general approach to empyema thoracis

1. Dr. Makanga Winston
Job Joseph

2. BKM, 32 year old male from Karura, newly
diagnosed ICDP with CD4 476 cells

3. Diagnosed with PTB with right pleural effusion.
Started on RHZE/B6, a chest tube drain was also
‘successfully put’. Patient was 5/52 into the
medications. With no much improvement.

4. progressive dyspnea for 5/52

5. G/Exam: essentially normal except that he was
fairly wasted
Vitals: all normal except an increase in the
respiratory rate 26 BPM pulse rate- 111b/min
Systemic exam R/S had a large dressing on the
right peri-axillary region, sinus discharging pus
++, reduced chest movement on the right with
respiration compared to the left; moderate
tenderness over the right chest; stony dullness on
percussion ; no air entry on the right lung field
from the mid to the lower lobe

6. 22/2/13
1/3/13

7. Thoracotomy and
decortication

8. Accumulation of excessive fluid within the pleural space is
pleural effusion.
Not a disease entity but a sign/effect of a disease process
on the normal lung physiology i.e. systemic or local
[lungs].
Mechanism - Normally a balance between the secretion
and absorption of the fluid exists.
Accumulation of pus in the pleura is empyema thoracis
Empyema neccesitans

9. Any alteration of systemic factors that influence
the formation and absorption of the pleural fluid.
For example,
Increase in hydrostatic pressures in the
microcirculation: CCF, SVC obstruction,
constrictive pericarditis, pulmonary embolism etc.
Reduction in the oncotic pressure in the
microcirculation: hypoalbunaemia, nephrotic
syndrome, Liver cirrhosis, peritoneal dialysis etc.

10. Any alteration of local factors which influence the
secretion and absorption of pleural fluid. For
example,
Factors that increase the permeability of the
microcirculation: pneumonia, PTB, tumors.
Obstruction to the lymphatic drainage: neoplasms
[bronchogenic ,metastatic, lymphomas or
mesotheliomas]
Others : intra-abdominal diseases like sub-phrenic
abscess, pancreatitis, Meigs syndrome, trauma,
collagen vascular diseases etc.

11. Lab perimeter Exudative Transudative
Wbc’s <1000/mm3 >10000/mm3
Color Clear/serous Cloudy
Rb’s <10000/mm3 >10000/mm3
Glucose Normal -
Gravity <1.016 >1.016
LDH Normal >67% of the normal
Protein <3g/dl >3g/dl

12.  Stage 1
 Clear, straw coloured fluid, no septations
 Stage 2
 Purulent fluid or microscopically contains high WBC
count
 Stage 3
 Organized effusion with loculations and fibrosis
 Recurrent/refractory PE

15.  Stage 1
 Antibiotics (only if it is parapneumonic)
 Repeated aspirations (caveats…)
 Simple drainage with indwelling catheter
 US guided drain placement
 !! Formal chest drain

17.  Stage 2
 Wide chest tube
 Specific treatment for underlying cause
 Anti TBs
 Antibiotics

19. HEIMLICH VALVE

20. Heimlich valve Conventional Underwater seal
Portable Restricts patient to bed
Less Nursing Care Close care
Cheaper Expensive to set up
Easier to teach Steep learning curve
Less prone to accidents Prone to dangerous accidents

21.  Stage 3
 Trial of chest tube
 Fibrinolysis with intrapleural streprokinase
 Thoracotomy
 Decortication and release of loculations
 Rib resection and open drainage
 Video-assisted thoacoscopic surgery (VATS)

23.  Recurrent effusion
 Pleurodesis
 Talc
 Doxycycline
 Pleuroperitoneal shunts
 Permanent tunneled drains
 Empyema necessitans
 Open drainage + follow-up decortication

24.  Stage 1 – aspiration
 Stage 2 – chest tube
 Stage 3 – thoracotomy
 Recurrent effusion – pleurodesis