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Chalya P.L. 1
THORACIC EMPYEMA
Dr Phillipo Leo ChalyaM.D. [Dar]; M.MED surg [Mak]Surgeon Specialist - BMC
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OUTLINEDefinition Historical backgroundEtiology Bacteology Classification Pathophysiology Clinical presentationWork upTreatment Complications
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DEFINITION
Present of pus in the pleural cavity
It is not a primary diseaseIt is secondary to other
underlying diseases It is a complication of other
diseases
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HISTORICAL BACKGROUND
For centuries, ET has been recognized as a serious problem
Around 500 BC, Hippocrates recommended treating ET with open drainage
In 1876,Hewitt described a method of UWSD
In early 20th century surgical therapies for ET i.e. thoracoplasty and decortication were introduced
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ETIOLOGY
Classified as– Local causes– Systemic causes
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Local 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
Sub-diaphragmatic causes– Subphrenic abscess– Hepatic abscess
Iatrogenic causes– Esophageal perforation during
esophagoscopy– Pleural tap– Postpneumonectomy– Postthoracotomy
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Systemic causes
Septicaemia
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BACTEOLOGY
Staphylococcus aureusSteptococcus pneumoniaeEscherichia ColiM. TuberculosisAerobacter aerogenes Proteous Salmonella etc
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CLASSIFICATIONS
Anatomical classificationClinical classificationPathological classification
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Anatomical classification
Total thoracic empyema– The whole pleural cavity is
involvedLocalized or encysted
thoracic empyema– Only part of the thoracic cavity
is involved
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Clinical classificationAcute thoracic empyema
– In which there is profound toxemia and shock
– Patient presents with high grade fever, cough with pleuritic chest pain and shallow breathing
Sub-acute thoracic empyema– This is less severe form of
presentation in patients who was on antibiotics for pneumonia
Chronic thoracic empyema– This usually results from
mismanagement of the acute form
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Pathological classification
Exudative (early) empyemaFibrino-purulent (established)
empyemaOrganizing empyema
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PATHOPHYSIOLOGY
According to the American Thoracic Society [1962], the development of thoracic empyema passes through 3 stages:-– Exudative stage– Fibrino-purulent stage– Organizing stage
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Stage I: Exudative (early) stage
This is purely an inflammatory process in which there is an increase in permeability of small blood vessels leading to exudation of fluid in the pleural cavity
The fluid is very thin with low cellular content and underlying lung that re-expands readily
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Stage II: Fibrino-purulent (established) stageThis stage is characterized
by:- – large number of
polymorphonuclear leucocytes– deposition of fibrin on both
visceral and parietal surfaces of the involved pleura
– Bacterial invasion of the pleural space
– Tendency towards loculation formation
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Stage III: Organizing stage
In this case fibroblasts appear in the now heavier fibrin coating of the pleural membranes
The fluid (exudates) is quite thick
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CLINICAL PRESENTATION
Symptoms– Cough – Pleuritic chest pain– Breathlessness– ±Haemoptysis– Fever– Rigors– General body weakness
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Signs
Febrile DyspnoeaToxicChest examination
– Evidence of fluid in the chest cavity-stony hard percussion note
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WORK UP
Lab studies– 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 – 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
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Modalities of treatment – Depends on the stage of the
empyema– Divided into:-
•Non-surgical therapy– Antibiotics – Intrapleural thrombolytic agents
– Needle aspiration (Thoracocentesis)
•Surgical therapy– Thoracoscopy – Closed chest drainage (underwater
seal drainage-UWSD)– Open chest drainage (rib resection)– Decortications– Thoracoplasty
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Needle aspiration (thoracocentesis)
This is both diagnostic and therapeutic
It may be adequate only in exudative stage (stage I)
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Closed chest drainage (UWSD)This is done if the fluid (pus)
in the pleural sac is thicker to evacuated by simple needle aspiration
It applied only in stage I & II
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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
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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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COMPLICATIONS
Respiratory insufficiencySystemic septicaemiaSeptic emboli to the brainBroncho-pleural fistulaLung collapseEmpyema necessitansAmyloidosis
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SPECIAL THANKS TOSADRU MOHAMED FOR MAKING THESE SLIDES AVAILABLE [email protected]+255759212578