1. Department of Medicine Manipal College of Medical Sciences
EMPYEMA
ALOK SINHA
Department of Medicine
Manipal College of Medical Sciences
Pokhara, Nepal

2. EMPYEMA presence of pus in the pleural space
empyema continues to be a significant cause of morbidity and mortality even in developed countries
Associated with delay in the diagnosis or instigation of appropriate therapy
so thick that it is impossible
to aspirate even through a
wide-bore needle
as thin as serous fluid ?

3. Aetiology
Mostly secondary to infection in a neighbouring structure - usually the lung
bacterial pneumonias
T.B.
rupture of a subphrenic abscess through the diaphragm
infection of a haemothorax
Iatrogenic – following pleural aspiration

4. Pathology
Both layers of pleura are covered with a thick, shaggy inflammatory exudate
pus is under considerable pressure &
may rupture into a
bronchus causing
track through chest wall
with formation of
subcutaneous abscess
sinus
bronchopleural fistula
pyopneumothorax

5. empyema can heal
by eradication of the infection
obliteration of the empyema space
Early apposition of the visceral & parietal pleural layers are essential

6. Factors keeping pleura apart
air entering through a broncho pleural fistula
underlying disease in the lung, such as
Bronchiectasis
bronchial carcinoma
pulmonary TB
prevents re-expansion
In these circumstances empyema become chronic. Surgical intervention required for healing

7. Clinical features
empyema should be suspected in patients with pulmonary infection
persistence or recurrence of pyrexia despite the administration of a suitable antibiotic
Some times first definite clinical features may be due to the empyema itself
Once an empyema has developed, two separate groups of clinical features are found

8. 2. Local features 1. Systemic features Symptoms: Signs:
Pyrexia, usually high and remittent
Rigors, sweating, malaise and weight loss
Polymorphonuclear leucocytosis, high CRP
2. Local features
Symptoms:
Pleural pain
breathlessness
cough and sputum – underlying lung disease
copious purulent sputum – empyema ruptures into a bronchus
Signs:
Clubbing – regular feature in pyogenic infections
Clinical signs of fluid in the pleural space
Cause restrictive defect

9. Empyema necessitans
A very rare condition in which an empyema goes undetected over a long period of time and progresses to the chronic stage
Eventually the empyema erodes through the chest wall and spontaneously drains onto the surface of the body

10. INVESTIGATIONS

11. Radiological examination:
indistinguishable from those of pleural effusion
Loculated fluid may be seen
When air is present in addition to pus pyopneumothorax horizontal 'fluid level'

12. Homogenous density
Loculated
Loss of cardiophrenic angle
Loss of lateral portion of  diaphragmatic  silhouette

13. Ultrasound position of the fluid extent of pleural thickening
single collection or multiloculated

14. CT
useful in assessing the underlying lung parenchyma and patency of the major bronchi

15. Aspiration of pus confirms presence of empyema
performed using a wide-bore needle under Ultrasound or CT guidance
pus frequently sterile when antibiotics have already been given
Distinction between tuberculous and non-tuberculous disease can be difficult and often requires pleural histology and culture

16. .
Management

17. intercostal tube with water-seal drain inserted in acutely ill ptient
If initial aspirate – turbid or frank pus or loculated -tube should be put on suction (5-10 cm H2O) and flushed regularly with 20 ml normal saline
Pus culture & appropriate antibiotic given for 2-4 weeks

18. SURGICAL INTERVENTION
Decompression of lung secured at an early stage by removal of all the pus from the pleural space to prevent visceral pleura becoming grossly thickened & rigid
surgical intervention required when pus is thick or loculated
Surgical 'decortication' of the lung - required if gross thickening of the visceral pleura prevents re-expansion of the lung