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Empyemapresentation 180425170318 PDF
Empyemapresentation 180425170318 PDF
Mohammad Tailakh
Contents
Definition
Etiology
Stages
Symptoms & signs
Complications
Investigations
Management
Definition
THORACIC EXTRATHORACIC
SEPSIS NON-
SEPSIS IATROGENIC
IATROGENIC
LUNG
PULMONARY OSTEOMYELI SUBPHRENIC
RESECTION,
DISEASE MEDIASTINITIS ABSCESS,
TIS OESOPHAGEAL STABBINGS,G
HEPATIC TEARS, UNSHOT
ABSCESS PARACETESIS WOUNDS,ETC
THORACIS,
PNEUMONIA, TB, LIVER BIOPSY
STERNUM,
BRONCHIECTASIS
VERTEBRAE,
,LUNG ABCESS
RIBS
etiology
PARAPNEUMONIC( secondary to a
pneumonia)the most common
Post trauma.
Post surgery(esophageal or pulmonary(
Subphrenic Abscess
Bacteriological data.
Streptococcus pneumoniae: most common
Increased resistance
Staphylococcus:15-30%
Streptococcus spp
Gram Negative: 20-50%
Klebsiella,
Enterobacter,
Pseudomonas, Hemophilus, E.Coli
Anaerobes:
Fusobacterium, Bacteroides fragilis
Influence of predisposing factors
In adults – empyema arises as a complication of
CAP,often pneumococcal.
Most common empyema in children post-pneumonia
parcent 80% ,adult 20%.
Aerobic gram negative bacilli infection likely to affect
pleura – from below diaphragm or as a result of
oesophageal instrumentation.
Mycobacteria and fungi more common in
immunocompromised.
Uncommon microbial causes
Tuberculous
Fungal – Aspergillous,Cryptococcus,Blastomyces,
Histoplasmosis.
Actinomyces – aerobic gram negative filamentous
bacteria.
Clostridia – anaerobic organism.
Hydatid disease – Echinococcus.
Lung fluke – Paragonimus westermani.
Protozoa – Trichomonas,Entamoeba histolytica.
Pathology-Stages
Stages cont,
Stages cont,
Stage of vascularization:
Fibrinous layers starts to organize as collagen.
Becomes vascularized by ingrowth of capillaries.
Stages cont,
Organizing (chronic) Stage: after 21 days.
Usually 4-6 weeks.
Empyema cavity becomes surrounded by a cortex.
Contains pus.
Inner layers shows inflammatory cells.
Outer layers gets fibrous – exerts restrictive effect.
Compressing the underlying lung (trapped lung
effect).
Draws the ribs together producing chest deformity.
Later on gets calcified – fibrothorax.
RISK FACTORS
alcoholism.
drug use.
HIV infection.
neoplasm .
pre-existent pulmonary disease
.
Symptoms & signs
Depends on nature of infecting organism
competence of patients immune system.
Ranges from complete absence of symptoms to a severe
illness with all usual manifestations of systemic toxicity.
Fever
Cough & Expectoration.
Pleuretic chest pain.
Dyspnoea
Easy fatiguability.
Loss of weight.
Night sweating.
Signs of pleural effusion.
Finger clubbing.
Complications
Size: 20 - 28 F
Passed under USG guidance,helps in
breaking fibrinous septa and pus
rapidly gets removed
Bedside
Pleural Lavage
Isotonic saline
+/- Noxyflex (noxytioline)
Modalités
3 way stopcock
Directly through the CT: 250 to 500 ml
Cautiously if suspicion of broncho-pleural
fistula
Timing:
Immediately after CT placement+++
Once a day until the liquid is clear
Fibrinolytics
Intrapleural Streptokinase;
Indications
Acute or fibrino purulent stage
Presence of loculations.
Incomplete drainage after tube insertion
Contraindications:
Chronic stage
Post-operative empyema
Empyema with BPF.
Fibrinolytics
Was reported in 1949.
Then was abandoned due to allergic reactions,but taken up
again due to availability of purer forms of
streptokinase,urokinase.
(Davies RJO,Trail ZC Thorax 1997; 52:416.)
Urokinase: 100 000 or 300 000 IU .
Streptokinase: 250000 IU .
250.000 IU in 10-20 ml isotonic saline.
Don’t evacuate before 24 to 48 hours.
Constantly associated with fever (38-39°C).
Then evacuate.
Local antibiotics
Intrapleural instillation of antibiotics, especially
metronidazole,Colimycin.
Still debated.
Do not replace systemic treatment.
Video-assisted thoracic surgery
VATS.
If closed drainage does not result in
prompt re-expansion of the lung and
especially if loculi have been identified
by USG.
Decision to intervene early is made.
Debridement and drainage.
Breakage of loculi,evacuating pus,debris
and freeing lung.
Helps in re expansion of lung.
Compare Chest Tube + Streptokinase
(n=9) vs VATS (n=11)
Thoracocentesis
Clear liquid Not clear or purulent effusion
Failure Failure
Hamm et al, ERJ 1997
VATS Surgery
Surgery