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

 Chronic Stage : after 2 weeks or with the formation of the thick peel and loculations.Clinical stages  Acute stage : within the first 2 weeks of the onset. .

 Chronic pulmonary disease ( T. . or fungal Infection)  Immunosupressed patients.  Presence of foreign body within the pleural space.B.Causes of chronicity  Inadequate tube drainage.

.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. and chest pain  In severe cases. or even fall into a coma . cough up blood. greenish– brown sputum. including fever. the patient may become dehydrated. SOB. fatigue. cough. or run a fever as high as 40˚C.

 Aerobic pus usually gives off a little odor .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.

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 .

and a very low level of blood sugar . and a sample of fluid is withdrawn  It is performed under local anesthetics  If the patient has empyema. there will be leukocytosis.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. a high level of protein.

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 .5.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. LDH in pleural fluid greater than or equal to 200 IU.

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

and sometimes fibrinolytic therapy  Late-course: continuous drainage or surgical debridement & decortication . Ab.Management  Early-course: aspiration.

.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.

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

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

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Acute or fibrinopurulent stage .Post-operative empyema .Chronic stage .Fibrionlytic therapy  Studies used Streptokinase or Urokinase  Most effective in the early fibrinopurulent stage and may make surgical drainage unnecessary  Indications: .Incomplete drainage after tube insertion  Contraindications: .Empyema with broncopleural fistual .Presence of loculations .

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 .

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

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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 .

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