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Purulent chest disease

Purulent chest disease. Surgery department №2, DSMA. Effusions classification. Uncomplicated effusion. Thoracic empyema. Uncomplicated Effusion. Nonpurulent. Negative Gram’s stain result, negative culture. Free flowing, pH 7.3, normal glucose level, LDH less than 1000 IU/L.

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Purulent chest disease

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  1. Purulent chest disease Surgery department №2, DSMA

  2. Effusions classification • Uncomplicated effusion. • Thoracic empyema.

  3. Uncomplicated Effusion • Nonpurulent. • Negative Gram’s stain result, negative culture. • Free flowing, pH 7.3, normal glucose level, LDH less than 1000 IU/L. • Most resolve with appropriate antibiotics treatment and resolution of the pulmonary infection.

  4. Thoracic Empyema • Bacteria invade the normally sterile pleural space. • Three stage • Table 58-1

  5. Thoracic Empyema-- Stage 1 • Exudative effusion. • Increase permeability of the inflammatory and swollen pleural surface. • Correspond to the uncomplicated parapneumonic effusion. • Sterile, fibrin and PMN may present.

  6. Thoracic Empyema-- Stage 2 • Fibropurulent, true empyema, complicated pleural effusion. • Initial-- fluid is clear : WBC greater than 500 cell/μL, gravity greater than 1.08, protein level greater than 2.5 g/dL, ph less 7.2, LDH reach 1000 IU/L, fibrin deposit. • Angioblastic and fibroblastic proliferation, heavy fibrin deposition on both pleura, particularly the parietal pleura. • Later– fluid purulent, WBC 15000, ph less 7.0, glucose less than 50 mg/dL, LDH greater 1000 IU/L.

  7. Thoracic Empyema-- Stage 3 • 1 week after infection-- collagen organization, entrapment the underlying lung. • 3-4 week-- mature, turned peel. • Chronic-- dense fibrosis contraction and trapping the lung, atelectasis and prolonged pulmonary infection, reduction the size of hemithorax. • Fibrothorax-- invasion the chest wall and narrow the intercostals space-- As the end stage of the process.

  8. Complication of Empyema • Early or late. • Necrosis of visceral pleura. • Bronchopleural fistula. • Necrosis parietal pleura and chest wall. • Osteomyelitis of rib or spine. • Esophageal fistula. • Metastatic spread（brain abscess）.

  9. BACTERIOLOGY • Before antibiotics（1941）, 10% pf pneumonia develop the empyema, the streptoccus and pneumococcus were most frequently. • After antibiotics, the empyema decrease as mortality. Staphylococcus became the most prevalent. • Recently, the penicillin-resistant staphylococcus, gram’s –negative, anaerobic been predominant microbes.

  10. BACTERIOLOGY • Predominant aerobic-- Streptococcus pneumonia, Staphylococcus aureus, E. coli, Klebsiella pneumoniae, Hoemophilus influenzae. • Predominat anaerobic-- Anaerobic cocci, pigmented prevotella, porphyromonas, bacteroid fragilis, fusobacterium spp.

  11. BACTERIOLOGY • S. pneumoniae responsible for 60%-75% community acquired pneumonia, only 2% develop empyema. • S. aures account 1-2% community-acquired pneumonia, 10% adult and 50% children develop empyema. • In hospital, the staphylococcus and gram’negative are most common.

  12. CLINICAL FEATURE • Shortness of breath, cough , chest pain-- common to pneumonia. • Febrile respiratory illness, accentuation, prolongation the symptoms in pneumonia-- alert the possibility of empyema. • Aerobic empyema-- acute febrile illness. • Anaerobic empyema-- more indolent, usually 10 days.

  13. DIAGNOSIS • Chest x-ray—The posterior lateral diaphragmatic angle-- The most dependent position-- Most empyema are found. (Inverted D or pregnant lady sign). • Sonography– guide thoracocentesis. • Fluid analysis. • Aerobic pus-- little odor. • Anaerobic-- foul smelling.

  14. Differential diagnosis • Lung abscess. • Bronchopleural fistula. • Lung abscess-- air-fluid level in both PA and lateral view. • Empyema-- air-fluid level rare in same in these view.

  15. MAMAGEMENT • Effective management require: 1) Control infection and sepsis by antibiotics. 2) Evacuation of pus from pleural space. 3) Obliteration the empyema cavity. ﹡Delay in drainage increase mortality from 3.4% to 16%.

  16. Antibiotics Therapy • Blood, empyema culture, gram stain. • Community-acquired--- Third-generation cephalosporin or clindamycin. • Gram negative or anaerobes-- third generation cephalosporin and clindamycin. • Hospital-acquired-- should guide by culture.

  17. Thoracocentesis • 18-gauge needle. • Fluid analysis. • Chest x ray repeated in 24 hours. • Repeated thoracocentesis if volume increased.

  18. Chest tube drainage • First step in treatment of acute empyema. • Highly effective in treating-- Uncomplicated parapneumonic effusion and classic empyema without loculation. • 36 Fr, suction –20 cmH2O. • Clinical improve in 48-72 hour. • Remove-- drainage less than 50 ml within 24 hour, lung re-expansion. Usually within 5-10 day. • Antibiotics should continue 6 week.

  19. Intrapleural fibrinolytic agents • Empyema cavity– Composed of fibrin. • Fibrolysis agent—Streptokinase and Streptodornase— Significant systemic reaction, unsatisfactory. • Purified streptokinase, urokinase– Not allergic– • Success rate– 80% for streptokinase（250000 U/100ml normal saline）, 90% for urokinase（100000U/100ml normal saline ）.

  20. Open drainage • Cutting off the chest tube a few centimeter from the skin. • Anchoring it with safety pin and tape. • Tube may withdrawn a few centimeter each week as the granulation tissue fill the tract.

  21. Video-assisted thoracoscopy（VATS） • Primary modality for treating complicated empyema after initial therapy. • Adhesiolysis and débridement with better exposure and mini-thoracotomy, decortation for lung expansion. • Higher successful rate（90%）, shorter hospital stay, less cost. • Three-port triangle approach. • Morbidity low, chest tube can be removed 3-4 day.

  22. Chronic Empyema. • Chronicity– continued infection associated with both fibrosis and bronchopleural fistula. • Uncommon. • Thoracotomy and decortication • Empyemectomy. • Thoracoplasty.

  23. Lung Abcess • •Localized infection • •Air-fluid filled cavity -WBCs -Protein • - Tissue Debris • •Pyogenic Membrane

  24. Etiology • • Aspiration • -Staphylococcal aureus -Anaerobic organisms •Alcohol Abuse •Seizure disorder •CVA •Head trauma •General Anesthesia •Secondary cavitating infection

  25. Lung abscess classification • Acute • Chronic By quantity: Single or Multiple By side: Left or right side By complication: uncomplicated, complicated by sepsis or pyopneumothorax

  26. Radiologic Findings • •Increased opacity • -Consolidation -Atelectasis • •Cavity formation • -Air-fluid • •Fibrosis and calcification • •Pleural effusion

  27. Lung abscess treatment tactics • For acute – conservative treatment (antibiotics, mucolytics, postural drenaige, santion bronchoscopy) • For chronic – operative (atypical resection of lung, lobectomy or bilobectomy)

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