Empyema Thoracis Flashcards
Definition
pus collection in pleural Space
Diagnostic criteria
Aspiration of grossly purulent material on thoracentesis + 1 of the following
• Pleural fluid with positive gram stain or culture
• Pleural fluid glucose <40 milligrams / dl
• Pleural fluid pH <7.1
• Pleural fluid lactate dehydrogenase > 1000IU/L
Causes of empyema
Bacteria pneumonia
Complications of penetrating trauma / abdominal trauma
Esophageal perforation
Extension form lung abscess , osteomyelitis , other near pleural infections
Infected hemothorax, chylothorax, hydrothorax
Iatrogenic (complication of lung or thoracic surgery, inoculation of pleural cavity after thoracenteris or chest tube placement )
Extension of subdiaphragmatic or para vertebral abscess
Risk factors of empyema
bacteria pneumonia
Age (Children, Elderly)
Debilitation
Comorbidities diseases (Bronchiectasis,Rheumatoid arthritis)
Alcoholism
Diabetes
GERD
Neurologic dx
Malignancy
HIV, Immunocompromised
Signs and symptoms of empyema
preceded by pneumonia (Coughing, Fever! Pleuritic Chest pain , Malaise
Onset may be insidious
Chronically ill (Weight loss)
night sweats
Anemia
Dehydration
Halitosis
Hemoptysis
Offensive sputum woth fetid odor
Findings of empyema in examination
Look like pleural effusion
Dull percussion
Decreased tactile fremitus
Stages of empyema
Exudative (1-3 days )
Fibrinopurulent ( 4-14 days )
Organizing stage ( after 14 days )
Characteristics of exudative stage
Immediate response
Outpouring of fluid
Low cellular content
Parapneumonic effusion with normal pH and glucose levels
Pleural fluid/serum protein more than 0.5
LDH less tha 1000 IU/L
Gram stain and culture negative for organism
Characteristics of fibrinopurulent stage
Increased polymorphonuclear leukocytes
Fibrin accumulation
PH and glucose fall
LDH rises
Effusion become purulent and viscous => empyema
Loculation and formation of limiting membranes
Ph less than 7.10
Glucose less than 40 mg/dl
LDH more than 1000IU/L
Positive gram stain and culture
Characteristics of organizing stage
Fibroblast grow into exudates on both visceral and parietal pleural surface
Inelastic membrane forms => the peel which can prevent entry of antibiotics in pleural space making treatment ineffective
Peel also lead to Restriction of lung movement known as trapped lung
Clinical features when pneumonia associated with empyema
Symptoms that do not resolve such as cough, fever, pleuritic chest pain, malaise
Clinical features of empyema
Insidious symptoms
Chronically ill like weight loss
Night sweats
Anemia
Dehydration
Halitosis
Hemoptysis
Offensive sputum
Examination findings
Decreased tactile fremitus
Dullness on chest during percussion
Imaging to do
Chest x ray to find parapneumonic fluid
Pleural US (echo genie , swirling fluid witching pleural effusion)
CT scan of chest
What are the findings in empyema when doing thoracocentesis
Macroscopic features of purulent / turbid fluid
Positive bacterial cultures
Glucose <40mg/dl
PH<7.1
LDH>1000 IU/L
ADA > 60 U/L IN tuberculous pleural empyema
What others diagnostic tools are used in empyema
Flexible bronchoscopy in bronchial fistula or obstruction
Pleural biopsy
Diagnostic videothoracoscopy
Diagnostic thoracotomy
Sputum culture
Pleural fluid culture
Blood culture sometimes
Pleural fluid PCR or strep antigen
AIM of treatment
Control the infection
Pus drainage
Expansion of lungs
Main antibiotics use to control infection
Clindamycin in anaerobic organisms
Cephalosporin , aminoglycosides in anti staph
Method used for drainage of pus
CT scan or USG guided drainage when small empyema
Or
Chest tube drainage to do until 30-50ml left per day
Or
Surgical drainage ( open drainage , rib resection and drainage , thpracotomy and décortication ) in complicated cases
Complications of empyema pain
Dissection into lung parenchyma (bronchopleural fistulas , pyopneumothorax )
Dissection into chest wall => empyema nécessitatis
Dissection into abdominal cavity
Skeletal deformity (scoliosis )
Fibrothorax
