discharged with an empyema tube (12.9 ± 1.3) and patients undergoing flap reconstruction (11.8 ± 2.5), there was no significant difference from patients undergoing decortication (14.1 ± 1.0). The number of computed tomograms (Table 4) performed were significantly increased in patients with successful IDC (2.8 ± 0.5) and failed IDC (3.2 ± 0.6) as compared with patients undergoing decortication (1.3 ± 0.4) or surgical flaps (0.6 ± 0.3).

The length of stay for patients treated with ET was 17 ± 2.5 days (range, 4 to 68 days) and the mean stay in the intensive care unit was 1.8 ± 0.7 days (range, 0 to 40 days) (Table 5). Length of stay was reduced for decortication patients (17 ± 2.1 days) compared with patients with an IDC (21.8 ± 3.9 days) and failed initial IDC (29.7 ± 2.6 days). As expected, patients who underwent flap reconstruction had the longest intensive care unit stay (5.6 ± 1.4 days). There was no significant increase in intensive care unit stay for patients undergoing decortication (1.2 ± 1.0 days) as compared with IDC (1.1 ± 0.4 days). Ten patients (13%) died during the 7-year period (Table 5). All 4 patients (100%) who did not receive any invasive treatment died. Of the remaining 6 patients who died (2 patients had multiple treatment modalities), 2 patients had failed IDC, 3 had chest tubes, 1 had decortication, and 2 had definitive surgical flaps.

The optimal initial intervention for the treatment of ET remains controversial. As economic resources for patient health care continues to be restricted, we must amend our treatment strategies for ET to include the most cost-effective primary intervention. Studies evaluating the most economical treatment strategies for ET are lacking. In this retrospective study of 77 patients diagnosed with ET at a single institution, we have reviewed hospital charges associated with medical and surgical treatment strategies for ET. Our series revealed a similar patient population as compared with reported series [4]. The most common cause of ET was parapneumonic (65%) and most effusions were multiloculated (68%). We stratified our patients into 3 groups: group 1, antibiotics only; group 2, primary intervention: IDC or CT; and group 3, secondary intervention: decortication or open surgical drainage or muscle flap interposition. Thirty-four percent of patients failed primary intervention (IDC or CT) and required surgical intervention. Ninety-four percent of patients who underwent decortication had multiloculated effusions, compared with 40% with IDC and 67% with CT. Furthermore, 78% of patients who failed IDC had multiloculated effusions compared with 9% with successful IDC. Length of stay was reduced for decortication patients (17 days) compared with IDC (21.8 days) or CT (19.6 days). Although hospital charges per patient were comparable between IDC, CT, and decortication ($37,869.41 versus $31,412.69 versus $34,770.79), there was a decrease in charges between failed IDC or CT and decortication ($55,609.32 versus $43,168.63 versus $34,770.79). Our study revealed that early decortication had charges similar to those of primary intervention (IDC or CT), but is more cost-effective than failed IDC. The use of early surgical intervention (decortication) for multiloculated effusions is the most cost-effective initial treatment modality for ET.

Optimal effective treatment for ET requires control of infection, evacuation of pus, and reexpansion of lung. Nonsurgical treatment methods of empyema include antimicrobial regimen, daily thoracentesis and lavage, radiologically guided percutaneous catheter, intrapleural fibrinolytic debridement, or CT [8]. Appropriate systemic antibiotic therapy may reduce the progression of parapneumonic effusions and prevent the formation of an organized empyema by decreasing lung capillary leak and resulting in more rapid clearance of pleural space bacteria [9]. Antimicrobial therapy has been described to successfully resolve small uniloculated pleural infections in 81% of patients with pleural fluid positive for Gram stains or cultures [10]. Nevertheless, most physicians advocate concomitant evacuation of infected pleural space through noninvasive or surgical modalities. All of the patients in our series were placed on appropriate intravenous systemic antimicrobial agents. Of the 4 patients in our series who were treated with antibiotics alone, none survived. All 4 patients had "do not resuscitate" status and were admitted to the hospital for end-stage hospice care.

Radiographic-guided intervention has emerged as a timely, expedient, and accurate modality for the evacuation of pus in ET [11, 12]. Ultrasound is a useful adjunct to standard radiographic imaging when loculation of pleural fluid of empyema is suggested [13]. Ultrasound has the advantage of portability allowing the procedure to be done at the bedside of critically ill patients. However, disadvantages of ultrasound include technician dependence and the fact that marked location is performed by one individual whereas thoracentesis is performed by another individual at a different time [13]. Furthermore, there may be difficulty discerning empyema effusion from nearby consolidated lung, especially if the empyema contains air or extensive echogenic debris [14]. We do not routinely use ultrasound for the placement of IDC in the treatment of ET. The most common radiographic intervention for ET at Emory University Medical Center is the computed tomographic scan-guided placement of drainage catheters. Image-directed catheters inserted using computed tomographic scan localization have been used successfully for the treatment of empyema [15, 16]. Placement of catheters and drainage should be performed as soon as the diagnosis of empyema is confirmed before formation of a visceral or parietal "peel" [13], as organization of the empyema or multiloculation of the effusion will decrease the complete drainage of the pleural effusion or empyema [14]. Success rates with IDC have been reported ranging from 57% to 90% [4, 17]. In our series, 20 patients underwent IDC as their initial intervention for ET. Fifty-five percent of patients required no further treatment. A majority of these patients (91%) presented with uniloculated effusions. However, of the 45% of patients who failed IDC treatment, 78% had multiloculated effusions and required further intervention. In agreement with previous studies [8, 14], we advocate the use of IDC for early uniloculated pleural effusions or ET, but not for multiloculated effusions.

Tube thoracostomy has been used routinely and successfully for the drainage of pleural effusions or ET. The standard option for pleural space drainage is with a surgeon-performed closed-chest CT [18]. The success rates of CT in the treatment of ET has been reported at 35% to 71% [5, 19]. Failures most commonly occur as a result of placement of CT in one loculation of a multiloculated empyema, clogging of the CT with debris or thick pleural effusions, or kinking of the CT. Placement of large-bore CT is facilitated by radiographic placement (ultrasound or computed tomography) in the most dependent portion of the empyema. In our series, 24 patients received CT for treatment of ET. Sixty-seven percent were discharged with empyema tubes and did not require further treatment. Of the remaining 8 patients, all had multiloculated effusions that were not amenable to closed-chest CT or intrapleural fibrinolysis (urokinase or streptokinase) and required surgical debridement.

Nonsurgical treatment modalities are adequate for most patients in whom ET has not organized. However, closed-chest drainage with antibiotics is ineffective once the empyema organizes into the fibrinopurulent stage. In these patients, surgical decortication effectively evacuates the contents of the empyema and facilitates restoration of normal respiratory function by reexpansion of the lung [20]. LeMense and colleagues [4] advocate a short trial (24 to 48 hours) of closed-chest drainage and antibiotics followed with early postprocedural radiologic imaging. If no resolution is appreciated, LeMense and colleagues practice early aggressive surgical approach with minimal morbidity and mortality. Similarly, Pothula and Krellenstein [21], Ashbaugh [22], and Van Way and associates [23] advocate aggressive surgical decortication after a brief trial of closed-chest thoracostomy. Decortication remains the initial treatment of choice in patients with chronic, multiloculated empyema thoracis. In our study, we confirmed that surgical decortication can be effectively performed in patients with multiloculated effusions with excellent success rate and minimal mortality (6%). For patients who may be too ill to tolerate a major thoracotomy or with advanced multiloculated empyemas, we advocate open surgical drainage (modified Eloesser procedure) or muscle flap interposition.

A variety of treatment modalities are available for the treatment of ET. The initial treatment not only depends on the clinical presentation and associated medical illnesses of the patient, but also on the organization or chronicity of the empyema. Moreover, in an era of cost-conscious medicine, the most effective primary intervention for the treatment of ET is still undetermined. Wait and coworkers [24] have shown that video-assisted thoracoscopic surgery as a primary treatment strategy for ET resulted in higher efficacy, shorter hospital stay, and less charges as compared with closed-chest drainage with fibrinolytic therapy. In our study, we conclude that early surgical treatment of multiloculated empyemas with decortication resulted in a reduction in hospital charges from failed CT and a significant reduction from failed IDC. The reduced charges of decortication may be attributed to the reduction in the length of stay and the decrease in the number of high-technological radiology procedures, including chest roentgenograms and computed tomographs.

We have confirmed that surgical decortication is a safe, effective procedure for the treatment of multiloculated ET and have shown that surgical decortication is comparable in charges with the more common noninvasive treatment modalities, but is more cost-effective when these modalities fail.

Footnotes

¹ This article has been selected for the open discussion forum on the STS Web site: http://www.sts.org/annals

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