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Pyothorax / Purulent Pleuritis / Empyema Thoracis
Prepared By:
Om verma
INTRODUCTION
 An empyema is an accumulation of
which purulent fluid within the pleural
space often with fibrin development & a
loculated ( exudative,pus,fluids ) (walled-
off) area where infection is located.
 Pleural empyema, also known as
pyothorax or purulent pleuritis,
is empyema (an accumulation of pus) in
the pleural cavity that can develop when
bacteria invade the pleural space,
 Definition:
“ Pleural empyema (also known as
a pyothorax or purulent pleuritis) is an accumulation
of pus in the pleural cavity. ”
Empyema itself is not disease it is actually a condition
complicated by another disease
Empyema is a condition in which pus accumulates in the
area between the lungs and the inner surface of the
chest wall. This area is known as the pleural space.
 Empyema is usually caused by an
infection that spreads from the lung. It
leads to a buildup of pus in the pleural
space
 Etiology:
o 2ndry to Bacterial Pneumonia Parapneumonic
Effusion A parapneumonic effusion is a type of
pleural effusion that arises as a result of a pneumonia, lung
abscess, or bronchiectasis.
.
o Other causes include:-
o Empyema thoracis can be caused by a number of different
organisms, including bacteria, fungi, and amoebas, in connection
with pneumonia.
o Common cause is pulmonary infection as a result of aerobic
bacteria such as Streptococcus pneumonia, Staphylococcus
aureus, E. coli, Klebsiella pneumoniae, Hoemophilus influenzae.
o Chest trauma(blunt chest wound, chest surgery, lung abscess, or
a ruptured esophagus)
o Septicaemia (very rare blood borne infection) blood poisoning,
especially that caused by bacteria or their toxins.
o Subdiaphragmatic causes as liver abscess
o Iatrogenic: In rare cases, empyema can occur
after a needle is inserted through the chest wall to
draw off fluid in the pleural space for medical
diagnosis or treatment (thoracentesis).
Stages:
 There are three stages:
1. Exudative (Acute)
2. Fibrinopurulent(Transitional)
3. Organizing(Chronic)
Stage -1: “Exudative”
- Sterile pleural fluid develops secondary to inflammation
without fusion( mixed) of the pleura; swelling of pleural
membranes
- Approximately in 7 days.
Stage- 2: “Fibrinopurulent”
- Thick, Opaque fluid ( not clear) with positive culture (pus)
- Deposition of thin fibrin layer over the pleura.
- Progressive loculation (pus) and formation of pouches in
the pleura.
- From 7 day to 21 days.
Stage-3 : “Organizing”
- scarring of the pleural space may lead to lung
entrapment ( 2nd infection lungs)
- Presence of very thick pus
- after 21 days
 Clinical Features:
 Symptoms of pleural empyema may vary in severity.
 Typical symptoms include:
 Chest pain, which worsens ( very difficulty )when you
breathe in deeply (pleurisy)
 Dry cough
 Excessive sweating, especially night sweats
 Fever and chills
 General discomfort, uneasiness (DISCOMFORT) , or
ill feeling (malaise)
 Shortness of breath
 Weight loss (unintentional)
 Clubbing may be present in cases of a chronic nature.
 There is a dull percussion note and reduced breath
sounds on the affected side of the chest.
 In severe cases, the patient may become dehydrated,
cough up blood, greenish–brown sputum, or run a
fever as high as 105F, or even fall into a coma
PATHOPHYSIOLOGY
 Pathophysiology
 Due to etiology factors

 First the pleural fluid is thin with a low
leukocyte count.
 Frequently progresses to a fibro purulent
stage.
 Finally to a stage where it encloses the
lung within a thick exudative membrane.
 Diagnosis:
 Chest X-ray.
 C-T scan.
 Thoracentesis
 Pleural fluid Gram stain and culture
Pleural fluid analysis is a group of tests
used to diagnose the cause of the fluid
... Gram stain – for direct observation of
bacteria or fungi under a microscope.
On chest X-ray, empyema
thoracis will appear as a cloudy or
opaque area.
CT Scan
 Diagnosis is confirmed by thoracentesis
 Thoracentesis :
 This is a procedure which involves the insertion of a needle into
the pleural cavity through the back between the ribs on the
infected side, and a sample of fluid is withdrawn
 It is performed under local anesthetics
 If the patient has empyema, there will be leukocytosis, ( increase
number of white blood cells ) a high level of protein, and a very
low level of blood sugar.
Management:
 Effective management require:
1. Control of infection and sepsis by antibiotics.
2. Evacuation of pus from pleural space.
3. Obliteration (total destruction ) of the empyema
cavity.
 Empyema is treated using a combination of
medications and surgical techniques
 Early-course: aspiration, Abx, and sometimes
fibrinolytic therapy.
 Late-course: continuous drainage or surgical
debridement & de cortication. Remove the fibrous
 Antibiotic therapy:
 Dependent on identification of causative
organism
 Appropriate therapy requires isolation of
organism from blood, pleural fluid or sputum S.
pneumonia, S. pyogenes and S. aureus
 Treatment with medication involves
intravenously administering a two-week course
of antibiotics.
 It is important to give antibiotics as soon as
possible to prevent first-stage empyema from
processing to its later stage.
 The antibiotics most commonly used are
penicillin and vancomycin, primaxin,tazobactum
 Drainage of Empyema
 First step in treating acute empyema
 Performed under general anesthesia
 Done for the dependent rib
 Open all the intact cyst that leads to conversion of
empyema with free pus
 Then place intercostal tube for drainage and close
the wound
 Antibiotics should continue for 6 weeks
Rib resection drainage
Videoscopic Assisted Thoracoscopy Surgery
(VATS) :
 Minimally invasive
 Can be used at any stage
 Advantages includes: Allowance of direct visualization
of pleura and lung Optimal placement of chest tube
 Fibrinolysis & decortications ( surgical removal of the
surface layer, membrane, or fibrous cover of an
organ.) can be performed.

Thoracostomy :
 Open drainage with pleural peel de cortication
 Excision( cuting) of the thick fibrous pleural rind and
removal of infectious material
Eloesser Flap Drainage
Decortication
 Complications:
 Rupture into the lung;
BronchoPleural fistula
A bronchopleural fistula is an abnormal passageway (sinus tract) that develops between
the large airways in the lungs (bronchial tree) and between the membranes that line the
lungs (the pleural cavity).
 Spread to the subcutaneous tissue;
Empyema Niscitanes
refers to extension of a pleural infection out of the thorax
 Septicemia is a an infection of the blood also known as bacterimia or blood
poisoning ….
 septic shock. That occur when sepsis which is organ injury or
damage in response to infection
Empyema om new

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Empyema om new

  • 1. Pyothorax / Purulent Pleuritis / Empyema Thoracis Prepared By: Om verma
  • 2. INTRODUCTION  An empyema is an accumulation of which purulent fluid within the pleural space often with fibrin development & a loculated ( exudative,pus,fluids ) (walled- off) area where infection is located.  Pleural empyema, also known as pyothorax or purulent pleuritis, is empyema (an accumulation of pus) in the pleural cavity that can develop when bacteria invade the pleural space,
  • 3.  Definition: “ Pleural empyema (also known as a pyothorax or purulent pleuritis) is an accumulation of pus in the pleural cavity. ” Empyema itself is not disease it is actually a condition complicated by another disease Empyema is a condition in which pus accumulates in the area between the lungs and the inner surface of the chest wall. This area is known as the pleural space.
  • 4.  Empyema is usually caused by an infection that spreads from the lung. It leads to a buildup of pus in the pleural space
  • 5.  Etiology: o 2ndry to Bacterial Pneumonia Parapneumonic Effusion A parapneumonic effusion is a type of pleural effusion that arises as a result of a pneumonia, lung abscess, or bronchiectasis. . o Other causes include:- o Empyema thoracis can be caused by a number of different organisms, including bacteria, fungi, and amoebas, in connection with pneumonia. o Common cause is pulmonary infection as a result of aerobic bacteria such as Streptococcus pneumonia, Staphylococcus aureus, E. coli, Klebsiella pneumoniae, Hoemophilus influenzae. o Chest trauma(blunt chest wound, chest surgery, lung abscess, or a ruptured esophagus) o Septicaemia (very rare blood borne infection) blood poisoning, especially that caused by bacteria or their toxins. o Subdiaphragmatic causes as liver abscess
  • 6. o Iatrogenic: In rare cases, empyema can occur after a needle is inserted through the chest wall to draw off fluid in the pleural space for medical diagnosis or treatment (thoracentesis).
  • 7. Stages:  There are three stages: 1. Exudative (Acute) 2. Fibrinopurulent(Transitional) 3. Organizing(Chronic) Stage -1: “Exudative” - Sterile pleural fluid develops secondary to inflammation without fusion( mixed) of the pleura; swelling of pleural membranes - Approximately in 7 days. Stage- 2: “Fibrinopurulent” - Thick, Opaque fluid ( not clear) with positive culture (pus) - Deposition of thin fibrin layer over the pleura. - Progressive loculation (pus) and formation of pouches in the pleura. - From 7 day to 21 days.
  • 8. Stage-3 : “Organizing” - scarring of the pleural space may lead to lung entrapment ( 2nd infection lungs) - Presence of very thick pus - after 21 days
  • 9.  Clinical Features:  Symptoms of pleural empyema may vary in severity.  Typical symptoms include:  Chest pain, which worsens ( very difficulty )when you breathe in deeply (pleurisy)  Dry cough  Excessive sweating, especially night sweats  Fever and chills  General discomfort, uneasiness (DISCOMFORT) , or ill feeling (malaise)  Shortness of breath
  • 10.  Weight loss (unintentional)  Clubbing may be present in cases of a chronic nature.  There is a dull percussion note and reduced breath sounds on the affected side of the chest.  In severe cases, the patient may become dehydrated, cough up blood, greenish–brown sputum, or run a fever as high as 105F, or even fall into a coma
  • 11. PATHOPHYSIOLOGY  Pathophysiology  Due to etiology factors   First the pleural fluid is thin with a low leukocyte count.  Frequently progresses to a fibro purulent stage.  Finally to a stage where it encloses the lung within a thick exudative membrane.
  • 12.  Diagnosis:  Chest X-ray.  C-T scan.  Thoracentesis  Pleural fluid Gram stain and culture Pleural fluid analysis is a group of tests used to diagnose the cause of the fluid ... Gram stain – for direct observation of bacteria or fungi under a microscope.
  • 13. On chest X-ray, empyema thoracis will appear as a cloudy or opaque area.
  • 15.  Diagnosis is confirmed by thoracentesis  Thoracentesis :  This is a procedure which involves the insertion of a needle into the pleural cavity through the back between the ribs on the infected side, and a sample of fluid is withdrawn  It is performed under local anesthetics  If the patient has empyema, there will be leukocytosis, ( increase number of white blood cells ) a high level of protein, and a very low level of blood sugar.
  • 16. Management:  Effective management require: 1. Control of infection and sepsis by antibiotics. 2. Evacuation of pus from pleural space. 3. Obliteration (total destruction ) of the empyema cavity.  Empyema is treated using a combination of medications and surgical techniques  Early-course: aspiration, Abx, and sometimes fibrinolytic therapy.  Late-course: continuous drainage or surgical debridement & de cortication. Remove the fibrous
  • 17.  Antibiotic therapy:  Dependent on identification of causative organism  Appropriate therapy requires isolation of organism from blood, pleural fluid or sputum S. pneumonia, S. pyogenes and S. aureus  Treatment with medication involves intravenously administering a two-week course of antibiotics.  It is important to give antibiotics as soon as possible to prevent first-stage empyema from processing to its later stage.  The antibiotics most commonly used are penicillin and vancomycin, primaxin,tazobactum
  • 18.  Drainage of Empyema  First step in treating acute empyema  Performed under general anesthesia  Done for the dependent rib  Open all the intact cyst that leads to conversion of empyema with free pus  Then place intercostal tube for drainage and close the wound  Antibiotics should continue for 6 weeks
  • 20. Videoscopic Assisted Thoracoscopy Surgery (VATS) :  Minimally invasive  Can be used at any stage  Advantages includes: Allowance of direct visualization of pleura and lung Optimal placement of chest tube  Fibrinolysis & decortications ( surgical removal of the surface layer, membrane, or fibrous cover of an organ.) can be performed.  Thoracostomy :  Open drainage with pleural peel de cortication  Excision( cuting) of the thick fibrous pleural rind and removal of infectious material
  • 23.  Complications:  Rupture into the lung; BronchoPleural fistula A bronchopleural fistula is an abnormal passageway (sinus tract) that develops between the large airways in the lungs (bronchial tree) and between the membranes that line the lungs (the pleural cavity).  Spread to the subcutaneous tissue; Empyema Niscitanes refers to extension of a pleural infection out of the thorax  Septicemia is a an infection of the blood also known as bacterimia or blood poisoning ….  septic shock. That occur when sepsis which is organ injury or damage in response to infection