Thoracic empyema

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THORACIC EMPYEMA

Dr Phillipo Leo ChalyaM.D. [Dar]; M.MED surg [Mak]Surgeon Specialist - BMC

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OUTLINEDefinition Historical backgroundEtiology Bacteology Classification Pathophysiology Clinical presentationWork upTreatment Complications

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DEFINITION

Present of pus in the pleural cavity

It is not a primary diseaseIt is secondary to other

underlying diseases It is a complication of other

diseases

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HISTORICAL BACKGROUND

For centuries, ET has been recognized as a serious problem

Around 500 BC, Hippocrates recommended treating ET with open drainage

In 1876,Hewitt described a method of UWSD

In early 20th century surgical therapies for ET i.e. thoracoplasty and decortication were introduced

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ETIOLOGY

Classified as– Local causes– Systemic causes

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Local causes

Chest wall causes– Osteomyelitis of ribs / thoracic

vertebrae– Penetrating wounds– Thoracic wall abscess

Pleural causes– Pneumothorax– Haemothorax

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Pulmonary causes– Pneumonia– Bronchitis– Pulmonary TB– Lung abscess– Bronchiectasis

Sub-diaphragmatic causes– Subphrenic abscess– Hepatic abscess

Iatrogenic causes– Esophageal perforation during

esophagoscopy– Pleural tap– Postpneumonectomy– Postthoracotomy

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Systemic causes

Septicaemia

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BACTEOLOGY

Staphylococcus aureusSteptococcus pneumoniaeEscherichia ColiM. TuberculosisAerobacter aerogenes Proteous Salmonella etc

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CLASSIFICATIONS

Anatomical classificationClinical classificationPathological classification

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Anatomical classification

Total thoracic empyema– The whole pleural cavity is

involvedLocalized or encysted

thoracic empyema– Only part of the thoracic cavity

is involved

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Clinical classificationAcute thoracic empyema

– In which there is profound toxemia and shock

– Patient presents with high grade fever, cough with pleuritic chest pain and shallow breathing

Sub-acute thoracic empyema– This is less severe form of

presentation in patients who was on antibiotics for pneumonia

Chronic thoracic empyema– This usually results from

mismanagement of the acute form

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Pathological classification

Exudative (early) empyemaFibrino-purulent (established)

empyemaOrganizing empyema

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PATHOPHYSIOLOGY

According to the American Thoracic Society [1962], the development of thoracic empyema passes through 3 stages:-– Exudative stage– Fibrino-purulent stage– Organizing stage

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Stage I: Exudative (early) stage

This is purely an inflammatory process in which there is an increase in permeability of small blood vessels leading to exudation of fluid in the pleural cavity

The fluid is very thin with low cellular content and underlying lung that re-expands readily

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Stage II: Fibrino-purulent (established) stageThis stage is characterized

by:- – large number of

polymorphonuclear leucocytes– deposition of fibrin on both

visceral and parietal surfaces of the involved pleura

– Bacterial invasion of the pleural space

– Tendency towards loculation formation

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Stage III: Organizing stage

In this case fibroblasts appear in the now heavier fibrin coating of the pleural membranes

The fluid (exudates) is quite thick

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CLINICAL PRESENTATION

Symptoms– Cough – Pleuritic chest pain– Breathlessness– ±Haemoptysis– Fever– Rigors– General body weakness

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Signs

Febrile DyspnoeaToxicChest examination

– Evidence of fluid in the chest cavity-stony hard percussion note

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WORK UP

Lab studies– Haematological investigations

•Haemoglobin•WBC count + ESR•ELISA test for HIV

– Bacteriological investigations•Sputum for AFB•Sputum for culture and sensitivity•Pus for culture and sensitivity

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Imaging investigations– Chest x-ray– Abdominal USS to rule out hepatic

abscess– CT scan of the chest

• Help to delineate the pleural fluid loculations

• Can also detect airway or parenchymal abnormality e.g. endobronchial obstruction or the presence of lung abscess

Diagnostic procedures– Aspiration of pus to confirm diagnosis

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TREATMENT

Objectives of treatment – To control the primary infection

by appropriate medications– Evacuation of purulent content

of the empyema sac and eradication of the sac to control chronicity i.e. to obliterate empyema space

– Re-expansion of the underlying lung to restore function

– To prevent complications

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Modalities of treatment – Depends on the stage of the

empyema– Divided into:-

•Non-surgical therapy– Antibiotics – Intrapleural thrombolytic agents

– Needle aspiration (Thoracocentesis)

•Surgical therapy– Thoracoscopy – Closed chest drainage (underwater

seal drainage-UWSD)– Open chest drainage (rib resection)– Decortications– Thoracoplasty

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Needle aspiration (thoracocentesis)

This is both diagnostic and therapeutic

It may be adequate only in exudative stage (stage I)

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Closed chest drainage (UWSD)This is done if the fluid (pus)

in the pleural sac is thicker to evacuated by simple needle aspiration

It applied only in stage I & II

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Open chest drainage (Rib resection)In this case, 2-3 ribs are

resected to allow evacuation of pus, break up loculations and adherence, wash the cavity and put UWSD to prevent re-accumulation of empyema

This is done if the pus is too thick to be evacuated by UWSD

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Decortications

In this case, thoracotomy is done and peel out the cortical layer over the parietal and visceral surfaces

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Thoracoplasty

In this case ribs are taken away to compress the chest

Due to high mortality and morbidity the procedure has been ABANDONED

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COMPLICATIONS

Respiratory insufficiencySystemic septicaemiaSeptic emboli to the brainBroncho-pleural fistulaLung collapseEmpyema necessitansAmyloidosis

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