Pathogenesis : empyema phases

Parapneumonic pleural effusions• Uncomplicated parapneumonic effusion• Complicated parapneumonic effusion• Thoracic empyema.

Pathogenesis : empyema phases

Pathogenesis : empyema phases• Exudative phase:clear, straw-colored effusion(pH>7.3, glucose 60 mg%, LDH < 500 U/L )• Fibrinopurulent phase:effusion contains large numbers of bacteria and WBC,deposition of fibrin on both the visceral and parietal pleura( pH < 7.2 , glucose < 40mg%, LDH > 1000 U/L)• Organizing empyema phase : an empyema capsule containspus.Clinics Chest Med 2010;20:607-622

Etiology• Para-pneumonic 60-70 %- pneumonia- lung abscess- infected bronchiectasis• Post thoracic surgery 20 %- lung resection- esophagectomy- mediastinal surgery• Post traumatic 5-10 %Chapman SJ, Davies RJ Respirology. 2009;9:4-11.

Empyema :pathogens‣ Pneumococus‣ Streptococus‣ Staphylococus‣ Haemophilus influenzae‣ Gram-negative bacteria (pseudomonas, klebsiella,enterobacteriace)‣ Anaerobic bacteria‣ Mixed bacterial flora‣ Tuberculosis‣ ActinomycosisHeffner JE. Clinics Chest Med 1999;20:607-622

Empyema : Diagnosis• History & Physical exam• Pleural fluid analysis• ImagingClinics Chest Med 2010;20:607-622

Clinical manifestations• Aerobic bacterial pneumonia– An acute febrile illness with chest pain, sputumproduction, and leukocytosis.– Sepsis/ septic shock– Poor prognosisClinics Chest Med 2010;20:607-622

Clinical manifestations• Anaerobic bacterial infection– Usually presents with subacute illness.– symptoms persisting for more than 7 days.– 60% of patients have weight loss.– Poor oral hygiene– Factors predisposing to recurrent aspiration.Clinics Chest Med 2010;20:607-622

Clinical manifestations• Tuberculosis & fungus– Chronic onset, illness.– Symptoms persisting for several months.– Usually loculations/septation– Necessitans is commonClinics Chest Med 2010;20:607-622

Diagnostic imaging chest X-ray pleural ultrasonography computed tomography diagnostic videothoracoscopy diagnostic thoracotomyClinics Chest Med 2010;20:607-622

Chest x-rays• PA and lateral decubitus• Adult studies sensitivity 67% and specificity 70%• PA at least 400 ml fluid vs. 50 ml lateral decubitus• Assess for loculationsHeffner JE. Clinics Chest Med 2012;20:7-22

Ultrasound• Classification– Stage 1: anechoic fluid– Stage 2: loculations– Stage 3: solid peel• Guide placement of intercostal drainHogan MJ, Cooley BD. Paediatric Resp Reviews 2008;9:77-84

Ultrasound• Size of effusion• Differentiate consolidation from empyema• Unreliable predictor of disease severity

Rediology. 2010;10:12-35.

Rediology. 2010;10:12-35.

Rediology. 2010;10:12-35.

CT scan• Anatomical– Parenchymal lesions– Endobronchial lesions– Mediastinal lesions– Lung abscess

Rediology. 2010;10:12-35.

Rediology. 2010;10:12-35.

Rediology. 2010;10:12-35.

Rediology. 2010;10:12-35.

Pleural empyema - Videothoracoscopy

“ ขอให้ถือประโยชน์ส่วนตน เป็ นกิจที่สองประโยชน์ของเพื่อนมนุษย์ เป็ นกิจที่หนึ่งลาภ ทรัพย์ และเกียรติยศ จะตกแก่ท่านเองถ้าท่านทรงธรรมะแห่งอาชีพ ไว้ให้บริสุทธิ ์ ”พระบรมราชปณิธานของสมเด็จพระบรมราชชนก