Empyema dr yusuf imran

Empyema or

1. PAEDIATRIC EMPYEMA THORACIS CAUSES AND MANAGEMENT By – Dr. Yusuf Imran J.N Medical College AMU-Aligarh (INDIA)

2. INTRODUCTION Empyema is the accumulation of pus in the space between the lung and pleural space that occurs when an infection spreads from the lungs.

3. DEFINITION It is the presence/accumulation of pus between the pleural cavity of the lung.

4. STAGES While this disease evolves in a continuum, it has been divided into 3 distinct stages by the American Thoracic Society 1 . Exudative- in which a sterile exudate low in cellular count accumulates in the pleural space. 2 . Fibrinopurulent - in which frank pus is present with an increase in white cells. 3 . Organised - fibroblast proliferation leads to the formation of thick peel and potential lung entrapment, whereby the pleural space is characterised by a very thick exudate with heavy sediment.

5. DIFFERENTIATION OF PLEURAL FLUID   TRANSUDATE EMPYEMA Appearance Clear Cloudy or purulent Cell count (per mm 3 ) <1000 Often >50,000 (cell count has limited predictive value) Cell type Lymphocytes, monocytes Polymorphonuclear leukocytes (neutrophils) Lactate dehydrogenase <200 U/L >1000 U/L Pleural fluid/serum LDH ratio <0.6 >0.6 Protein >3g Unusual Common Pleural fluid/serum protein ratio <0.5 >0.5 Glucose Normal Low (<40 mg/dL) pH Normal (7.40-7.60) <7.10 Gram stain Negative Occasionally positive (less than one-third of cases)

6. ETIOLOGY OF EMPYEMA 1. Common cause is pulmonary infection as a result of aerobic bacteria such as : Streptococcus pneumonia, Staph aureus , E coli, Klebsiella pneumoniae , Hemophilus influenzae .

7. 2. Chest Trauma (blunt chest wound, chest surgery, lung abscess, or a ruptured esophagus ) 3. Septicemia ( very rare blood borne infection ) 4. Subdiaphragmatic causes as liver abscess.

8. Pneumococcal infection remains the most common isolated cause in developed countries, with Staphylococcus aureus the predominant pathogen in the developing world. Prevalence of S.pneumaoniae has decreased from 66 to 27 %. S aureus has become the most common organism isolated, with 78 % of those being resistant to methicillin .

9. PATHOPHYSIOLOGY The pleural space usually contains a small amount of fluid (0.3ml/kg of body weight), which is absorbed and secreted in equilibrium via the lymphatic drainage system . This circulatory system can cope with a substantial increase in fluid production; however disruption of this balance can lead to fluid accumulation and an associated pleural effusion.

10. Infection in the lung activates an immune response and stimulates pleural inflammation . Pleural vasculature becomes more permeable and inflammatory cells and bacteria leak into the pleural space causing pleural fluid infection and formation of pus resulting in the classical empyema.

11. CLINICAL HISTORY Risk factors should be determined on admission, and may include- H istory of chronic illness. C ongenital or chromosomal abnormality. A natomic or functional asplenia . I mmuno -compromise .

12. Previous invasive pneumococcal disease (IPD ). Vaccination status . Prematurity . Parental smoking history . History of recurrent infections in the child

13. CLINICAL PRESENTATION AND EXAMINATION Fever , malaise, tachypnoea are the presenting signs . Cough may be absent in the early part of the pneumonic process caused by Streptococcus pneumoniae but develops as the disease advances . Chest pain and diarrhoea . Children often lie on the affected side to minimise pain and to improve ventilation and perfusion matching . They may have a scoliosis to the affected side .

14. Chest examination typically reveals Decreased unilateral chest expansion with reduced breath sounds on auscultation. Stony dull percussion . Typically, a persistent fever despite 48 hours of appropriate antibiotic treatment, together with a change in physical signs should alert the clinician to the possible development of pleural fluid as a complication of pneumonia .

15. INVESTIGATIONS IMAGING – A ) Chest X-ray (CXR) – blunting of the costophrenic angle and pleural shadowing; B) Ultrasound - it is the best technique to differentiate pleural fluid and consolidation, estimate effusion size and grade complexity, demonstrate the presence of fibrinous septations and guide chest drain placement.

16. C) Computerised Tomography (CT) - Child fails to respond to treatment and there is concern that an abscess has developed. Presentation is atypical Concerns that the child may have other pathology such as a tumour .

17. INVESTIGATIONS CONT… BLOOD TESTS – A) Microbiology - The yield of isolating causative bacteria from blood cultures is low, probably due to prior antibiotic use. B ) Full blood count - White blood cells (WBC), particularly neutrophils, are raised at initial presentation and return to normal once the pleural space and lung parenchyma are sterilised . There is no role for routine WBC testing to monitor disease. Reduction of fever pattern is the most useful sign to indicated disease improvement.

18. MANAGEMENT AIM OF TREATMENT : To resolve clinical symptoms. Prevent further progression of empyema, Sterilise the pleural cavity, R educe fever, Shorten hospital stay Re-expand the lung with return to normal function.

19. A ) SUPPORTIVE THERAPY- S upplemental oxygen. Fluid replacement. Antipyretics. Analgesia. E arly mobilisation and encouragement of deep breathing and coughing.

20. B) ANTIBIOTICS – T he choice is dependent on local bacterial causes of community acquired pneumonia and local antibiotic policy. It is recommended that the initial empirical choice of antibiotics should cover at least Streptococcus pneumoniae and Staphylococcus aureus .

21. Macrolides should be used when Mycoplasma pneumoniae is thought to be the causative organism. Change to oral antibiotics once a child has been afebrile for 24 hours. L ength of oral antibiotic treatment varies from at least 1 week to 6 weeks.

22. C). DRAINAGE OF PLEURAL FLUID – The options available for definitive drainage are : C hest drain insertion alone or with instillation of fibrinolytics V ideo assisted thoracoscopic surgery ( VATS) O pen thoracotomy

23. INDICATIONS FOR PLEURAL CAVITY DRAINAGE – M oderate to severe respiratory distress, Large pleural effusion Ongoing sepsis .

24. TREATMENT FAILURE AND COMPLICATIONS Persistent fever. I ncorrect antibiotic choice. Failure of the antibiotics to penetrate the infected lung tissue or cavity. A CT scan is indicated for persistent fever which is not reducing and a rise in WBC and C-reactive protein, to exclude a pulmonary abscess .

25. Persistent lobar collapse is unusual and is in an indication for a bronchoscopy to exclude a foreign body. Cavitary necrosis, necrotising pneumonia and pneumatocoeles may be present on CT scans and are often a complication of empyema . A bronchopleural fistula occurs occasionally following the insertion of a chest drain or surgery for the treatment of empyema

26. DISCHARGE AND FOLLOW UP N o oxygen requirement and has been on oral antibiotics for 24 hours then he/she can be discharged . O ral antibiotics should be continued for at least one week and may be continued for up to 6 weeks . A repeat chest X-ray should be done at 4 to 6 weeks post discharge to confirm changes are resolving; most CXR are not completely normal at this time point.

27. THANK YOU By – Dr . Yusuf Imran J.N Medical College AMU-Aligarh (INDIA)