1) The document discusses the diagnosis and management of chronic empyema, beginning with the definition, causes, stages, and clinical presentation.
2) Diagnostic evaluations including imaging like chest X-ray, CT, and ultrasound are described, as well as biochemical analysis of pleural fluid.
3) Treatment options are provided for each stage of empyema, including thoracocentesis, chest tube drainage, fibrinolytics, VATS, decortication, and window thoracostomy. Antibiotic recommendations are also covered.
Hello!
This is a quick review PPT for medical students.
It includes description at a glance of all the commonly occuring benign anal and perianal conditions like; haemorrhoids, fissure in ano, fistula in ano etc.
Hope this is worth sharing
Right iliac fossa mass is a common clinical presentation and has a range of differentials that need to be excluded.
In this presentation will discuss RIF masses in briefly.
contact me / dr.3shaq@gmail.com
A brief presentation regarding etiology , clinical features , and management of chronic limb ischemia. It was presented by our unit at Department of surgery , Patna medical college
Isolated tuberculous inguinal lymphadenopathy: a diagnostic challenge KETAN VAGHOLKAR
Isolated tuberculous inguinal lymphadenopathy is a rare entity. Awareness of this as a distinct entity is important. Open biopsy is the best way for diagnosing this condition.
Drs. Milam and Thomas's CMC X-Ray Mastery Project: April CasesSean M. Fox
Drs. Claire Milam and Alyssa Thomas are Emergency Medicine Residents and interested in medical education. With the guidance of Dr. Michael Gibbs, a notable Professor of Emergency Medicine, they aim to help augment our understanding of emergent imaging. Follow along with the EMGuideWire.com team as they post these monthly educational, self-guided radiology slides on:
• Esophageal Perforation
• Perforated Viscous
• Pneumothorax
• Traumatic Diaphragmatic Hernia
• Pulmonary Contusion
• COVID-19 associated Pneumonia
• COVID-19
• Influenza Like Illness
Hello!
This is a quick review PPT for medical students.
It includes description at a glance of all the commonly occuring benign anal and perianal conditions like; haemorrhoids, fissure in ano, fistula in ano etc.
Hope this is worth sharing
Right iliac fossa mass is a common clinical presentation and has a range of differentials that need to be excluded.
In this presentation will discuss RIF masses in briefly.
contact me / dr.3shaq@gmail.com
A brief presentation regarding etiology , clinical features , and management of chronic limb ischemia. It was presented by our unit at Department of surgery , Patna medical college
Isolated tuberculous inguinal lymphadenopathy: a diagnostic challenge KETAN VAGHOLKAR
Isolated tuberculous inguinal lymphadenopathy is a rare entity. Awareness of this as a distinct entity is important. Open biopsy is the best way for diagnosing this condition.
Drs. Milam and Thomas's CMC X-Ray Mastery Project: April CasesSean M. Fox
Drs. Claire Milam and Alyssa Thomas are Emergency Medicine Residents and interested in medical education. With the guidance of Dr. Michael Gibbs, a notable Professor of Emergency Medicine, they aim to help augment our understanding of emergent imaging. Follow along with the EMGuideWire.com team as they post these monthly educational, self-guided radiology slides on:
• Esophageal Perforation
• Perforated Viscous
• Pneumothorax
• Traumatic Diaphragmatic Hernia
• Pulmonary Contusion
• COVID-19 associated Pneumonia
• COVID-19
• Influenza Like Illness
Drs. Olson’s and Jackson’s CMC Pediatric X-Ray Mastery: October CasesSean M. Fox
Drs. Olson and Jackson are interested in education and Pediatric Emergency Medicine. Follow along with the EMGuideWire.com team and Drs. Nikki Richardson, Mary Grady, and Michael Gibbs as they post these educational, self-guided radiology slides on Pediatric Emergency Medicine Radiology. This month’s topics include:
- Tuberculosis
- Button Battery Ingestion
- Constipation
- Hirschprung's Disease
- Aspiration Pneumonia
- Generalized Lymphatic Anomaly
- Pediatric Acute Respiratory Distress
Drs. Lorenzen and Barlock’s CMC X-Ray Mastery Project: May CasesSean M. Fox
Drs. Breeanna Lorenzen and Travis Barlock are Emergency Medicine Residents and interested in medical education. With the guidance of Dr. Michael Gibbs, a notable Professor of Emergency Medicine, they aim to help augment our understanding of emergent imaging. Follow along with the EMGuideWire.com team as they post these educational, self-guided radiology slides. This set will cover:
Pneumonia
Lung Masses
Pulmonary Nodules
Hilar Lymphadenopathy
Aorto-enteric Fistula
Diaphragmatic Hernia
Intra-aortic Balloon Pump
Pacemaker
Impella
International Lung Symposium on Pleural Diseases, Manila 2019.
Practice changing clinical trials in pleural diseases from 2017 to 2019 by Dr. Gary Lee.
The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and
offering a wide range of dental certified courses in different formats.
Management of parapneumonic effusion and empyemaDileep Benji
Any pleural effusion associated with bacterial pneumonia,lung abscess or bronchiectasis is defined as parapneumonic effusion.Presence of pus in pleural space is called empyema. Pathogenesis,bacteriology,clinical presentation,diagnosis,management has been described in this powerpoint presentation.
PAST, PRESENT AND FUTURE IN OBGYN INFECTIONS 01102023.pptxNiranjan Chavan
Today, we face new infectious threats; but also benefit from advanced diagnostics and treatments. Looking ahead, it’s crucial to continue
adapting to emerging pathogens, implement stringent preventive measures, and
leverage cutting-edge technologies to ensure the safety and well-being of our patients in the ever-evolving landscape of obstetrics and gynecology.
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
Basavarajeeyam is an important text for ayurvedic physician belonging to andhra pradehs. It is a popular compendium in various parts of our country as well as in andhra pradesh. The content of the text was presented in sanskrit and telugu language (Bilingual). One of the most famous book in ayurvedic pharmaceutics and therapeutics. This book contains 25 chapters called as prakaranas. Many rasaoushadis were explained, pioneer of dhatu druti, nadi pareeksha, mutra pareeksha etc. Belongs to the period of 15-16 century. New diseases like upadamsha, phiranga rogas are explained.
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
CDSCO and Phamacovigilance {Regulatory body in India}NEHA GUPTA
The Central Drugs Standard Control Organization (CDSCO) is India's national regulatory body for pharmaceuticals and medical devices. Operating under the Directorate General of Health Services, Ministry of Health & Family Welfare, Government of India, the CDSCO is responsible for approving new drugs, conducting clinical trials, setting standards for drugs, controlling the quality of imported drugs, and coordinating the activities of State Drug Control Organizations by providing expert advice.
Pharmacovigilance, on the other hand, is the science and activities related to the detection, assessment, understanding, and prevention of adverse effects or any other drug-related problems. The primary aim of pharmacovigilance is to ensure the safety and efficacy of medicines, thereby protecting public health.
In India, pharmacovigilance activities are monitored by the Pharmacovigilance Programme of India (PvPI), which works closely with CDSCO to collect, analyze, and act upon data regarding adverse drug reactions (ADRs). Together, they play a critical role in ensuring that the benefits of drugs outweigh their risks, maintaining high standards of patient safety, and promoting the rational use of medicines.
Basavarajeeyam is a Sreshta Sangraha grantha (Compiled book ), written by Neelkanta kotturu Basavaraja Virachita. It contains 25 Prakaranas, First 24 Chapters related to Rogas& 25th to Rasadravyas.
The Gram stain is a fundamental technique in microbiology used to classify bacteria based on their cell wall structure. It provides a quick and simple method to distinguish between Gram-positive and Gram-negative bacteria, which have different susceptibilities to antibiotics
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
2. Empyema Thoracis
• Defined as “pus in the
plural space”.
• Ancient disease.
• Hippocrates credited with
first description of natural
history and treatment.
• Open thoracic surgery was
advocated by Hippocrates
for complex chronic
empyema.
The American Association for Thoracic Surgery consensus guidelines, 2017
3. • Occurs after a reactive pleural effusion as a
consequence of a lung infection & systemic
infection.
• Streptococcal or pneumococcal pneumonia most
common cause.
• Gram negative and anaerobic organisms are
other common cause.
The American Association for Thoracic Surgery consensus guidelines, 2017
4. • Chronic pulmonary TB - major causative agent in low
socioeconomic society.
• Other causes are
Thoracic Trauma & Surgery.
Mediastinal diseases, cervical and thoracic spine
infections.
Upper GI pathology
Bronchogenic Carcinoma
The American Association for Thoracic Surgery consensus guidelines, 2017
5. Anatomical Consideration:
Visceral pleura -
• develop from splanchnopleural layers of the lateral
plate mesoderm.
• Arterial supply and Venous drainage - the bronchial
vessels.
• Autonomic neural innervation.
Standring, S.,& gray H. (2016), Gray’s Anatomy: the anatomical basis of clinical practice, 41th
ed. Edinburgh:Churchil Livingstone/Elsevier
6. Parietal pleura
• Develops from somatopleural layer.
• Somatic arterial supply and drained by pulmonary
veins.
• Neural innervation by intercostal nerve and
phrenic nerve.
• The lymphatic drainage - deep pulmonary plexus
within the interlobar and peribronchial spaces.
Standring, S.,& gray H. (2016), Gray’s Anatomy: the anatomical basis of clinical practice, 41th ed.
Edinburgh:Churchil Livingstone/Elsevier
8. Pathophysiology
• 5-10 liter pleural fluid is produced in 24 hours.
• Most pleural fluid is reabsorbed through
lymphatics of the parietal pleura.
• Visceral pleura is relatively impermeable to
plural fluid proteins.
• Left pleural cavity is smaller than right due to cardiac
asymmetry, hence more effusions are seen in right.
Sabiston, David C., and Courtney M. Townsend. 2016. Sabiston Textbook of Surgery : the Biological Basis of Modern
Surgical Practice. Philadelphia :Elsevier Saunders, p1604-1610.
9. • Pleural effusion develops when balance between
accumulation and reabsorption disturbs.
• This imbalance occurs with -
hydrostatic pressure,
Negative intrapleural pressure,
capillary permeability,
plasma oncotic pressure,
Interrupted lymphatic drainage.
Sabiston, David C., and Courtney M. Townsend. 2016. Sabiston Textbook of Surgery : the Biological Basis of
Modern Surgical Practice. Philadelphia :Elsevier Saunders, p1604-1610.
10. • Exudates are important in empyema .
• Light’s criteria.
Sabiston, David C., and Courtney M. Townsend. 2016. Sabiston Textbook of Surgery : the Biological Basis of
Modern Surgical Practice. Philadelphia :Elsevier Saunders, p1604-1610.
11. Stages :
• Exudative stage (1-3 days )
• Fibrino- purulent stage (4 to 14 days)
• Organizing stage (after 14 days)
Sabiston, David C., and Courtney M. Townsend. 2016. Sabiston Textbook of Surgery : the Biological
Basis of Modern Surgical Practice. Philadelphia :Elsevier Saunders, p1604-1610.
12. Stage I (Exudative Stage):
• Pleural fluid is thin & oedema over both pleura.
• Pleural membrane inflamation -> Increased
permeability.
• Increased neutrophils in fluid, however normal
glucose , LDH level and pH.
Sabiston, David C., and Courtney M. Townsend. 2016. Sabiston Textbook of Surgery : the Biological Basis of Modern
Surgical Practice. Philadelphia :Elsevier Saunders, p1604-1610.
13. Stage II (Fibrino- purulent stage )
• Pleural fluid becomes thick & fibrin deposits over
the pleural surfaces.
• Bacterial stains present , frank pus, neutrophils
increase.
• pH and glucose levels become low.
• LDH and protien levels increase.
Sabiston, David C., and Courtney M. Townsend. 2016. Sabiston Textbook of Surgery : the Biological Basis
of Modern Surgical Practice. Philadelphia :Elsevier Saunders, p1604-1610.
14. Stage III (Organizing phase/ chronic phase)
• Fibrins converted in to fibroblasts, new Capillary
ingrowth begins.
• Effusion grossly purulent, thick like curd
• Entrapment of lung.
• Contraction thorax
Sabiston, David C., and Courtney M. Townsend. 2016. Sabiston Textbook of Surgery : the
Biological Basis of Modern Surgical Practice. Philadelphia :Elsevier Saunders, p1604-1610.
15. Presentation:
• General malaise
• Fever
• Loss of appetite
• Weight loss
• Cough
• Dyspnea
Sabiston, David C., and Courtney M. Townsend. 2016. Sabiston Textbook of Surgery : the Biological
Basis of Modern Surgical Practice. Philadelphia :Elsevier Saunders, p1604-1610.
16. Signs :
Inspection:
• Asymmetric chest expansion
• May be Discharging wound
Palpation:
• Raised local temperature in acute phase
• Local Tenderness
• Crepitus
17. Percussion:
• Dullness.
(Chest percussion penetrates to a maximum depth of 6 cm)
Auscultation:
• Decreased tactile fremitus.
• Egophony.
• Pleural friction rub.
• Decreased breath sounds.
18. A. Radiology
Chest X-Ray
Ultrasonography
CT Scan
B. Pleural fluid
Routine and microscopy
ADA
ϒ-Interferon
RT PCR
CBNAAT
Biochemical
Diagnosis:
• History and Clinical examination,
• Routine blood investigation
• Specific examination
19. Patients at risk for empyema (Class I, LOE B) ?
• All patients presenting with signs and symptoms
of pneumonia, or unexplained sepsis.
• Failure of a community or nosocomial pneumonia
to respond clinically to appropriate antibiotic
therapy.
The American Association for Thoracic Surgery consensus guidelines, 2015
20. Chest Xray-
• Erect and Lateral views
• Loculations present as lenticular shaped
opacities.
• Complex parapneumonic effusion are often
loculated, may be missed on chest Xray.
The American Association for Thoracic Surgery consensus guidelines, 2017
21.
22.
23.
24.
25.
26.
27. For pleural fluid detection-
• Erect lateral view- Minimum 50 ml.
• Standard PA view- Minimum 175 ml*.
• Physical examination- Minimum 300 ml.
• Supine AP radiograph has lesser sensitivity than
lateral decubitus view. .
Ricardo Franco, Paul H. et al. Ultrasound in the diagnosis & management of pleural effusion. 2016. J
Hosp Med, Texas.
*The American Association for Thoracic Surgery consensus guidelines, 2017.
28. Ultrasonography:
• 2-5 MHz phased array transducer for scanning
intercostal space.
• Amount of fluid , and loculations are imaged.
• As an add in USG guided diagnostic/therapeutic
thoracocentesis.
Ricardo Franco, Paul H. et al. Ultrasound in the diagnosis & management of pleural effusion. 2016. J
Hosp Med, Texas.
29. • Can detect physiological amount of pleural fluid,
i.e. 5 ml.
• 100% senitivity for effusion >100 ml.
• Ultrasound should be routinely performed in addition to
conventional chest X-ray. both for diagnostic purposes
and image-guidance for pleural interventions. (Class I,
LOE B)
• Reducing pneumothorax risk from 9% to 4%.
Ricardo Franco, Paul H. et al. Ultrasound in the diagnosis & management of pleural effusion. 2016. J Hosp Med, Texas.
30. CT scan:
• Reference standard in plural diseases.
• Distinguish pleural with parenchymal
abnormalities as well as involved and opposite
lung paranchyma.
• Determine precise location, extent and
loculations.
Ricardo Franco, Paul H. et al. Ultrasound in the diagnosis & management of pleural effusion. 2016. J
Hosp Med, Texas.
31. • Enhancing, thickened visceral and parietal
pleural layers separated by an intervening
layer of low attenuation fluid (Split pleura
sign)
32. Limitation of chest CT
• Lower sensitivity in distinguishing small effusions
from pleural thickning.
• Lower sensitivity for detection plural fluid septation
than ultrasound.
• One avarage CT scan exposure (7 mSv) radiation
equivalent dosage of 350 chest radiographs.
Chest CT scan should be obtained when pleural space infection
is suspected. (Class IIa, LOE B)
The American Association for Thoracic Surgery consensus guidelines, 2017
Ricardo Franco, Paul H. et al. Ultrasound in the diagnosis & management of pleural effusion. 2016. J Hosp Med, Texas.
33. Biochemical :
Pleural fluid should be analyzed for
• Cytology, cell counts, Gram stain, culture for
aerobic, anaerobic, and fungal organisms,
tuberculosis testing.
• Simultaneous pleural and serum protein, glucose,
LDH, and pH.
Sabiston, David C., and Courtney M. Townsend. 2016. Sabiston Textbook of Surgery : the Biological Basis
of Modern Surgical Practice. Philadelphia :Elsevier Saunders, p1604-1610.
34. • Obtain pleural fluid cultures only from direct
aspiration or drainage procedure, not from
previously inserted tubes or drains. (Class I, LOE B)
• Inoculate freshly drained pleural fluid into aerobic
and anaerobic blood culture vials in addition to
standard, sterile containers used for gram stain
and culture. (Class I, LOE B)
• Swab culture should not be used.
The American Association for Thoracic Surgery consensus guidelines, 2017
35. Pus, Gm + stain, +
culture in pleural
fluid
pH< 7.2, with
suspected pleural
space infection
predicts a
complicated
clinical course.
Pleural fluid LDH >
1000 IU/L, glucose
< 40 mg/dL or a
loculated pleural
effusion.-> unlikely
to resolve with
antibiotics alone
ICD then surgical
intervention if
required.
ICD then surgical
intervention if
required.
Thoracostomy
Class I, LOE B Class I, LOE B Class IIa, LOE B
The American Association for Thoracic Surgery consensus guidelines, 2017
36. Management
Objective:
• Evacuation of pus.
• Treatment of underlying disease.
• Restoration of lung volume
Sabiston, David C., and Courtney M. Townsend. 2016. Sabiston Textbook of Surgery : the Biological Basis
of Modern Surgical Practice. Philadelphia :Elsevier Saunders, p1604-1610.
37. Treatment Options
• Non-Operative
General measures
Antibiotics
Thoracocentesis
ICD
Fibrinolysis
• Operative
Decortication
Window thoracostomy
2 stages surgery
(window thoracostomy
followed by
thoracomyoplasty)
The American Association for Thoracic Surgery consensus guidelines, 2017
38. Treatment according to stages
• Stage I:
– Thoracocentesis
– Antibiotics/ATT
– Chest physiotherapy
The American Association for Thoracic Surgery consensus guidelines, 2017
39. • British Thoracic Society guidelines recommend
that all thoracocentesis be performed under USG.
• Success rate 66-90 % in stage I patients along
with antibiotics and physiotherapies.
• Minimum effusion depth of 1.5cm is required to
perform diagnostic thoracocentesis.
40. • Thoracocentesis without pleural drain placement is
not recommended in empyema (LOE C)
• Routine drain flushing is recommended if small bore
catheters are used. (Class I, LOE B)
The American Association for Thoracic Surgery consensus guidelines, 2017
41. Stage II
ICD + antibiotics/ATT + chest physiotherapy
VATS+ antibiotics/ATT + chest physiotherapy
• VATS should be the first line approach in all
patients with stage II acute empyema (Class IIa,
LOE B)
The American Association for Thoracic Surgery consensus guidelines, 2017
42. • Study shows equivalent success rates with use of
tubes <14 F and tubes >14 F.
• In our setup, patient present in mixed stage
rather pure stage II.
The American Association for Thoracic Surgery consensus guidelines, 2017
43. • Fibrinolytic agent—Streptokinase (250,000 U and
urokinase 100000 U)
• Intrapleural fibrinolytics may be used for
complicated pleural effusions (but not routinely)
and early empyemas but definitive management
continues to be surgical adhesiolysis with or
without decortication (Class IIa, LOE A)
The American Association for Thoracic Surgery consensus guidelines, 2017
44. Stage III
– VATS+ antibiotics/ATT + chest physiotherapy
– Decortication + antibiotics/ATT + chest
physiotherapy
– In Indian scenario, most patient need open
thoracotomy but in pyogenic cases VATS is good
option.
46. Antibiotics…
• 2nd and 3rd gen i.v. cephalosporine with
metronidazole, or i.v. aminopeniciline and β-
lactamase inhibitor.
• In nosocomial/post procedural empyema, against
MRSA and Pseudomonas aeruginosa (e.g. vancomycin,
cefepime, and metronidazole orvancomycin and
piperacillin/tazobactam) (Class IIa, level C)
The American Association for Thoracic Surgery consensus guidelines, 2017
47. • Whenever possible, choose antibiotic therapy
based upon culture results. (Class I, LOE C)
• Consider continuing anaerobic coverage
empirically unless specified.(Class IIa, LOE C)
• Avoid aminoglycosides in the management of
empyema. (Class I, LOE B)
• There is no role for intrapleural administration of
antibiotics. (Class I, LOE C)
The American Association for Thoracic Surgery consensus guidelines, 2017
48. • Surgical removal of thick, inelastic, restrictive
pleural peel via thoracotomy.
• All fibrous tissue is removed from the visceral
pleural peel and pus is subsequently drained from
the pleural space.
• Approached via open thoracotomy or VATS.
Decortication
49. • Decortication is reasonable in patients with
chronic empyemas who are medically operable to
tolerate major thoracic surgery. (Class IIa , LOE B)
The American Association for Thoracic Surgery consensus guidelines, 2017
50. • For frail and ill patients, neither VATS nor an open
thoracotomy may be appropriate.
• 2 or 3 rib resections may be considered to
obliterate any infection in the residual space by
bringing the chest wall down to fill the space.
Window thoracostomy
The American Association for Thoracic Surgery consensus guidelines, 2017
51. • Removal of segments of the rib in the most
dependent position to allow for drainage
internationally.
• In our setup, one rib higher segment is
selected as drainage and domiciliary sponge
dressing is explained.
• This method is more cost effective and wound
management is more feasible.
52. • Pedicled muscle flaps or omentum can be
useful to fill empyema cavities or close a
bronchopleural fistula. (Class IIa , LOE C)
The American Association for Thoracic Surgery consensus guidelines, 2017
53. • Adequate visualization despite limited access to
the thorax.
• For patients who have marginal pulmonary
reserve.
• Management of pulmonary, mediastinal, and
pleural pathology.
Video Assisted Thoraco-Scopy(VATS)
The American Association for Thoracic Surgery consensus guidelines, 2017
54. Benefits:
• Less blood loss
• Shorter operating time
• Less postoperative morbidity
• Earlier return to normal activity than with
thoracotomy.
• Reduction in 30 days mortality.
The American Association for Thoracic Surgery consensus guidelines, 2017
55. Complications:
• Persistent air leak.
• Bleeding from pulmonary vessels.
• Intercostal nerve damage.
• Complications from single-lung ventilation,
• Postoperative reexpansion pulmonary edema
• Tumor implantation following VATS.
56. Contraindication:
• Unable to tolerate one lung ventilation
• Severe coagulopathy.
Drawbacks:
• Increased operative time
• Increased cost
• Steeper learning curve
• Often requiring additional procedure.
The American Association for Thoracic Surgery consensus guidelines, 2017