Dr. Ashraf A. Esmat A.Prof.Cardio-thoracic surgery Cairo university EMPYEMA THORACIS Dr. Ashraf A. Esmat A.Prof.Cardio-thoracic surgery Cairo university

Definition Accumulation of Pus in the Pleural cavity. It comes from the greek word empyein ,which means :pus –producing (suppurates).

Aetiology Lung diseases: Pneumonia (the most common cause) Lung abscess. Subphrenic abscess. Post traumatic. Iatrogenic. Post-operative. Blood spread .

Organisms The most common: Staph.aureus .(90% of causes in infants & children) Strept.pneuomonie. H.influenzae.

Pathological Stages Acute (exudative) stage: Pleura fills with thin fluid that shows one or more of these criteria; Ph < 7.4 Glucose <40 mg/dl LDH> 1000 iu/dl Protein > 2.5 gm/dl Sp.gravity >1.018

Stages (cont.) Fibrinopurulent stage: Thick,Opaque fluid with positive culture (pus) and Deposition of thin fibrin layer over the pleura. Progressive loculation and formation of pouches in the pleura.

Stages (cont.) Organizing Stage: Presence of very thick pus . Thick Inelaastic peel over both pleurae causing entrapment of the lung.

Clinical stages Acute stage : within the first 2 weeks of the onset. Chronic Stage : after 2 weeks or with the formation of the thick peel and loculations.

Causes of chronicity: Inadequate Tube Drainage. Chronic pulmonary Disease( T.B. or Fungal Infection) Immunosupressed patients. Presence of Foreign body within the pleural space.

Symptoms & signs Fever Cough & Expectoration. Pleuretic chest pain. Easy fatiguability. Loss of weight. Night sweating.

Complications Rupture into the lung; BronchoPleural fistula Spread to the subcutaneous tissue; Empyema Niscitanes Septicaemia & septic shock.

Investigations Chest X-ray. C-T scan. Ultrasonography Thoracentesis

Management Control of the Infection process. Drainage of pus form the pleura. Obliteration of the space & complete Re-expansion of the Lung.

Drainage of Empyema Intercostal tube thoracostomy. Intrapleural instillation of streptokinase . V.A.T.S. Rib Resection Drainage. Eloesser Flap .

Tube thoracostomy Indications Technique When to remove When to convert to open drainage

Intrapleural Streptokinase Indications Acute or fibrino purulent stage Presence of loculations. Incomplete drainage after tube insertion Contraindications: Chronic stage Post-operative empyema Empyema with BPF.

Technique Streptokinase 25000 iu in 50 cc of 0.9% saline solution. Clamp the tube for 6 hours. Open the clamp and connect tube to suction

Video Assisted Thoracoscopy Indications Technique Limitations complications

Rib Resection Drainage Indication Technique Limitations

Eloesser Flap Drainage Indication. Technique. Advantage. Disadvantage.

Reexpansion of the lung & obliteration of the space Decortication. Muscle Transposition. Thoracoplasty.

Decortication Indications. Technique. Postoperative care.

Thoracoplasty Conventional alexander . Tailoring thoracoplasty.

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