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