Empyema

Mohamad hafyfy bin Mhd Alias

070100415

Pleural Empyema / Pyothorax / Purulent Pleuritis / Empyema Thoracis

Accumulation of pus in the pleural cavity

Stages
Acute (exudative) stage:
Approximately in 3-7 days

Pleura fills with thin serous fluid that shows one or more of these criteria;
- Ph < 7.4 - Glucose <40 mg/dl - LDH> 1000 iu/dl - Protein > 2.5 gm/dl

Stages
Transitional (Fibrinopurulent) stage:
From day 7 to 21 day

Thick,opaque fluid with positive culture (pus) and deposition of thin fibrin layer over the pleura. Progressive loculation and formation of pouches in the pleura.

Stages
Chronic (organizing) stage:
after 21 days

Presence of very thick pus Thick inelastic peel over both pleura causing entrapment of the lung (abscess formation)

Clinical stages
Acute stage : within the first 2 weeks of the onset.

Chronic Stage : after 2 weeks or with the formation of the thick peel and loculations.

Causes of chronicity
Inadequate tube drainage. Chronic pulmonary disease ( T.B. or fungal Infection) Immunosupressed patients.

Presence of foreign body within the pleural space.

Complications
Rupture into the lung: Bronchopleural fistula Spread to the subcutaneous tissue: Empyema Niscitanes Septicaemia & septic shock.

Symptoms & Signs

The signs and symptoms of empyema vary according to the location of the infection and its severity Patients usually exhibit symptoms of pneumonia, including fever, fatigue, cough, SOB, and chest pain In severe cases, the patient may become dehydrated, cough up blood, greenish brown sputum, or run a fever as high as 40C, or even fall into a coma

Diagnosis
On a chest X-ray, empyema will appear as a cloudy or opaque area In physical examination:
Contralateral tracheal shift possible with large effusions Decreased tactile fremitus Dullness to percussion Decreased or absent breath sounds

The diagnosis of empyema has to be confirmed with laboratory tests based on fluid analysis because its symptoms can be caused by other disease conditions. Aerobic pus usually gives off a little odor

Investigations
Chest X-ray C-T scan Ultrasonography Thoracentesis

Chest X ray

The white patch in both x-ray photographs is due to the presence of pus.

CT scan

Arrows point at pleural empyema seen on a chest CT scan

USG

Ultrasound image of a large parapneumonic effusion demonstrates thick septations (white arrows) within the fluid in keeping with an exudate

Thoracentesis
This is a procedure which involves the insertion of a needle into the pleural cavity through the back between the ribs on the infected side, and a sample of fluid is withdrawn It is performed under local anesthetics If the patient has empyema, there will be leukocytosis, a high level of protein, and a very low level of blood sugar

Thoracentesis
This is the most useful test that conducts analysis of aspirated pleural fluid which shows: transudative effusions: lactate dehydrogenase (LDH) levels less than 200 IU and protein levels less than 3 g/dl exudative effusions: ratio of protein in pleural fluid to serum greater than or equal to 0.5, LDH in pleural fluid greater than or equal to 200 IU, and ratio of LDH in pleural fluid to LDH in serum greater than or equal to 0.6 empyema: acute inflammatory white blood cells and microorganisms empyema or rheumatoid arthritis: extremely decreased pleural fluid glucose levels

Management
Control of the Infection process Drainage of pus form the pleura Obliteration of the space & complete Reexpansion of the Lung

Management
Early-course: aspiration, Ab, and sometimes fibrinolytic therapy

Late-course: continuous drainage or surgical debridement & decortication

Management
Empyema is treated using a combination of medications and surgical Treatment with medication involves intravenously administering a two-week course of antibiotics It is important to give antibiotics as soon as possible to prevent first-stage empyema from processing to its later stage The antibiotics most commonly used are penicillin and vancomycin.

Management
In 1st stage empyema, give Ab and fibrinolytic therapy, drainage if effusion is significant In 2nd stage empyema, insertion a chest tube in the patients rib cage or remove part of a rib (rib resection) In 3rd stage empyema, cuting or peel away the thick fibrous layer coating the lung, a procedure which is called decortication

Ab therapy
Dependent on identification of causative organism Appropriate therapy requires isolation of organism from blood, pleural fluid or sputum Empiric therapy should be based on local epidemiology and should cover S. pneumonia, S. pyogenes and S. aureus Broad spectrum therapy with Ceftriaxone/Cefotaxime plus Clindomycin

Fibrionlytic therapy
Studies used Streptokinase or Urokinase Most effective in the early fibrinopurulent stage and may make surgical drainage unnecessary Indications:
- Acute or fibrinopurulent stage - Presence of loculations - Incomplete drainage after tube insertion

Contraindications:
- Chronic stage - Post-operative empyema - Empyema with broncopleural fistual

Chest drainage/Rib resection

First step in treating acute empyema Performed under general anesthesia when the pus is thick and loculated Open all the intact cyst that leads to conversion of empyema with free pus Then place intercostal tube for drainage and close the wound Antibiotics should continue for 6 weeks

Video assisted troracoscopy surgery

Minimally invasive Can be used at any stage Advantages includes: - Allowance of direct visualization of pleura and lung - Optimal placement of chest tube - Fibrinolysis & decortication can be performed - less pain and faster recovery

Troracotomy
Open drainage with pleural peel decortication Excision of the thick fibrous pleural and removal of infectious material Longer & complicated procedure Reserved for late presenting empyema with significant fibrous pleural, complex empyema & chronic empyema

Eloesser Flap Drainage

Open chest drainage (Eloesser flap). Once the ribs have been resected, the skin overlying the thoracostomy is marsupialized to the parietal pleura to permit packing and open pleural drainage.