PARA PNEUMONIC EFFUSION

PARA PNEUMONIC EFFUSION

1. PARA PNEUMONIC EFFUSION Dr MUHAMMED ASLAM PG RESPIRATORY MEDICINE

2. A  parapneumonic effusion is a type of pleural effusion that arises as a result of a pneumonia, lung abscess, or bronchiectasis

3. CLASSIFICATION Uncomplicated (UPPE) Complicated (CPPE) Empyema thoracis

4. Uncomplicated parapneumonic effusions Exudative , predominantly neutrophilic effusions reflecting increasing passage of interstitial fluid as a result of inflammation associated with pneumonia. cloudy or even clear, without any organisms noted on Gram stain or culture. They resolve with appropriate antibiotic treatment of the pneumonia.

5. Complicated Parapneumonic effusions Bacterial invasion into the pleural space Increased number of neutrophils , decreased glucose levels, pleural fluid acidosis, and an elevated lactic dehydrogenase (LDH) Often are sterile. Classified as complicated because it requires drainage for resolution.

6. Empyema thoracis Frank pus accumulates in the pleural space

7. Etiology Bacterial, viral,Atypical Aerobic gram-positive – S pneumoniae   Staphylococcus aureus  , streptococcus milleri   Aerobic gram-negative Klebsiella,Pseudomonas , E coli,  and  Haemophilus   Anaerobic - Bacteroides  and  Peptostreptococcus   Patients with pneumonia due to Legionella species

8. Pathophysiology 3 stages Exudative Fibrinopurulent Organization stages.

9. Exudative stage The pleural fluid originates in the interstitial spaces of the lung and in the capillaries of the visceral pleura because of increased permeability. Sterile pleural fluid Low WBC count and LDH level Glucose and pH levels are normal Resolve with antibiotic therapy, and chest tube insertion is not required. 2-5 days from the onset of pneumonia.

10.   Fibrinopurulent stage Bacterial invasion of the pleural space Accumulation of neutrophils , bacteria, and cellular debris. A tendency toward loculation and septation pleural fluid pH (< 7.20) and glucose levels are lower (< 60 mg/ dL ), and the LDH level increases. Bacteriological stains or cultures of the pleural fluid can be positive for microorganisms. 5-10 days after pneumonia onset.

11. Organization stage Fibroblasts grow into the exudates from both the visceral and parietal pleural surfaces and forms inelastic membrane called pleural peel. Pleural fluid is thick. In an untreated patient, pleural fluid may drain spontaneously through the chest wall ( empyema necessitatis ). Take 2-3 weeks to develop.

12. Risk factors for Empyema thoracis Age -children and elderly persons Debilitation Bronchiectasis Rheumatoid arthritis Alcoholism Diabetes Gastroesophageal reflux disease Intravenous drug abuse

13. Clinical manifestations Depend on aerobic or anaerobic infection. Aerobic infections are more acute in onset Anaerobic infections can be indolent

14. Aerobic Patients present with an acute febrile illness with chest pain, cough with sputum production, and dyspnoea. A complicated parapneumonic effusion is suggested by the presence of a fever lasting more than 48 hours after the initiation of antibiotic therapy.

15. Anaerobic bacterial infection Usually subacute illness. Most have symptoms for more than 7 days a/ i Poor oral hygiene,alcoholism , and factors predispose to recurrent aspiration.

16. ON EXAMINATION Febrile with Tachypnea and tachycardia Decreased tactile fremitus and VR Dullness to percussion Decreased or absent breath sounds Tracheal shift possible with large effusions In areas in which pneumonia and lung consolidation are adjacent and more extensive than pleural fluid-crackles ,bronchial breath sounds , egophony .

17. INVESTIGATIONS BLOOD- leukocytosis may be present (>12,000/µL Sputum for Gram stain &culture. ***

18. Chest radiography PA , Lateral and Decubitus view ***

19. Chest radiograph of a 63-year-old woman with left lower lobe pneumonitis

20. The patient developed a large leftsided pleural effusion despite 5 days of oral antibiotic therapy

21. Ultrasonography Localize fluid for a thoracentesis Distinguish loculated pleural fluid from an infiltrate.

22. Sonographic study of the pleural space showed marked septation throughout the fluid collection

23. CT Thorax Pleural enhancement can be seen in patients with active inflammation “split pleura sign” Distinguish pleural from parenchymal abnormalities Determine the precise location and extent Detect loculations Find airway and parenchymal abnormalities that may be relevant to the etiology of the pleural infection.

24. split pleura sign

25. Thoracentesis When parapneumonic pleural effusion is greater than or equal to 10 mm thick on a lateral decubitus chest radiograph

26. Pleural fluid Appearance -clear yellow liquid to an opaque turbid fluid to grossly purulent thick, viscous, foul-smelling pus(anaerobic infection). WBC count Total protein LDH Glucose pH Microbiology

27. Complicated pleural effusion or empyema LDH value of greater than 1000 U/L Glucose level of less than 40 mg/d pH of less than 7.20.

28. Staging Category 1 ( parapneumonic effusion) Minimal free-flowing fluid, smaller than 10 mm on decubitus films Culture, Gram stain, and pH unknown No thoracentesis needed; treatment with antibiotics alone

29. Category 2 (uncomplicated parapneumonic effusion) Larger than 10 mm fluid and less than half the hemithorax on decubitus films Gram stain and culture negative pH higher than 7.20 Treatment with antibiotics alone

30. Category 3 (complicated parapneumonic effusion ) Large free-flowing effusion, more than half the hemithorax pH lower than 7.20, LDH level greater than 1000 U/L and glucose level less than 40 mg/ dL Gram stain or culture positive Treatment with tube thoracostomy and antibiotics Multiloculated effusions may require multiple tubes Thrombolytics may help resolution

31. Category 4 ( empyema ) Large free-flowing effusion, greater than equal to half the hemithorax Loculated effusion or effusion with thickened pleura Gross pus on aspiration Treatment with tube thoracostomy Thrombolytics may help resolution May require decortication

32. TREATMENT selection of an appropriate antibiotic Assessment of need for drainage of pleural fluid

33. ANTIBIOTIC SELECTION Community-acquired pneumonia : second- or third-generation cephalosporins in addition to a macrolide . severe community-acquired pneumonia-initiate treatment with a macrolide plus a third-generation cephalosporin with antipseudomonal activity. If aspiration is evident or suspected, oral anaerobes should also be covered.

34. In the absence of a positive gram stain, coverage for Legionella species and Chlamydia pneumoniae should be added For nosocomial infections, broader antibiotic coverage for gram-negative organisms is recommended

35. Duration of antibiotic therapy antibiotics are continued until: (1) the patient is afebrile and the white blood cell count is normal; (2) the tube thoracostomy drainage yields less than 50 ml of fluid daily (3) the radiograph shows considerable clearing. Typically, 3 to 6 weeks of antibiotic therapy is required to achieve these results.

36. Pleural space drainage . If the diagnostic thoracentesis yields thick pus( empyema thoracis ) definitive pleural drainage is required. If the pleural fluid is not thick pus, then results of pleural fluid Gram stain or culture, pleural fluid pH and glucose levels, and the presence or absence of pleural fluid loculations should guide the course of action

37. Indications for drainage Prolonged pneumonia symptoms, co morbid disease Failure to respond to antibiotic therapy Presence of anaerobic organisms Chest radiograph –Effusion involving >50% of the hemothorax , loculation , and an air-fluid level.

38. Aspiration of pus, a putrid odor associated with an anaerobic infection, a positive Gram stain or culture result, pH <7.20, a glucose level <40 mg/ dL , and an LDH level >1000 IU/L USG-Stranding or septation CT-marked pleural enhancement, pleural thickening, and the split pleura sign

39. Pleural space drainage Repeated thoracentesis Use of a standard chest tube An image-guided insertion of a small-bore catheter.

40. Intrapleural thrombolytic agents Most effective in the early fibrinolytic stage streptokinase,streptodornase,urokinase , and tPA Indications occluded small-bore catheter, multiloculated pleural space as a trial before committing the patient to surgery.

41. Surgical Care Thoracoscopy , Video-assisted thoracic surgery (VATS), Standard thoracotomy Open drainage

42. Indication When Tube thoracostomy has been ineffective in controlling the pleural infection. Empyema that has been present for several days to weeks and that has multiple loculations Patients with impaired pulmonary function and debilitation can be treated effectively with VATS

43. Open Thoracotomy Recommended for persistent pleural sepsis and failure of less invasive procedures When VATS cannot adequately access the pleural space optimal method for successful debridement and decortication . Decortication (i.e., stripping of the visceral pleural peel) can be performed early to control pleural sepsis and late (3–6 months after the onset of empyema or CPPE) to treat a symptomatic, restrictive ventilatory defect.

44. Nutrition Patients with empyema enter a catabolic state ; hence ,good nutrition is vital

45. Conclusions The outcome of a PPE depends on the point in the clinical course when the patient presents to the physician, co morbidities, and efficient clinical management. Early antibiotic therapy prevents the development of a PPE and progression to a CPPE and empyema .

46. Thank You