1 / 19

Parapneumonic Effusions and Empyema

Parapneumonic Effusions and Empyema. Journal Club Preethi Yeturu and Navneesh Sharma February 18, 2009. Pleural Effusions. Abnormal accumulation of fluid in the pleural space due to a disruption of the equilibrium across pleural membranes Normal pleural fluid clear ultrafiltrate of plasma

edith
Download Presentation

Parapneumonic Effusions and Empyema

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. Parapneumonic Effusions and Empyema Journal Club Preethi Yeturu and Navneesh Sharma February 18, 2009

  2. Pleural Effusions • Abnormal accumulation of fluid in the pleural space due to a disruption of the equilibrium across pleural membranes • Normal pleural fluid • clear ultrafiltrate of plasma • pH 7.6 - 7.64 • Protein content <2%, WBC <1000 • LDH <50% of plasma LDH • Two types • Transudate • Exudate

  3. Transudate • Increased capillary hydrostatic pressure or decreased colloid oncotic pressure • Pleural membranes intact • Permiability of capillary membranes normal • Fluid is an ultrafiltrate of plasma • Causes • CHF • Cirrhosis • Nephritic syndrome

  4. Exudate • Altered permeability of pleural membranes and capillaries or obstruction of lymphatic drainage of pleural space • Light’s criteria: one or more of following must be present • Pleural fluid/serum protein >0.5 • Pleural fluid/serum LDH>0.6 • Pleural fluid specific gravity >1.018 • Causes • Parapneumonic • TB • Malignancy • PE

  5. Parapneumonic Effusions • Any pleural effusion associated with bacterial pneumonia, lung abscess or bronchiectasis • Most common cause of exudative pleural effusions in US • 40-60% of bacterial pneumonias result in pleural effusions • Three types • Uncomplicated parapneumonic effusion • Complicated parapneumonic effusion • Empyema

  6. Uncomplicated Effusions • Parenchymal infection leads to increased interstitial fluid that causes accumulation of sterile pleural effusion • Pleural fluid is often small (<10mm) • sterile w/ small amount of PMNs • glucose and pH wnl • Resolve with resolution of pneumonia and treatment w/ antibiotics

  7. Complicated Effusions • Persistent bacterial infection of previously sterile pleural fluid • Pleural fluid • Many PMNs, bacteria and cell debris • Acidosis - pH and glucose decrease • LDH increases • Possible deposition of fibrin on pleura - formation of multiple locules

  8. Empyema • Characterized by bacteria seen on gram stain or aspiration of pus • 60% from complicated parapneumonic effusions • 20% after thoracic surgery • Pleural fluid • Possible formation of pleural peel that can encase the lung and hinder reexpansion

  9. Clinical Manifestations • History • Acute febrile episode • Dyspnea • Cough - w/ purulent sputum • Pleuritic chest pain • Weight loss • Physical exam • Dullness to percussion • Diminished breath sounds in affected hemithorax • Decreased tactile fremitus • Egophony • Pleuritic friction rub

  10. Diagnosis - Imaging CXR • blunting of costrophrenic angle on upright films • Lateral decubitus films - better view of subpulmonic effusions, show if effusion is freely-flowing, thickness of effusion

  11. Diagnosis - Imaging CT - w/ IV contrast is optimal • Allow for differentiation betwn parenchymal and pleural disease • Contrast enhances pleural surface

  12. Diagnosis • Thoracentesis • Sample if any of following are present • Free flowing but >10mm in lateral decubitus film • Loculated • Associated w/ thickened parietal pleura on CT - suggests empyema • Complications - pain, bleeding, pneumothorax, puncture of liver or spleen

  13. Analysis of Pleural Fluid • Gross examination for color, turbidity and odor • Microbiology - gram stain and cultures • pH or glucose, LDH, protein • CBC w/ differential

  14. Analysis of Pleural Fluid • Characteristics of Pleural Fluid

  15. Categories risk for poor outcomes

  16. Treatment • Depends on type and category of effusion • Uncomplicated - category 1 or 2 • Resolves w/ antibiotic treatment alone • Does not need drainage • Complicated - category 3 • Variable response to antibiotics alone - thus often treated like empyema • Empyema - category 4 • Requires complete drainage • Goal of therapy: • Sterilization of cavity - antibiotics for 4-6 weeks • Complete drainage as evidenced by minimal chest tube output and CT documentation that no residual loculations persist • Obliteration of empyema cavity w/ adequate lung expansion

  17. Drainage of Effusion • Theurapeutic thoracentesis • Tube thoracotomy • Often left until rate of drainage <50mL/day and cavity is closed • W/ fibrinolytics - intrapleural administration was suggested for loculated effusions • Reported data does not demonstrate benefit in most pts • Thoracoscopy • Alternative treatment for multiloculated empyema • Open thoracostomy • Open drainage at inferior border of empyema cavity w/ chest tube • Preferred in pts who cannot tolerate thoracotomy

  18. Drainage of Effusion • Thoracotomy w/ decortication • For pts who require additional drainage after trial of tube thoracostomy and thoracoscopy • Or pt who have fibrin deposition that hinders ability of lung to expand

  19. Thank you!!

More Related