Empyema

Maria V. P. Hartanuh Company

Madyline Victorya Katipana LOGO
 Definition
Purulent pleural effusion
Infection of the pleural space and commonly
an exudate

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 Causes
Typically occurs following a reactive pleural
effusion as a consequence of a lung infection
Parapneumonic
Pneumoccoci
Staphylococci
Gram-Negative Bacteria
E. coli
Klebsiella
Pseudmonas
Enterobacteriaceae
Anaerobe Bacteria
Mycobateria or Fungi Rare

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 Causes
Trauma or thoracic surgery
Bronchopleural fistula
Hematologic spread
From gingival and upper resiratory tract
infection or Mycobacterium tuberculosis
Rupture of a pulmonary or mediastinal
abcess
Esophageal perforation

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Etiology and Pathogenesis

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 Epidemiology
All ages
Older or debilitated patients >>
Mortality rate depends on the degree of
severity of the comorbidity
1 40 % in immunocompromised patient

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 Pathophysiology
The route of organism entry into the pleural
cavity Contagious, direct contamination,
and hematogeneous
As organism enter the pleural space influx
of PMN release of inflammatory mediator
and toxic oxygen radicals Influx of fluid
into the pleural space

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 The early effusion watery and free
flowing in the pleural cavity
The pleural fluid thick and loculated
and may be associated with fibrinous
adhesion hours to days
Further progression the formation of
pleural peel a thick pleural rind
trapped lung

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 Patogenesis
There are three clinically relevant stages
Acute
Fibrinopurulent
Organizing

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 Acute
A rapid influx exudative fluid into the pleural
space
Pleural Fluid :
Bacteria (-)
pH >7.20
Glucose (Normal)
LDH <3 times the uper limit of normal
Respond to antibiotics
Drainage is generally not required

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 Fibrinopurulent
Untreated exudative effusion
Pleural fluid :
Microbial (+)
pH <7,20
LDH >3 times the upper limit
Low glucose
Loculations may develop complicated
The critical characteristic There is the disturbance of
physiological equilibrium between clotting and
fibrinolysis within the pleural space. Mediator for coagulation
and inhibittor of fibrinolysis : TNF- (release of plasminogen
activator inhibitor) increased plasminogen activator
inhibitor-2 and depressed of tissue plasminogen activator
(tPA)

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 Fibrinopurulent
Pleural surface coated with fibrin and fibrin
strands with secondary adhesions and
loculations

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 Organizing
Fibroblast grow into the pleural space both
the visceral and parietal pleura
Result in a thick pleural peel restricts chest
mechanics
Need surgical decortication

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 Clinical Manifestatiom
Acutely ill the clinical presentation is similar
to pneumonia
General malaise
Fever
Loss of apppetite
Weight loss
Cough
Dyspnea
anemia

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 Diagnosis
Chest x-ray (PA and Lateral decubitus)
Small to moderate effusion with or without
parenchymal infiltrate
Evidence of loculations and air fluid level
Xray effusion<1 cm resolved with
antibiotic therapy alone and did not
required pleural aspiration thoracontesis
Thoracic ultrasound
more sensitive than decubitus expiratory
films
Guiding pleural aspiration and drainage

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 Diagnosis
CT-Scan
Thickening of the parietal pleura on a
contrasted CT-Scan is suggestive of
empyema (indication for thoracocentesis)
Pleural fluid

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 Treatment
Complete and dependent drainage is
required
Non-invasive
Supportive :
Antibiotics
Fluids
Nutrition

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 Semi-invasive
Therapeutic aspiration
Tube thoracostomy
Fibrinolytic agent
Tissue plasminogen activator
Invasive
Thoracoscopy
Thoracotomy
Open drainage

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Categorizes parapneumonic
effusion that need for drainage

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 Treatment
Antibiotic
Amoxycillin with clavulanic acid
2nd generation Cephalosporin (e.g cefuroxime)
Metronidazole
Clindamycin monotherapy for ps with -lactam
alergy
Gram-negative
Carbapenem
Antipseudomonal penicillins (e.g.
piperacillin/tazobactam)
3rd or 4th generation of cephalosporin (e.g.
ceftazidime, cefepime
Metronidazole
Methicillin-resistant S. aureus
Vancomycin
linezolid

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 Treatment
Tube thoracostomy
Indications :
Empyema
Complicated parapneumonic effusions
pH <7,20
Loculation or positive bacteriological
Large effusion > half of a hemithorax
Position in the dependent part of a free-flowing
pleural effusion (posterior costophrenic recess)
Close-drainage until symphysis of the visceral
and parietal surface takes place
Open drainage : Posterior rib resection and
insertion

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 Treatment
Thrombolytic
Complicated parapneumonic effusion and
empyema procoagulant state within the
pleural space dense layer of fibrin and
loculations.
Intrapleural fibrinolytic give early in the
fibrinopurulent phase should prevent
loculations and promote pleural drainage
Thrombolytic agents : Streptokinase,
urokinase and streptodornase

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 Treatment
Thoracoscopy
For the patient with an incompletely
drained loculaated parapneumonic effusion
Visual inspection of the pleura may guide
decisions regarding the need for an open
surgical procedure
VATS/Videoscopic-assisted thoracoscopy
surgery

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 Treatment
Surgery
Decortication, Thoracotomy
Thoracostomy incision the chest wall with rib
resection produce a stoma with continous
drainage of the chest cavity
Lobectomy or pneumonectomy for
bronchopleural fistula
The aim:
Control sepsis
Removing restrictive fibrotic peel encasing the
lung

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 Treatment
Decortication major surgical excision of
all fibrous tissue from the pleural with or
without the evacuation of assiciated pus and
debris from the pleural cavity

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 Thank you

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