EMPYEMA
Pneumothorax
TABINDAH REHMAN , GROUP 2, SEM 7
EMPYEMA
DEFINITION
Empyema or Purulent Pleurisy: Empyema is an
accumulation of pus in the pleural space
Most often associated with pneumonia due to Staphylococcus
aureus & Streptococcus pneumoniaea
The relative incidence of Haemophilus influenzae empyema
has decreased (Hib vaccination)
Also produced by rupture of a lung abscess into the pleural
space, by contamination introduced from trauma or thoracic
surgery or by mediastinitis or the extension of intra-
abdominal abscesses
EPIDEMIOLOGY
Most frequently encountered in infants & preschool children
Predisposing factors: preceding history of pustules, blunt
trauma to the chest, viral infection, severe malnutrition,
contiguous extension
PATHOLOGY
Empyema has 3 stages: exudative, fibrinopurulent, and
organizational
Exudative stage: 1-3 days
Fibrinopurulent stage: 4-14 days
Organizational stage: After 14 days
PATHOLOGY
Exudative stage: fibrinous exudate forms on the pleural surfaces
Fibrinopurulent stage: fibrinous septa form, causing loculation of
the fluid & thickening of the parietal pleura
If the pus is not drained, it may dissect through the pleura into lung
parenchyma, producing bronchopleural fistulas and
pyopneumothorax, or into the abdominal cavity or through the chest
wall (empyema necessitatis)
Organizational stage: fibroblast proliferation; pockets of loculated
pus develop into thick-walled abscess cavities or the lung may
collapse & become surrounded by a thick, inelastic envelope (peel)
CLINICAL MANIFESTATIONS
The initial signs & symptoms are primarily those of bacterial pneumonia
Children treated with antibiotic agents may have an interval of a few days
between the clinical pneumonia phase & the evidence of empyema
Most patients are febrile (fever may be absent in immunocompromised
patients), develop increased work of breathing or respiratory distress &
often appear more ill
Physical findings are identical to those for uncomplicated parapneumonic
effusion & the 2 conditions are differentiated only by thoracentesis
DIAGNOSIS
The effusion is empyema if bacteria are present on Gram
staining, the pH is <7.20, glucose<40 mg/dl and LDH>1000
IU/L and there are >100,000 neutrophils/µL
Cultures of the fluid must always be performed
Blood cultures also have a high yield
COMPLICATIONS
1. Bronchopleural fistulas
Usually respond to adequate drainage, nutritional support &
sealing of the open communication over the lung surface
Prolonged bronchopleural fistulas (>2-3 weeks) requires
decortication, lobectomy or thoracoplasty
COMPLICATIONS
2. Pyopneumothorax
3. Purulent pericarditis & pulmonary abscesses
4. Peritonitis from extension through the diaphragm & osteomyelitis of
the ribs
5. Septic complications: meningitis, arthritis
6. Septicemia is often encountered in H. influenzae and pneumococcal
infections
7. Peel: may restrict lung expansion and may be associated with persistent
fever and temporary scoliosis
8. Empyema necessitans
9. Gastropleural fistula
TREATMENT
Systemic antibiotics
Staphylococcus aureus: cloxacillin & aminoglycoside or 3 gen
cephlosporin & aminoglycoside
Gram-ve organism: cefotaxim & aminoglycoside
Gram stain inconclusive: cefotaxim & cloxacillin
Resistant Staphylococcus: vancomycin, teicoplanin & linezolid
Thoracentesis
TREATMENT
Chest tube drainage with or without a fibrinolytic agent
Indications for surgical treatment:
a) Pleural thickening
b) Loculated empyema
c) Non-expansion of lungs with intercostal drainage
d) Bronchopeural fistula
1. Video-assisted thorascopic surgery: effective in lysis of adhesions in
multiloculted effusions & removal of fibrinous material from pleural cavity
2. Open decortication: significant pleural thickening
TREATMENT
The long-term clinical prognosis for adequately treated
empyema is excellent & follow-up pulmonary function studies
suggest that residual restrictive disease is uncommon, with or
without surgical intervention
PNEUMOTHORAX
PNEUMOTHORAX
DEFINITION
Accumulation of extra pulmonary air within the chest, most
commonly from leakage of air from within the lung
ETIOLOGY
Closed pneumothorax Open pneumothorax
-Pulmonary disease Invasive pleural &
Foreign body pulmonary procedures
RDS Chest trauma
Respiratory infections
Bronchial asthma Spontaneous pneumothorax
Cystic fibrosis Idiopathic (ruptured
Chemical pneumonitis subpleural blebs)
Diffuse lung disease Familial
Tumors
-Iatrogenic
Mechanical ventilation
Central venous catheterization
PATHOGENESIS
The tendency of the lung to collapse is balanced in the normal resting
state by the inherent tendency of the chest wall to expand outward,
creating negative pressure in the intrapleural space
When air enters the pleural space, the lung collapses
In simple pneumothorax, intrapleural pressure is atmospheric, and the
lung collapses up to 30%.
In complicated, or tension pneumothorax, continuing leak causes
increasing positive pressure in the pleural space, with further
compression of the lung, contralateral shift of mediastinal structures
& decreases in venous return and cardiac output
CLINICAL MANIFESTATIONS
Sudden onset
Dyspnea, pain, & cyanosis
Trachea & heart may be shifted toward the unaffected side
Hyperinflation & reduced movements on affected side
Respiratory distress with retractions
Decreased vocal fremitus & vocal resonance
Markedly decreased breath sounds and a tympanitic percussion note
over the involved hemithorax
When fluid is present, there is usually a sharply limited area of
tympany above a level of flatness to percussion
CLINICAL MANIFESTATIONS
Succussion splash: to rule out hydropneumothorax
Coin test
Friction test
DIAGNOSIS
By radiographic examination
When the possibility of diaphragmatic hernia is being
considered, a small amount of barium may be necessary to
demonstrate that it is not free air but is a portion of the
gastrointestinal tract that is in the thoracic cavity
Ultrasound can also be used to establish the diagnosis
TREATMENT
Extent of the collapse & nature and severity of the underlying
disease
A small (<5%) or even moderate-sized pneumothorax in an
otherwise normal child may resolve without specific treatment,
usually within about 1 wk
Needle aspiration: tension pneumothorax & primary spontaneous
pneumothorax
If the pneumothorax is recurrent, secondary or under tension or there
is >5% collapse: chest tube drainage
Pneumothorax complicating malignancy: chemical pleurodesis or
surgical thoracotomy
TREATMENT
Closed thoracotomy: adequate to reexpand the lung in most patients
Chemical pleurodesis: recurrent pneumothoraces; introduction of
talc, doxycycline, or iodopovidone into the pleural space
Open thoracotomy: plication of blebs, closure of fistula, stripping of
the pleura and basilar pleural abrasion; Stripping and abrading the
pleura leaves raw, inflamed surfaces that heal with sealing adhesions
VATS: preferred therapy for blebectomy, pleural stripping, pleural
brushing and instillation of sclerosing agents; less morbidity than
with open thoracotomy
