Symptoms. Uncontrolled infection : pain, weight loss, asthenia and fever. Restriction and V/P mismatch : dyspnea. Signs of infection : leucocytosis, rise of CRP.
Epidemiology. Elderly and debilitated. 82% of patients had one or more underlying illnesses. Individuals without access to medical care or from lowest social class. Mortality ranges from 1% to 19% ( for immunocompromised up to 40% ). Prognosis worse with hospital-acquired or culture-positive empyemas.
Fibrinopurulent stage. Fibrin deposition. Septations on lateral decubitus chest x-ray, US and CT. Drop of ph ( 1000 U/L ) : a. increased utilization of glucose by both PMN cells and bacteria. b. glucose metabolits ( carbon dioxide and lactic acid ) increase of purulent collections. c. LDH rises in proportion to cell lysis.
Diagnosis. Chest radiography. Computed tomography. Ultrasonography. Thoracentesis : a. cell count, glucose, LDH, ph. b. Gram staining and aerobic and anaerobic cultures. c. mycobacteria and fungi if indicated clinically.
Goals of treatment. Evacuation of pus. Expansion of lung. Prevention of ongoing infection.
Management. Antimicrobial agents. Tube thoracostomy. CT-guided chest tube insertion and intrapleural fibrinolytic debridment. VATS thoracoscopy. Surgery ( rib resection, decortication, thoracoplasty, open window ).
Antibiotics. Early empiric treatment. Antibiotics altered according to the patient clinical course or results of pleural fluid cultures. Repeat cultures with any deviation of patients clinical status.
Tube thoracostomy. Large thoracostomy tube. Smaller CT-guided chest tubes for multi-loculated empyemas. Success rates of 50% without further treatment. Chest tubes kept under suction (?).
Intrapleural fibrinolitic therapy. Streprokinase / Urokinase. Safe and effective in adults and children. Intrapleural hemorrhage and bronchopleural fistula are contraindication.
Keep in mind. Early detection of pleural effusions. Accurate definition of empyemas stage. Appropriate antimicrobial therapy. Effective and complete drainage of empyema and achievement of lung reexpansion prevents surgery. Treatment of underlying conditions. Adequate nutrition.
Our experience. 133 patients with empyema treated in our department (7 years). 88 patients treated by chest tubes with Urokinase installations. 23 patients operated due to failure of fibrinolitic therapy. 22 patients operated without initial fibrinolitic treatment.
Our experience. 63 patients with complicated parapneumonic effusion ( 47.3%). 26 patients after Thoracic Surgery ( 19.6% ). 17 patients with traumatic empyema ( 12.8% ). 27 other causes ( 20.3% ).