Thoracic empyema

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

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OUTLINE
Definition
Historical background
Etiology
Bacteology
Classification
Pathophysiology
Clinical presentation
Work up
Treatment
Complications

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DEFINITION
Present of pus in the pleural cavity
It is not a primary disease
It 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 20
th
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 aureus
Steptococcus pneumoniae
Escherichia Coli
M. Tuberculosis
Aerobacter aerogenes
Proteous
Salmonella
etc

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CLASSIFICATIONS
Anatomical classification
Clinical classification
Pathological classification

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Anatomical classification
Total thoracic empyema
–The whole pleural cavity is involved
Localized or encysted thoracic
empyema
–Only part of the thoracic cavity is involved

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Clinical classification
Acute 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) empyema
Fibrino-purulent (established) empyema
Organizing 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) stage
This 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
Dyspnoea
Toxic
Chest 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 insufficiency
Systemic septicaemia
Septic emboli to the brain
Broncho-pleural fistula
Lung collapse
Empyema necessitans
Amyloidosis

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