Transcript PARAPNEUMONIC EMPYEMA

Purulent chest
disease
Surgery department №2,
DSMA
Effusions classification
• Uncomplicated effusion.
• Thoracic empyema.
Uncomplicated Effusion
• Nonpurulent.
• Negative Gram’s stain result, negative
culture.
• Free flowing, pH 7.3, normal glucose level,
LDH less than 1000 IU/L.
• Most resolve with appropriate antibiotics
treatment and resolution of the pulmonary
infection.
Thoracic Empyema
• Bacteria invade the normally sterile
pleural space.
• Three stage
• Table 58-1
Thoracic Empyema-- Stage 1
• Exudative effusion.
• Increase permeability of the inflammatory
and swollen pleural surface.
• Correspond to the uncomplicated
parapneumonic effusion.
• Sterile, fibrin and PMN may present.
Thoracic Empyema-- Stage 2
• Fibropurulent, true empyema, complicated pleural
effusion.
• Initial-- fluid is clear : WBC greater than 500
cell/μL, gravity greater than 1.08, protein level
greater than 2.5 g/dL, ph less 7.2, LDH reach 1000
IU/L, fibrin deposit.
• Angioblastic and fibroblastic proliferation, heavy
fibrin deposition on both pleura, particularly the
parietal pleura.
• Later– fluid purulent, WBC 15000, ph less 7.0,
glucose less than 50 mg/dL, LDH greater 1000
IU/L.
Thoracic Empyema-- Stage 3
• 1 week after infection-- collagen organization,
entrapment the underlying lung.
• 3-4 week-- mature, turned peel.
• Chronic-- dense fibrosis contraction and trapping
the lung, atelectasis and prolonged pulmonary
infection, reduction the size of hemithorax.
• Fibrothorax-- invasion the chest wall and narrow
the intercostals space-- As the end stage of the
process.
Complication of Empyema
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Early or late.
Necrosis of visceral pleura.
Bronchopleural fistula.
Necrosis parietal pleura and chest wall.
Osteomyelitis of rib or spine.
Esophageal fistula.
Metastatic spread（brain abscess）.
BACTERIOLOGY
• Before antibiotics（1941）, 10% pf pneumonia
develop the empyema, the streptoccus and
pneumococcus were most frequently.
• After antibiotics, the empyema decrease as
mortality. Staphylococcus became the most
prevalent.
• Recently, the penicillin-resistant staphylococcus,
gram’s –negative, anaerobic been predominant
microbes.
BACTERIOLOGY
• Predominant aerobic-- Streptococcus
pneumonia, Staphylococcus aureus, E. coli,
Klebsiella pneumoniae, Hoemophilus
influenzae.
• Predominat anaerobic-- Anaerobic cocci,
pigmented prevotella, porphyromonas,
bacteroid fragilis, fusobacterium spp.
BACTERIOLOGY
• S. pneumoniae responsible for 60%-75%
community acquired pneumonia, only 2% develop
empyema.
• S. aures account 1-2% community-acquired
pneumonia, 10% adult and 50% children develop
empyema.
• In hospital, the staphylococcus and gram’negative
are most common.
CLINICAL FEATURE
• Shortness of breath, cough , chest pain-common to pneumonia.
• Febrile respiratory illness, accentuation,
prolongation the symptoms in pneumonia-alert the possibility of empyema.
• Aerobic empyema-- acute febrile illness.
• Anaerobic empyema-- more indolent,
usually 10 days.
DIAGNOSIS
• Chest x-ray—The posterior lateral
diaphragmatic angle-- The most dependent
position-- Most empyema are found.
(Inverted D or pregnant lady sign).
• Sonography– guide thoracocentesis.
• Fluid analysis.
• Aerobic pus-- little odor.
• Anaerobic-- foul smelling.
Differential diagnosis
• Lung abscess.
• Bronchopleural fistula.
• Lung abscess-- air-fluid level in both
PA and lateral view.
• Empyema-- air-fluid level rare in same
in these view.
MAMAGEMENT
• Effective management require:
1) Control infection and sepsis by antibiotics.
2) Evacuation of pus from pleural space.
3) Obliteration the empyema cavity.
﹡Delay in drainage increase mortality from
3.4% to 16%.
Antibiotics Therapy
• Blood, empyema culture, gram stain.
• Community-acquired--- Third-generation
cephalosporin or clindamycin.
• Gram negative or anaerobes-- third
generation cephalosporin and clindamycin.
• Hospital-acquired-- should guide by culture.
Thoracocentesis
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18-gauge needle.
Fluid analysis.
Chest x ray repeated in 24 hours.
Repeated thoracocentesis if volume
increased.
Chest tube drainage
• First step in treatment of acute empyema.
• Highly effective in treating-- Uncomplicated
parapneumonic effusion and classic empyema
without loculation.
• 36 Fr, suction –20 cmH2O.
• Clinical improve in 48-72 hour.
• Remove-- drainage less than 50 ml within 24 hour,
lung re-expansion. Usually within 5-10 day.
• Antibiotics should continue 6 week.
Intrapleural fibrinolytic agents
• Empyema cavity– Composed of fibrin.
• Fibrolysis agent—Streptokinase and
Streptodornase— Significant systemic reaction,
unsatisfactory.
• Purified streptokinase, urokinase– Not allergic–
• Success rate– 80% for streptokinase（250000
U/100ml normal saline）, 90% for urokinase
（100000U/100ml normal saline ）.
Open drainage
• Cutting off the chest tube a few centimeter
from the skin.
• Anchoring it with safety pin and tape.
• Tube may withdrawn a few centimeter each
week as the granulation tissue fill the tract.
Video-assisted thoracoscopy
（VATS）
• Primary modality for treating complicated
empyema after initial therapy.
• Adhesiolysis and débridement with better exposure
and mini-thoracotomy, decortation for lung
expansion.
• Higher successful rate（90%）, shorter hospital
stay, less cost.
• Three-port triangle approach.
• Morbidity low, chest tube can be removed 3-4 day.
Chronic Empyema.
• Chronicity– continued infection associated
with both fibrosis and bronchopleural fistula.
• Uncommon.
• Thoracotomy and decortication
• Empyemectomy.
• Thoracoplasty.
Lung Abcess
•Localized infection
•Air-fluid filled cavity -WBCs -Protein
- Tissue Debris
•Pyogenic Membrane
Etiology
• Aspiration
- Staphylococcal aureus
- Anaerobic organisms
•Alcohol Abuse
•Seizure disorder •CVA
•Head trauma
•General Anesthesia
•Secondary cavitating infection
Lung abscess classification
• Acute
• Chronic
By quantity: Single or Multiple
By side: Left or right side
By complication: uncomplicated, complicated by
sepsis or pyopneumothorax
Radiologic Findings
•Increased opacity
- Consolidation -Atelectasis
•Cavity formation
- Air-fluid
•Fibrosis and calcification
•Pleural effusion
Lung abscess treatment tactics
• For acute – conservative treatment
(antibiotics, mucolytics, postural
drenaige, santion bronchoscopy)
• For chronic – operative (atypical
resection of lung, lobectomy or
bilobectomy)