Pleural empyema

Pleural empyema

Pleural empyema is an accumulation of purulent exudate in the pleural cavity with secondary compression of the lung tissue during pleurisy. Classification

    • By localization
    • Single sided or double sided
    • Limited (localized in some part of the pleural cavity, surrounded by pleural adhesions) and total (purulent exudate fills the entire pleural cavity)
    • Nasal or para-mediastinal
    • Because of
    • Metapneumonic, developed in the outcome of pneumonia
    • Parapneumonic, occurring simultaneously with pneumonia
    • Postoperative, which arose as a complication of a surgical operation on the organs of the thoracic or upper abdominal cavity
    • With the flow
    • Acute (disease duration – up to 8 weeks)
    • Chronic (duration – more than 8 weeks). Etiology
    • Pathogens:
    • staphylococci
    • pneumococci
    • facultative and obligate anaerobes
    • direct route of infection
    • lung injury
    • chest wounds
    • Rupture of the esophagus
    • Pneumonia
    • Tuberculosis
    • Progression of bacterial damage to the lungs (abscess or bacterial deformity)
    • bronchiectasis
    • Lung resection
    • Pneumothorax
    • Indirect route of infection
    • Subdiaphragmatic abscess
    • Acute pancreatitis
    • Liver abscesses
    • Inflammation of the soft tissues and bone skeleton of the chest wall
    • Idiopathic empyema.

Pathogenesis

    • Acute (serous) phase (up to 7 days). Primary pleural effusion
    • Fibrinous-purulent phase (7-21 days). The fluid occupies the lower parts of the pleural cavity. In the absence of adequate drainage, a multilocular empyema appears
    • Chronic phase (after 21 days). As a result of the deposition of fibrin, the pleura thickens along the border of the pleural effusion. Abscesses appear in neighboring areas.

Pathomorphology

    • Hyperemia and leukocyte infiltration of the pleura
    • fibrin deposition
    • Accumulation of fluid in the pleural cavity
    • Thickening of the pleura, the formation of mooring
    • Organization of empyema, formation of connective tissue.

Clinical picture

    • Acute pleural empyema
    • Cough with expectoration. Prolonged and frequent bouts of coughing with a large amount of sputum indicate the presence of a bronchopleural fistula
    • Pain in the chest is minimally expressed during quiet breathing, increases sharply during a full deep breath
    • Dyspnea
    • Impaired voice trembling or distinct egophony
    • Dull or blunted percussion sound on the side of the lesion, the upper limit of dullness corresponds to the Amis-Damuazo-S line within
    • Decreased or absent breathing on auscultation over the effusion
    • Bronchial breathing over the compressed lung adjacent to the effusion
    • Redness of the skin occurs only when pus breaks out of the empyema cavity under the skin
    • The general condition progressively worsens: weakness, loss of appetite, weight loss, hectic body temperature, rapid pulse.
    • Chronic pleural empyema
    • Body temperature can be subfebrile or normal, if the outflow of pus is disturbed, it becomes hectic
    • Cough with purulent sputum
    • Deformation of the chest on the side of the lesion due to narrowing of the intercostal spaces. Toddlers develop scoliosis
    • Percussion data depend on the degree of filling of the cavity with pus; breath sounds over the cavity are not heard.

Laboratory research

    • Leukocytosis, shift of the leukocyte formula to the left, hypo- and dysproteinemia, increased ESR
    • Analysis of the pleural fluid – exudate (relative density above 1.015, protein over 30 g / l, albumin / globulin ratio -0.5-2.0. Rivalta test is positive, leukocytes are above 15). Special Studies
    • Thoracocentesis – pleural fluid is cloudy, thick, gradually turning into true pus, has a specific unpleasant odor
    • Laboratory study of aspirated fluid
    • Bacterioscopy of a smear with Grom stain
    • Bacteriological examination (often the results of these methods differ)
    • Determination of pH – with empyema pH less than 7.2
    • X-ray examination
    • The mediastinum is displaced to the side opposite to the side of effusion accumulation
    • Basal opacity with a horizontal level in putrefactive infection or bronchopleural fistula.

Differential Diagnosis

    • rib fracture
    • Costal chondritis
    • Intercostal nerve compression
    • Shingles
    • Acute bronchitis
    • Pathology of the cardiovascular system and esophagus.

Treatment:

General principles

    • Early complete removal of exudate from

pleural cavity by puncture or drainage

    • Straightening of the lung using constant aspiration, exercise therapy
    • Rational antibiotic therapy.

Conservative therapy

    • Early acute empyema – repeated pleural punctures with aspiration of purulent exudate and adequate antibiotic therapy are necessary
    • Formed empyema with thick purulent exudate is an indication for long closed drainage. Surgery
    • Acute empyema
    • Free empyema of the pleura – constant washing of the pleural cavity through two tubes, after 2-3 days the contents are sucked out through both tubes and the lungs are completely expanded
    • Wide thoracotomy with resection of the ribs, toilet of the pleural cavity and subsequent drainage is indicated in the presence of large sequesters and clots in the pleural cavity
    • With the ineffectiveness of the above measures, early decortication of the lung is indicated.
    • Chronic empyema
    • Drainage of the pleural cavity with active aspiration and washing of the cavity with antiseptic products. Conducted simultaneously. exercise therapy
    • If these measures are ineffective, decortication of the lung or thoracoplasty with tamponade of the cavity with a muscle flap is indicated.
    • In bronchopleural fistula, tamponade of the bronchus with a muscle on the leg is used.

Complications

    • Perforation
    • In the lung parenchyma with the formation of bronchopleural fistulas
    • Through the chest with accumulation of pus in the soft tissues of the chest wall
    • Septicopyemia. The prognosis for timely treatment is favorable.

Synonyms

    • Purulent pleurisy
    • Pyothorax.

See also Pleurisy

ICD J86 Pyothorax

Literature. Treatment of acute pleural empyema. Shoikhet YAN, Tsey-

max EA. Barnaul, 1996

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