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EMPYEMA
ALOK SINHADepartment of Medicine
Manipal College of Medical SciencesPokhara, Nepal
EMPYEMA presence of pus in the pleural space
empyema continues to be a significant cause of morbidity and mortality even in developed countries
Associated with delay in the diagnosis or instigation of appropriate therapy
as thin as serous fluidso thick that it is impossible to aspirate even through a wide-bore needle
?
Aetiology
• Mostly secondary to infection in a neighbouring structure - usually the lung bacterial pneumonias T.B. rupture of a subphrenic abscess
through the diaphragm infection of a haemothorax Iatrogenic – following pleural aspiration
Pathology Both layers of pleura are covered with a
thick, shaggy inflammatory exudate pus is under considerable pressure &
may rupture into a bronchus causing
track through chest wall with formation of
• bronchopleural fistula • pyopneumothorax
• subcutaneous abscess
• sinus
empyema can heal • by eradication of the infection • obliteration of the empyema space
Early apposition of the visceral & parietal pleural layers are essential
Factors keeping pleura apart• air entering through a broncho pleural
fistula • underlying disease in the lung, such as
Bronchiectasis bronchial carcinoma pulmonary TB
prevents re-expansion
In these circumstances empyema become chronic. Surgical intervention required for healing
Clinical features empyema should be suspected in patients
with pulmonary infection • persistence or recurrence of pyrexia despite
the administration of a suitable antibiotic Some times first definite clinical features
may be due to the empyema itself Once an empyema has developed, two
separate groups of clinical features are found
1. Systemic features
Pyrexia, usually high and remittent Rigors, sweating, malaise and weight loss Polymorphonuclear leucocytosis, high CRP
2. Local features
Symptoms:Pleural painbreathlessnesscough and sputum – underlying lung disease copious purulent sputum – empyema ruptures into a bronchus Signs:Clubbing – regular feature in pyogenic infectionsClinical signs of fluid in the pleural space Cause restrictive defect
Empyema necessitans A very rare condition in which an
empyema goes undetected over a long period of time and progresses to the chronic stage
Eventually the empyema erodes through the chest wall and spontaneously drains onto the surface of the body
INVESTIGATIONS
Radiological examination: indistinguishable from those of
pleural effusion Loculated fluid may be seen When air is present in addition to pus
pyopneumothorax -horizontal 'fluid level'
Homogenous density Loculated Loss of cardiophrenic angle Loss of lateral portion of diaphragmatic silhouette
Ultrasound
position of the fluid extent of pleural thickening single collection or multiloculated
CT
useful in assessing the underlying lung parenchyma and patency of the major bronchi
Aspiration of pus confirms presence of empyema
performed using a wide-bore needle under Ultrasound or CT guidance
pus frequently sterile when antibiotics
have already been given
Distinction between tuberculous and non-tuberculous disease can be difficult and often requires pleural histology and culture
.
intercostal tube with water-seal drain inserted in acutely ill ptient
If initial aspirate – turbid or frank pus or loculated -tube should be put on suction (5-
10 cm H2O) and flushed regularly with 20 ml normal saline
Pus culture & appropriate antibiotic given for 2-4 weeks
SURGICAL INTERVENTION Decompression of lung secured at an
early stage by removal of all the pus from the pleural space to prevent visceral pleura becoming grossly thickened & rigid
surgical intervention required when pus is
thick or loculated
Surgical 'decortication' of the lung - required if gross thickening of the visceral pleura prevents re-expansion of the lung