Purulent chest

disease
Surgery department 2,
DSMA

Effusions classification
Uncomplicated effusion.
Thoracic empyema.

Uncomplicated Effusion
Nonpurulent.
Negative Grams stain result, negative
culture.
Free flowing, pH 7.3, normal glucose level,
LDH less than 1000 IU/L.
Most resolve with appropriate antibiotics
treatment and resolution of the pulmonary
infection.

Thoracic Empyema
Bacteria invade the normally sterile
pleural space.
Three stage
Table 58-1

Thoracic Empyema-- Stage 1

Exudative effusion.
Increase permeability of the inflammatory
and swollen pleural surface.
Correspond to the uncomplicated
parapneumonic effusion.
Sterile, fibrin and PMN may present.

Thoracic Empyema-- Stage 2

Fibropurulent, true empyema, complicated pleural
effusion.
Initial-- fluid is clear : WBC greater than 500
cell/L, gravity greater than 1.08, protein level
greater than 2.5 g/dL, ph less 7.2, LDH reach 1000
IU/L, fibrin deposit.
Angioblastic and fibroblastic proliferation, heavy
fibrin deposition on both pleura, particularly the
parietal pleura.
Later fluid purulent, WBC 15000, ph less 7.0,
glucose less than 50 mg/dL, LDH greater 1000
IU/L.

Thoracic Empyema-- Stage 3

1 week after infection-- collagen organization,
entrapment the underlying lung.
3-4 week-- mature, turned peel.
Chronic-- dense fibrosis contraction and trapping
the lung, atelectasis and prolonged pulmonary
infection, reduction the size of hemithorax.
Fibrothorax-- invasion the chest wall and narrow
the intercostals space-- As the end stage of the
process.

Complication of Empyema

Early or late.
Necrosis of visceral pleura.
Bronchopleural fistula.
Necrosis parietal pleura and chest wall.
Osteomyelitis of rib or spine.
Esophageal fistula.
Metastatic spread brain abscess .

BACTERIOLOGY
Before antibiotics 1941 , 10% pf pneumonia
develop the empyema, the streptoccus and
pneumococcus were most frequently.
After antibiotics, the empyema decrease as
mortality. Staphylococcus became the most
prevalent.
Recently, the penicillin-resistant staphylococcus,
grams negative, anaerobic been predominant
microbes.

BACTERIOLOGY
Predominant aerobic-- Streptococcus
pneumonia, Staphylococcus aureus, E. coli,
Klebsiella pneumoniae, Hoemophilus
influenzae.
Predominat anaerobic-- Anaerobic cocci,
pigmented prevotella, porphyromonas,
bacteroid fragilis, fusobacterium spp.

BACTERIOLOGY
S. pneumoniae responsible for 60%-75%
community acquired pneumonia, only 2% develop
empyema.
S. aures account 1-2% community-acquired
pneumonia, 10% adult and 50% children develop
empyema.
In hospital, the staphylococcus and gramnegative
are most common.

CLINICAL FEATURE
Shortness of breath, cough , chest pain-common to pneumonia.
Febrile respiratory illness, accentuation,
prolongation the symptoms in pneumonia-alert the possibility of empyema.
Aerobic empyema-- acute febrile illness.
Anaerobic empyema-- more indolent,
usually 10 days.

DIAGNOSIS
Chest x-rayThe posterior lateral
diaphragmatic angle-- The most dependent
position-- Most empyema are found.
(Inverted D or pregnant lady sign).
Sonography guide thoracocentesis.
Fluid analysis.
Aerobic pus-- little odor.
Anaerobic-- foul smelling.

Differential diagnosis
Lung abscess.
Bronchopleural fistula.
Lung abscess-- air-fluid level in both
PA and lateral view.
Empyema-- air-fluid level rare in same
in these view.

MAMAGEMENT
Effective management require:
1) Control infection and sepsis by antibiotics.
2) Evacuation of pus from pleural space.
3) Obliteration the empyema cavity.
Delay in drainage increase mortality from
3.4% to 16%.

Antibiotics Therapy
Blood, empyema culture, gram stain.
Community-acquired--- Third-generation
cephalosporin or clindamycin.
Gram negative or anaerobes-- third
generation cephalosporin and clindamycin.
Hospital-acquired-- should guide by culture.

Thoracocentesis

18-gauge needle.
Fluid analysis.
Chest x ray repeated in 24 hours.
Repeated thoracocentesis if volume
increased.

Chest tube drainage

First step in treatment of acute empyema.
Highly effective in treating-- Uncomplicated
parapneumonic effusion and classic empyema
without loculation.
36 Fr, suction 20 cmH2O.
Clinical improve in 48-72 hour.
Remove-- drainage less than 50 ml within 24 hour,
lung re-expansion. Usually within 5-10 day.
Antibiotics should continue 6 week.

Intrapleural fibrinolytic agents

Empyema cavity Composed of fibrin.
Fibrolysis agentStreptokinase and
Streptodornase Significant systemic reaction,
unsatisfactory.
Purified streptokinase, urokinase Not allergic
Success rate 80% for streptokinase 250000
U/100ml normal saline , 90% for urokinase
100000U/100ml normal saline .

Open drainage
Cutting off the chest tube a few centimeter
from the skin.
Anchoring it with safety pin and tape.
Tube may withdrawn a few centimeter each
week as the granulation tissue fill the tract.

Video-assisted
thoracoscopy VATS
Primary modality for treating complicated
empyema after initial therapy.
Adhesiolysis and dbridement with better exposure
and mini-thoracotomy, decortation for lung
expansion.
Higher successful rate 90% , shorter hospital
stay, less cost.
Three-port triangle approach.
Morbidity low, chest tube can be removed 3-4 day.

Chronic Empyema.
Chronicity continued infection associated
with both fibrosis and bronchopleural
fistula.
Uncommon.
Thoracotomy and decortication
Empyemectomy.
Thoracoplasty.

Lung Abcess
Localized infection
Air-fluid filled cavity
-WBCs -Protein
- Tissue Debris

Pyogenic Membrane

Etiology
Aspiration
- Staphylococcal aureus
- Anaerobic organisms

Alcohol Abuse
Seizure disorder
CVA
Head trauma
General Anesthesia
Secondary cavitating infection

Lung abscess classification

Acute
Chronic
By quantity: Single or Multiple
By side: Left or right side
By complication: uncomplicated, complicated by
sepsis or pyopneumothorax

Radiologic Findings
Increased opacity
- Consolidation
-Atelectasis

Cavity formation
- Air-fluid

Fibrosis and
calcification
Pleural effusion

Lung abscess treatment tactics

For acute conservative treatment
(antibiotics, mucolytics, postural
drenaige, santion bronchoscopy)
For chronic operative (atypical
resection of lung, lobectomy or
bilobectomy)