EMPYEMA THORACIS

ISSAH J. KISWAGALA

M.B.B.S

PHYSIOLOGICAL ANATOMY

The Lungs

• A major organ of the respiratory system.
• The lungs are pyramid-shaped, paired organs that are connected to the trachea by the right and left bronchi; on the inferior surface, the lungs are bordered by the diaphragm.
• The main function of the lungs is to perform the exchange of oxygen and carbon dioxide with air from the atmosphere.

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DEFINITION

• Empyema thoracis is defined as collection of purulent material in the pleural space
• It comes from the Greek word “empyein” ,which means :pus –producing (suppurates)
• It is not a primary disease
• It is secondary to other underlying diseases
• It is a complication of other diseases

ETIOLOGY

• Classified as
• Local causes
• Systemic causes

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Local causes

• Chest wall causes
• Pleural causes
• Pulmonary causes
• Sub-diaphragmatic causes
• Iatrogenic causes

Chest wall causes

• Osteomyelitis of ribs / thoracic vertebrae
• Penetrating wounds
• Thoracic wall abscess

Pleural causes

• Pneumothorax
• Haemothorax

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Pulmonary causes

• Pneumonia
• Bronchitis
• Pulmonary TB
• Lung abscess
• Bronchiectasis

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Sub-diaphragmatic causes

• Sub-phrenic abscess
• Hepatic abscess

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Iatrogenic causes

• Esophageal perforation during esophagoscopy
• Pleural tap
• Post-pneumonectomy
• Post-thoracotomy

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Systemic causes

• Septicemia

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BACTEOLOGY

• Staphylococcus aureus
• Steptococcus pneumoniae
• Escherichia Coli
• M. Tuberculosis
• Aerobacter aerogenes
• Proteous
• Salmonella
• etc

RISK FACTORS

• Risk factors include
• Alcoholism
• Drug use
• HIV infection
• Neoplasm
• Pre-existent pulmonary disease

Clinical classification

• Acute empyema thoracis
• In which there is profound toxemia and shock
• Patient presents with high grade fever, cough with pleuritic chest pain and shallow breathing
• Sub-acute empyema thoracis
• This is less severe form of presentation in patients who was on antibiotics for pneumonia
• Chronic empyema thoracis
• This usually results from mismanagement of the acute form

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Anatomical classification

• Total thoracic empyema
• The whole pleural cavity is involved
• Localized or encysted thoracic empyema
• Only part of the thoracic cavity is involved

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PATHOPHYSIOLOGY

• According to the American Thoracic Society [1962], the development of thoracic empyema passes through 3 stages:-
• Exudative stage (Early stage 1-3days)
• Fibrino-purulent stage (Established stage 4-14 days)
• Organizing stage (>14 days, Development of an inelastic membrane "the peel“).

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CLINICAL PRESENTATION

• History
• Physical examination

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History

• Cough
• Pleuritic chest pain
• Breathlessness
• ± Haemoptysis
• Fever
• Rigors
• General body weakness

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Physical examination

• Febrile
• Dyspnoea
• Toxic
• Chest examination
• Evidence of fluid in the chest cavity-stony dullness percussion note

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Management

• Lab investigations
• Haematological investigations
• Haemoglobin
• WBC count + ESR
• ELISA test for HIV
• Bacteriological investigations
• Sputum for AFB
• Sputum for culture and sensitivity
• Pus for culture and sensitivity

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• Imaging investigations
• Chest x-ray
• Abdominal USS to rule out hepatic abscess
• CT scan of the chest
• Help to delineate the pleural fluid loculations
• Can also detect airway or parenchymal abnormality e.g. endobronchial obstruction or the presence of lung abscess
• Diagnostic procedures
• Aspiration of pus to confirm diagnosis

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TREATMENT

• Objectives of treatment
• Modalities of treatment

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Objectives of treatment

• To control the primary infection by appropriate medications
• Evacuation of purulent content of the empyema sac and eradication of the sac to control chronicity i.e. to obliterate empyema space
• Re-expansion of the underlying lung to restore function
• To prevent complications

Modalities of treatment

• Non-surgical therapy
• Surgical treatment

Non-surgical therapy

• Antibiotic therapy - The specific antimicrobial agent should be chosen based on Gram stain and culture. Good pleural fluid and empyema penetration has been reported for penicillins, ceftriaxone, metronidazole, clindamycin, vancomycin, gentamycin and ciprofloxacin
• Intra-pleural thrombolytic agents - Useful in multiloculated empyema. It hydrolyse fibrin leading to hydrolysis of fibrin coagulum then improve drainage and thus improve clinical outcome
• Needle aspiration (Thoracocentesis)- is both diagnostic and therapeutic, adequate only in exudative stage

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Surgical treatment

• Closed chest drainage (underwater seal drainage-UWSD)
• Open chest drainage (rib resection)
• Decortications
• Thoracoplasty
• Video-assisted thoracoscopic surgery (VATS)

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Closed chest drainage (UWSD)

Open chest drainage (Rib resection)

• In this case, 2-3 ribs are resected to allow evacuation of pus, break up loculations and adherence, wash the cavity and put UWSD to prevent re-accumulation of empyema
• This is done if the pus is too thick to be evacuated by UWSD

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Decortications

• In this case, thoracotomy is done and peel out the cortical layer over the parietal and visceral surfaces

Thoracoplasty

• In this case ribs are taken away to compress the chest
• Due to high mortality and morbidity the procedure has been ABANDONED

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Video-assisted thoracoscopic surgery

• Video-assisted thoracoscopic surgery (VATS) is used as a first-line therapy in many hospitals, although open thoracic drainage remains a frequently used alternative technique
• It is quite effective in lysis of adhesions in multiloculated effusions and removal of fibrinous material from pleural cavity
• VATS is often not as useful in organizing stage.

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COMPLICATIONS

• Respiratory insufficiency
• Systemic septicaemia
• Septic emboli to the brain
• Broncho-pleural fistula
• Lung collapse
• Empyema necessitans
• Amyloidosis