EMPYEMA

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

2. EMPYEMA • so thick that it is impossible • to aspirate even through a • wide-bore needle • presence of pus in the pleural space • 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 as thin as serous fluid ?

3. Aetiology • 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 • pus is under considerable pressure & may rupture into a bronchus causing track through chest wall with formation of • subcutaneous abscess • sinus • bronchopleural fistula • pyopneumothorax

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

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

7. Clinical features • empyema should be suspected in patients with pulmonary infection • persistence or recurrence of pyrexia despite the administration of a suitable antibiotic • 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

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 • 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 • Loculated fluid may be seen • 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 • extent of pleural thickening • single collection or multiloculated

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

15. Aspiration of pus confirms presence of empyema • performed using a wide-bore needle under Ultrasound or CT guidance • 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

16. Management • .

17. 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 • 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 • 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