Empyema thoracis

Empyema thoracis

1. Empyema Thoracis Dr. Anuj Mehta DNB-CTU , GKNM Hospital

2. Accumulation of pus in the pleural cavity. Incidence: 5-10 % of hospitalized patient with parapneumonic effusion.

3. ETIOLOGY

4. Pathology First or exudative stage: has relatively low LDH, normal glucose and normal pH. Second or fibropurulent stage: increased fibrin deposition, cellular debris and blood cells formation of fibrinous membranes producing loculations. Third or organization stage: fibroblasts grow into fibrin sheet coating the visceral and parital pleura "pleural peel" causing entrapment of the lung.

5. Clinical Stages Acute : Within the first 2 weeks of the onset. Chronic : After 2 weeks or with the formation of the thick peel and loculations.

6. COMPLICATIONS more likely to develop during chronic stage

7. Suspicion - Acute respiratory illnesses with associated pleural effusion. The most common initial manifestations - dyspnoea (82%), fever (81%), cough (70%), and chest pain (67%). Tachycardia, malaise, anorexia, and weight loss very acutely or develop insidiously over weeks. Physical examination - diminished mobility of the involved hemithorax , decreased breath soun ds, and dullness on percussion.

8. Diagnosis 1- Pus obtained on thoracocentesis. Glucose concentration < 40 mg/dl, LDH > 3 times the upper limit of normal, and PH < 7.2 2- Chest x ray: Posteroanterior and lateral. 150- 200 ml needed to blunt costophrenic angle.

9. 3- Ultrasonography: Localize small amount of fluid and loculation and identify pleural peel.

10. 4- CT Scan: Differentiating empyema, lung abscess, subdiaphragmatic fluid SPLIT PLEURA

11. Cohen and colleagues - empyema management depends on its cause , clinical stage , state of the underlying lung, presence or absence of a bronchopleural fistula , and the patient’s clinical and nutritional status.

12. Management Medical : Non interventional therapy often contraindicated Thoracocentesis and culture sensitivity based antibiotic therapy generally successful for stage I NOT stage II or III.

13. Surgical : 1) Tube thoracostomy (28-36 Fr.), connected to negative suction of 20 mmHg the tube withdrawn slowly several weeks until removed. 2) Insertion of pigtail catheter (8 fr to 14 fr) with administration of fibrinolytics such as streptokinase or urokinase until the pleural space is cleared. —> surgery contraindicated

14. 3) Thoracoscopy (VATS): The next therapeutic option after fibrnolysis, Advantages Visualisation Determine if complete drainage of all empyema Disruption of all adhesions and loculations.

15. Decortication of the lung Space filling by muscle transplants, space collapse, and space sterilization are alternative therapeutic options

16. 4) Decortication: Via thoracotomy should be performed when third stage is suggested by CT Scan. i) Remove all purulent fluid, fibrinous debris, thickened parietal pleura from the pleural space. ii) Resection of visceral pleural peel.

17. Rib Resection Drainage and Open Thoracic Window resection of a short segment of rib over the most dependent part of the cavity the opening and deloculation of the space insertion of a large multi- fenestrated tube into the cavity. If the visceral pleura is thin and “stretchable,” space obliteration may eventually occur through lung re-expansion, contraction of the space, and filling by granulation tissue

18. A more permanent—> creation of an open-window thoracostomy. Dr. Leo Eloesser in 1935 particularly useful for patients in whom long-term drainage may be required Thourani and colleagues reported a series of patients who underwent a modified Eloesser flap for chronic empyema. The flap differed from the original flap in that it was an inverted U shape flap of skin and subcutaneous tissue

19. Bronchopleural fistulas aggravate the course of empyemas and present a major therapeutic challenge. indicates persistent contamination of the pleural space, difficulties in the re-expansion of the lung, and possible aspiration in the remaining lung.

20. coughing up of serosanguineous fluid or pus, fever, malaise, and general symptoms of toxicity. CXR- small space may be enlarging or a newly formed air-fluid level lowering or sudden disappearance of a pleural effusion or a mediastinal shift toward the contralateral side. A drop of at least two intercostal spaces is considered significant to suggest a bronchopleural fistula. The diagnosis of a bronchopleural fistula is usually made by bronchoscopy or by observing persistent air leak through the chest tube.

21. Conservative suction drainage fibrin sealants applied through the rigid bronchoscope the flexible fiberoptic broncho-scope. re-closure of the bronchus, re- amputation of the stump, additional sealing of the pulmonary sutures, or additional resection may be advisable.

22. Secondary failures (the bronchial stump reopens )because of local pressure by the purulent collection.In this situation, drainage should be done initially, followed by definitive management, which consists of bronchial re-closure, muscle flap, or thoracoplasty.