2. accumulation of pus in the pleural space whether it is
localized (encapsulated) or generalized involving the
entire pleural space.
Pathogenesis:
Acute or Exudative phase: Thin pus,Mobile
lung(expandable),Thin pleura
Trasitional or Fibrinopurulent phase: Turbid fluid
thick pleura, Less expandable lung
Chronic or Organization phase: fluid is
viscous,thicker pleura, restricted lung
3. Secondary changes in surrounding structures as empyema
continues :
Ribs drawn together & lose mobility
Diaphragm elevated and fixed
Mediastinum shifted
Lung encased in a rigid covering of fibrous tissue and is
immobile and functionless
4. Causes:
1-Pulmonary infection: Lobar pneumonia,lung
abscess
2-Trauma: Penetrating trauma,Postoperative
(post-pneumonectomy ),Esophageal
perforation
3-Extrapulmonary spread: Osteomyelitis of
dorsal spine, subphrinic abscess
4-Aspiration of pleural effusion (done under
septic technique)
5-Ruptured emphysematous bullae and
spontaneous pneumothorax → empyema
6- Generalized sepsis
5. Microorganisms:
Most common organisms are streptococcus ,pneumococcus ,Staph
aureus
Clinical features
constitutional symptoms of fever, malaise, anorexia, and weight loss
in late presentation
Pleuretic chest pain and sensation of heaviness
Shortness of breath and cough with purulent sputum
Complications:
Invasion of the chest wall → osteomyelitis → empyema necessitans
BPF( Bronchopleural fistula)
Mediastinal abscess
Septicemia
Metastatic abscess
Fibrothorax
6. Investigation:
1-CXR:
PA and lateral views show effusion, air fluid level
2-Thoracocentesis and fluid analysis :
Culture and sensitivity, gram stain, pH,, glucose,
protein, LDH
3-Sputum culture:
Is often helpful because organisms responsible for
pneumonia are a frequent cause of empyema.
4-Bronchoscopy: To exclude intrabronchial tumor or
foreign body
5-Ultrasound
6-CT scan
7.
8. Treatment
1- Thoracocentesis : for diagnostic and therapeutic
measures usualy for an early acute phase
2- Tube thoracostomy : done when there is large and thick
fluid
3- Image guided catheter placement with fibrinolytic
agents : for those where the 2nd option failed to evacuate
the pleura
4- VATS or Thoracotomy : decortications with
pleurectomy
9.
10. Lung Abscess
localized area of suppuration and cavitation in the lung
Etiology:
1-Primary necrotizing pneumonia:Aerobic,Anaerobic
2- Aspiration pneumonia:Anesthesia,Stroke
3- Bronchial obstruction :Neoplasm,Foreign body
4-Complication of systemic sepsis
5-Complication of pulmonary trauma :Infected hematoma
6-Direct extension from extra-pulmonary infection:
Pleural empyema, subphrinic abscess
12. Clinical picture
history of upper respiratory tract infection with
high fever, malaise, fatigue, and often is toxic
with weight loss
Recent onset of cough with copious foul smelling
sputum
Chest pain
Hemoptysis
13. Investigations;
CXR : Air fluid level is only seen in upright film
CT san : clarify the diagnosis when the CXR is equivocal
Bronchoscopy : To exclude or confirm Ca
To diagnose and remove foreign bodies
To drain an abscess
To obtain a bronchial wash for C/S
Differential diagnosis:
1-Cavitating lung carcinoma
2- Infected lung cyst or bullae
3-TB
4- Bronchiectasis
5-Pulmonary hydatid cyst
Differential diagnosis of a febrile patient with copious
production of foul sputum:
Lung abscess
Bronchiectasis
Cavitating carcinoma
14.
15. Treatment:
Medical :
Identification of the caustic microorganism, prober
antimicrobial therapy
Surgical :
Indications of surgical treatment:
Lack of response to medical treatment
Suspeicion of malignancy
Significant and recurrent hemoptysis
Complications of lung abscess : Empyema,BPF
Options of surgical treatment:
tube pneumonostomy
External drainage ie.
Pulmonary resection :lobectomy,segmentectomy,wedge
resection and rarely pneumonectony
16. Complications of lung abscess:
Massive hemoptysis
Endobronchial spread to other lung portions
Septicemia
Metastatic brain abscess
Rupture into pleural cavity →
Empyema
BPF
