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EMPYEMA ALOK SINHA Department of Medicine Manipal College of Medical Sciences Pokhara, Nepal.

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Presentation on theme: "EMPYEMA ALOK SINHA Department of Medicine Manipal College of Medical Sciences Pokhara, Nepal."— Presentation transcript:

1 EMPYEMA ALOK SINHA Department of Medicine Manipal College of Medical Sciences Pokhara, Nepal

2 EMPYEMA presence of pus in the pleural space presence of pus in the pleural space empyema continues to be a significant cause of morbidity and mortality even in developed countries empyema continues to be a significant cause of morbidity and mortality even in developed countries Associated with delay in the diagnosis or instigation of appropriate therapy Associated with delay in the diagnosis or instigation of appropriate therapy as thin as serous fluid so thick that it is impossible to aspirate even through a to aspirate even through a wide-bore needle wide-bore needle ?

3 Aetiology Mostly secondary to infection in a neighbouring structure - usually the lung Mostly secondary to infection in a neighbouring structure - usually the lung  bacterial pneumonias  T.B.  rupture of a subphrenic abscess through the diaphragm  infection of a haemothorax  Iatrogenic – following pleural aspiration

4 Pathology Both layers of pleura are covered with a thick, shaggy inflammatory exudate Both layers of pleura are covered with a thick, shaggy inflammatory exudate pus is under considerable pressure & pus is under considerable pressure & may rupture into a bronchus causing bronchus causing track through chest wall with formation of bronchopleural fistulabronchopleural fistula pyopneumothoraxpyopneumothorax subcutaneous abscesssubcutaneous abscess sinussinus

5 empyema can heal empyema can heal by eradication of the infectionby eradication of the infection obliteration of the empyema spaceobliteration of the empyema space Early apposition of the visceral & parietal pleural layers are essential Early apposition of the visceral & parietal pleural layers are essential

6 Factors keeping pleura apart air entering through a broncho pleural fistulaair entering through a broncho pleural fistula underlying disease in the lung, such asunderlying disease in the lung, such as Bronchiectasis Bronchiectasis bronchial carcinoma bronchial carcinoma pulmonary TB pulmonary TB prevents re-expansion In these circumstances empyema become chronic. Surgical intervention required for healing In these circumstances empyema become chronic. Surgical intervention required for healing

7 Clinical features empyema should be suspected in patients with pulmonary infection empyema should be suspected in patients with pulmonary infection persistence or recurrence of pyrexia despite the administration of a suitable antibioticpersistence or recurrence of pyrexia despite the administration of a suitable antibiotic Some times first definite clinical features may be due to the empyema itself Some times first definite clinical features may be due to the empyema itself Once an empyema has developed, two separate groups of clinical features are found Once an empyema has developed, two separate groups of clinical features are found

8 1. Systemic features  Pyrexia, usually high and remittent  Rigors, sweating, malaise and weight loss  Polymorphonuclear leucocytosis, high CRP 2. Local features  Symptoms:  Pleural pain  breathlessness  cough and sputum – underlying lung disease  copious purulent sputum – empyema ruptures into a bronchus  Signs:  Clubbing – regular feature in pyogenic infections  Clinical signs of fluid in the pleural space  Cause restrictive defect

9 Empyema necessitans A very rare condition in which an empyema goes undetected over a long period of time and progresses to the chronic stage A very rare condition in which an empyema goes undetected over a long period of time and progresses to the chronic stage Eventually the empyema erodes through the chest wall and spontaneously drains onto the surface of the body Eventually the empyema erodes through the chest wall and spontaneously drains onto the surface of the body

10 INVESTIGATIONS

11 Radiological examination: indistinguishable from those of pleural effusion indistinguishable from those of pleural effusion Loculated fluid may be seen Loculated fluid may be seen When air is present in addition to pus pyopneumothorax -horizontal 'fluid level' When air is present in addition to pus pyopneumothorax -horizontal 'fluid level'

12 Homogenous density Loculated Loss of cardiophrenic angle Loss of lateral portion of diaphragmatic silhouette

13 Ultrasound position of the fluid position of the fluid extent of pleural thickening extent of pleural thickening single collection or multiloculated single collection or multiloculated

14 CT useful in assessing the underlying lung parenchyma and patency of the major bronchi useful in assessing the underlying lung parenchyma and patency of the major bronchi

15 Aspiration of pus confirms presence of empyema Aspiration of pus confirms presence of empyema performed using a wide-bore needle under Ultrasound or CT guidance performed using a wide-bore needle under Ultrasound or CT guidance pus frequently sterile when antibiotics have already been given pus frequently sterile when antibiotics have already been given Distinction between tuberculous and non- tuberculous disease can be difficult and often requires pleural histology and culture Distinction between tuberculous and non- tuberculous disease can be difficult and often requires pleural histology and culture

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17 intercostal tube with water-seal drain inserted in acutely ill ptient intercostal tube with water-seal drain inserted in acutely ill ptient If initial aspirate – turbid or frank pus or loculated -tube should be put on suction (5-10 cm H2O) and flushed regularly with 20 ml normal saline If initial aspirate – turbid or frank pus or loculated -tube should be put on suction (5-10 cm H2O) and flushed regularly with 20 ml normal saline Pus culture & appropriate antibiotic given for 2-4 weeks Pus culture & appropriate antibiotic given for 2-4 weeks

18 SURGICAL INTERVENTION Decompression of lung secured at an early stage by removal of all the pus from the pleural space to prevent visceral pleura becoming grossly thickened & rigid Decompression of lung secured at an early stage by removal of all the pus from the pleural space to prevent visceral pleura becoming grossly thickened & rigid surgical intervention required when pus is thick or loculated surgical intervention required when pus is thick or loculated Surgical 'decortication' of the lung - required if gross thickening of the visceral pleura prevents re-expansion of the lung Surgical 'decortication' of the lung - required if gross thickening of the visceral pleura prevents re-expansion of the lung

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