PLEURAL

PLEURAL EMPYEMA
EMPYEMA
 Contents

Definition

Etiology

Stages

Symptoms & signs

Complications

Investigations

Management
 Pleural Empyema / Pyothorax /
Purulent Pleuritis / Empyema Thoracis
 Accumulation of Pus in the Pleural cavity.
 Etiology (Introduction of infection)
EMPYEMA

NON TRAUMATIC TRAUMATIC

THORACIC EXTRATHORACIC
SEPSIS NON-
SEPSIS IATROGENIC
IATROGENIC

LUNG
PULMONARY OSTEOMYELI SUBPHRENIC
RESECTION,
DISEASE MEDIASTINITIS ABSCESS,
TIS OESOPHAGEAL STABBINGS,G
HEPATIC TEARS, UNSHOT
ABSCESS PARACETESIS WOUNDS,ETC
THORACIS,
PNEUMONIA, TB, LIVER BIOPSY
STERNUM,
BRONCHIECTASIS
VERTEBRAE,
,LUNG ABCESS
RIBS
 Bacteriological data.
 Streptococcus pneumoniae: 15-20%
 Increased resistance
 Staphylococcus:15-30%
 Gram Negative: 20-50%
 Klebsiella, Enterobacter, Pseudomonas,
Hemophilus, E.Coli
 Anaerobes:
 Fusobacterium, Bacteroides fragilis
 Influence of predisposing factors

 In adults – empyema arises as a complication of CAP

(Community acquired pneumonia), often
pneumococcal.
 Aerobic gram negative bacilli infection likely to affect
pleura – from below diaphragm or as a result of
oesophageal instrumentation.
 Mycobacteria and fungi more common in
immunocompromised.
 Uncommon microbial causes
 Tuberculous
 Fungal – Aspergillous,Cryptococcus,Blastomyces,
Histoplasmosis.
 Actinomyces – aerobic gram negative filamentous
bacteria.
 Clostridia – anaerobic organism.
 Hydatid disease – Echinococcus.
 Protozoa – Trichomonas,Entamoeba histolytica.
 Pathology-Stages

 Acute (exudative) stage: Approximately in 7 days.

 Infected by pathogenic organism, pleural
membranes becomes edematous and produce
exudation of proteinaceous fluid that starts to fill
the pleural cavity.
 Pleura fills with thin serous fluid that shows
relatively low white cell count.
 Visceral pleura and underlying lung remains to be
mobile.
 Stages continuation
 Transitional (Fibrinopurulent) stage: From day 7 to 21 day.

 Is developing if infection proceeds unchecked by

antimicrobials.
 Thick, opaque fluid with positive culture (pus) and
deposition of thin fibrin layer over the pleura.(mainly
parietal pleura).
 Empyema fluid becomes to be thicker and turbid.
 Higher white cell count.
 Lung movements in this later stages become increasingly
restricted.
 Progressive loculation and formation of pouches in the
pleura.
 Stages cont,

 Stage of vascularization:
 Fibrinous layers starts to organize as collagen.
 Becomes vascularized by ingrowth of capillaries.
 Stages cont,
 Organizing (chronic) stage: usually after 4-6 weeks.
 Empyema cavity becomes surrounded by a cortex.
 Contains frank pus.
 Inner layers shows inflammatory cells.
 Outer layers gets fibrous – exerts restrictive effect.
 Compressing the underlying lung (trapped lung
effect).
 Draws the ribs together producing chest deformity.
 Later on gets calcified – fibrothorax.
 Symptoms & signs
 Depends on nature of infecting organism
 Competencey of patients immune system.
 Ranges from complete absence of symptoms to a severe
illness with all usual manifestations of systemic toxicity.
 Fever
 Cough & Expectoration.
 Pleuretic chest pain.
 Dyspnoea
 Easy fatiguability.
 Loss of weight.
 Night sweating.
 Finger clubbing (chronic stage).
 Signs of pleural effusion.

pus under tissue

anterior chest wall
 Complications
 Rupture into the lung;
 BronchoPleural fistula.
 Spread to the subcutaneous tissue;
 Septicaemia & septic shock.
 Diagnosis
 History and physical findings may be suggestive.
 CXR,USG,CT.
 Thoracentesis.
 Other findings (non specific): neutrophil leucocytosis
and hypoalbuminaemia.
 Chest x ray
 In early stages same as
uncomplicated pleural
effusion.
 As time passes, fibrosis
develops around empyema
cavity.
 Fluid contained in one
location.
 Homogenous shadow
extending upwards.
 Lateral cxr – opacity convex anteriorly.
 Tapering at its upper and lower ends
 Extending into the thorax.
 D – shaped shadow.
 Other findings on cxr
 Air fluid level – pneumothorax, gas
forming organisms such as
clostridia.
 Underlying pulmonary shadowing
-delayed resolution of
pneumonia,lung abcess,tumours of
lung,mediastinum,pleura.
 Hydatid cyst,partial lung collapse.
 CT thorax –inflamatory
lymphadenopathy
Postpneumonectomy empyema.
Pleural Empyema
Management
 Goals of the treatment
 Treat the infection.
 Drain the purulent effusion adequately and
completely.
 Re-expand the lung to fill the pleural space.
 Eliminate complications and avoid chronicity.
 Antimicrobial Therapy
 Choice of antibiotic – microbiological testing.
 Anaerobes- may be treated with Benzylpenicillin.
 If resistant – add metronidazole.
 Better response – Clindamycin + Penicillin ( active
against Bacteroids fragilis and other penicillin-
resistant anaerobes.
 Amoxyclav.(Beta lactam inhibitors).
 Ampicillin+Sulbactam.
 Piperacillin,Ticarcillin.(combined with tazobactum).
 Imipenam,meropenam(anaerobes as well as Gram
+/-)
 Cefoxitin – most potent cephalosporin.
 Chloramphenicol- very effective, but not routinely
given due to fear of bone marrow suppression.
 Macrolides,Quinolones not so effective.
 Pneumococcus
 Responds to high dose benzylpenicillin initially,
continuing with oral phenoxy methyl
penicillin(penicillin V) or amoxycillin.
 Alternatives for penicillin allergic individuals- Cefradin
or Clarithromycin.
 Staphylococcus aureus
 Dicloxacillin, oxacillin for parenteral use.
 First generation cephalosporins – cefradine.
 MRSA (Methicillin-resistant Staphylococcus
aureus)- vancomycin,Linezolid.
 Gram negative aerobes
 Serious aerobic infections may be treated with the
combination of a third generation cephalosporin –
Ceftazidime and an amynoglycoside such as
gentamycin.
 Mixed infection,including anaerobes – piperacillin.
 Adults with empyema who are admitted from the
community, and in whom infecting organism have not
yet been identified may be treated initially with a
combination that includes co-amoxyclav,
metronidazole and flucloxacillin.
 This regimen is modified in the light of cultures and the
patients clinical response.
 Duration of therapy is likely to be several weeks.
 It can be continued for at least 3 weeks after all
drainage has ceased.
 BTS guidelines for the management of empyema

Origin of infection Intravenous antibiotic Oral antibiotic treatment

treatment

Community acquired culture Cefuroxime 1.5 g tds iv + Amoxycillin 1 g tds +

negative pleural infection metronidazole 400 mg tds clavulanic acid 125 mg tds
orally or 500 mg tds iv

Benzyl penicillin 1.2 g qds iv Amoxycillin 1 g tds +

+ ciprofloxacin 400 mg bd iv metronidazole 400 mg tds

Meropenem 1 g tds iv + Clindamycin 300 mg qds

metronidazole 400 mg tds
orally or 500 mg tds iv

Hospital acquired culture Piperacillin + tazobactam 4.5 Not applicable

negative pleural infection g qds iv

Ceftazidime 2 g tds iv,

Meropenem 1 g tds iv ±
metronidazole 400 mg tds
orally or 500 mg tds iv
 Tuberculous Empyema
 It is a rare entity.
 Purulent fluid loaded with tuberculous organisms.
 Usually develops in fibrous scar tissue resulting from
pleurisy, artificial pneumothorax or thoracoplasty.
 Underlying pleura is heavily calcified.
 Sub acute or chronic illness
 Fatigue, low grade fever and weight loss.
 Radiographically – obvious pleural effusion, pleural
thickening.
 CT scan – thick calcified pleural rind and rib thickening
surrounded by loculated pleural fluid.
 Tuberculous Empyema
 Diagnosis – thoracentesis, AFB (Acid-Fast
Bacillus Testing) smear and culture.
 Treatment – intensive chemotherapy coupled
with serial thoracentesis can be curative at
times.
 Multiple drug regimen at their maximal
tolerated dosages.
 Strong tendency to develop resistant organisms.
 VATS/Decortication.
 Aspergillus – amphotericin or itraconazole.
 Cryptococcosis- in immunocompromised patient is
treated with amphotericin and flucytosine
 Blastomycosis, Coccidiomycosis –
amphotericin/Itraconazole.
 Actinomycosis – high doze Benzyl penicillin followed
by prolonged therapy with oral amoxycillin.
 Nocardia – co-trimoxazole,sulfadiazine or imipenam.
 Clostridial empyemas- high dose benzyl penicillin/
metronidazole or imipenam.
 Salmonella – ciprofloxacin or ceftazidime.
 Hydatid infection – surgical excision with
albendazole cover.
 Trichomonas – metronidazole.
 Empyema complicating amoebiasis –
metronidazole and diloxanide furoate.
 Primary treatment options
 Antibiotics alone;
 Recurrent thoracocentesis
 Insertion of chest drain alone or in combination with
fibrinolytics
 VATS.
 Open decortication
 Fibrinolytics
Intrapleural Streptokinase;

 Indications
 Acute or fibrino purulent stage
 Presence of loculations.
 Incomplete drainage after tube insertion
 Contraindications:
 Chronic stage
 Post-operative empyema
 Local antibiotics
 Intrapleural instillation of antibiotics, especially
metronidazole, Colimycin.
 Still debated.
 Do not replace systemic treatment.
 Video-assisted thoracic surgery
 VATS.
 If closed drainage does not have proper
result in prompt re-expansion of the
lung and especially if loculi have been
identified by USG.
 Decision to intervene early is made.
 Debridement and drainage.
 Breakage of loculi, evacuating pus,
debris and freeing lung.
 Helps in re expansion of lung.
 Bronchoscopy
 Is recommended following a successful conclusion
of closed drainage.
 In order to exclude any endobronchial causes of
obstruction, such as tumour or foreign body.
 Open drainage
 If empyema persists both clinically and radiologically.
 In whom closed drainage has proved unsuccessful.
 If VATS unavailable, unsuccessful or considered
inappropriate.
 Eloesser Flap .
 Eloesser Flap Drainage
 When drainage is protracted.
 Patient remains too ill.
 Unsuitable for thoracotomy.
 Then a more permanent fenestration or open
window thoracostomy may be performed.
 Once the ribs have been
resected, the skin overlying
the thoracostomy is
marsupialized to the parietal
pleura to permit packing and
open pleural drainage.
 Pleurocutaneous fistula.
 Stoma may be closed if the
underlying lung re-expanded
or may be left permanently
open with daily dressing
changes.
 Decortication
 Elective surgical procedure.
 Unsuitable for patients who are ill and toxic.
 Fibrous wall of the empyema cavity, referred as a
cortex is exposed at thoracotomy is stripped off and
adjacent visceral and parietal pleura should be left
intact.
 Indications
 Closed drainage/thoracoscopic methods have been
unsuccessful.
 Patients who has entered a chronic phase in which
underlying lung does not expand because of failure
of cortex to become reabsorbed.