4. Epidemiology
Pleural disease is common, with an annual incidence of ∼360 per 100 000 persons, and is associated
with significant morbidity and mortality.
The incidence is comparable to that of asthma and is expected to increase.
MPE affects ∼15% of all patients diagnosed with malignancy
57% of patients with pneumonia have an associated pleural effusion
CAP results in 20–40% develop a parapneumonic effusion and 5–10% a pleural empyema.
8% of Patients with TB
Pleural effusion in patients admitted with acute or chronic heart failure is observed in almost every
second patient
5. Mortality
Pleural infection recently reported a 30-day mortality of 10%
Worldwide, the average length of hospital stay is 19 days
Patients with empyema often have significant comorbidities, with studies
reporting between 40% and 68% ,and the proportion is increasing over
time
6. It is believed that the fluid that normally enters the pleural space originates in the capillaries in the
parietal pleura
The amount of pleural fluid formed daily in a 50-kg individual would be approximately 1 5 mL.
It appears unlikely that the fluid originates from the visceral pleura.
Likewise, both a lymphatic origin and a peritoneal cavity origin appear unlikely.
7. Clearance
The mean lymphatic flow from one pleural space in seven patients was 0.40 ml/kg/hour.
Normally, a small amount (0.0 1 mL/kg/hour) of fluid constantly enters the pleural space from the
capillaries in the parietal pleura.
Almost all of this fluid is removed by the lymphatics in the parietal pleura, which have a capacity to
remove at least 0.20 mL/kg/hour.
Note that the capacity of the lymphatics to remove fluid exceeds the normal rate of fluid formation by
a factor of 20-28 times.
8. Mechanism
Pleural fluid accumulates when the rate o f pleural fluid formation exceeds
the rate of pleural fluid absorption.
10. Effects of PL. Effusion
Pleural effusion can cause abnormal gas exchange and relatively modest arterial hypoxaemia. It
appears to be most severe when the effusion is large, chest wall compliance is reduced and/or
diaphragm function is impaired.
One primary mechanism may be an intrapulmonary shunt and ventilation–perfusion mismatch
resulting from atelectasis of the underlying lung.
Pleural effusions cause a restrictive ventilatory effect that is partly explained by reductions in lung
volume and compliance.
Significant reductions in forced vital capacity (FVC), forced expiratory volume, total lung capacity,
functional residual capacity and static expiratory lung compliance are seen with large pleural effusions.
Flattening/inversion of a hemidiaphragm and impaired/paradoxical movement are seen in both large
and small effusions
11. Examination/ S/S
Most effusions are in the dependent part of the pleural space, the signs of:
diminished movements,
dull percussion note and distant or
absent breath sounds are found here.
Bronchial breath sounds or aegophony (a nasal or bleeting quality of transmitted
voice sounds) may be heard immediately above an effusion
Cough
SOB
Exercise intolerance
Fever
23. PATHOGENESIS
Inflammation of Pleural space
Simple Parapneumonic Effusion
5-10% infected due to bacterial invasion
into Pleural space
Complicated Parapneumonic Effusion
Empyema
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26. Respiratory system findings
Inspection:
Decrease movement of affected side
Fullness of intercostal space
Erythematous overlying skin
Palpation:
Decreased in tactile fremitus
Intercostal tenderness
Raised local temperature
Percussion:
Dullness and percussion tenderness
Ausculatation:
Diminised vesicular breath sound
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27. Parapneumonic effusions Classification:
Category I Category II Category III Category IV
Simple
parapneumonic
effusion
Small
free-flowing
pleural effusion.
Simple
parapneumonic
effusion
Small to moderate
Gram stain and
culture of the pleural
fluid negative,
Pleural fluid
pH >7.2, and
Glucose >3.3
mmol/L (60 mg/dL).
Complicated
parapneumonic
effusion
more than half of
the haemithorax,
loculated
Gram stain or
culture positive
Pleural
fluid pH <7.2 or
glucose <3.3
mmol/L (60
mg/dL).
Empyema
Pus present
in the pleural
space
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28. Light’s Classification
Class 1: simple parapneumonic
Thickness of the fluid on the decubitus chest x-ray <10 mm.
No Thoracentesis
Class 2: Typical parapneumonic
Thickness of the fluid on the decubitus chest x-ray >10 mm,
pleural fluid pH >7.2, and
glucose >2.2 mmol/L (40mg/dL).
Antibiotics alone
Class 3: Borderline complicated
Pleural fluid pH 7.0 to 7.2 or
LDH >1000 IU/L
Gram stain and culture negative.
29. Class 4: Simple complicated
Pleural fluid pH <7.0
Gram stain or culture positive
Not loculated
No frank pus present.
Class 5: Complex complicated
Pleural fluid pH <7.0
Gram stain or culture positive
Multiple loculated.
Tube Thoracostomy + Fibrinolytics
Class 6: Simple empyema
Presence of frank pus
Single locule
Free-flowing effusion.
Tube Thoracostomy ± Decortication
Class 7: Complex empyema
32. ANTIBIOTICS
Culture
Empirical antibiotic treatment for hospital-acquired empyema should
include treatment for MRSA and anaerobic bacteria.
Penicillins, Penicillins combined with B-lactamase inhibitors,
Metronidazole , Clindamycin and Cephalosporins penetrate the pleural
space well
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34. Indication of chest tube drain
Frank/ purulent, turbid/cloudy effusion.
Presence of organism by Gram stain or Culture.
Pleural Fluid PH<7.2.
Pleural fluid glucose <40mg/dl
Pleural fluid LDH >3x Upper normal limit for serum
Loculated pleural fluid collection.
Massive non-purulent PE ≥ half of hemithorax.
38
35.
36. Chest tubes
Small bore catheter (24 F )
Regular flushing 6hourly (20-30ml NS )
Until volume < 50 ml/24 hrs and color becomes clear yellow.
Amount of sediment (WBC & debris) should be quantified
If drainage persists If larger cavity >50 ml persists
De-cortication Empyemectomy with de-cortication.
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37. Fibrinolytic Dose Instillation Duration
Streptokinase 250,000
IU
100-200ML
saline
Daily for 7 days (until
drainage <100ml/day
tPA 10-25mg 100ml
saline
BD for 3 days
Intrapleural fibrinolytics – practical use
Better drainage and breakage of septas with improved radiological criteria
May not improve Mortality ,Frequency of surgery, Residual lung function
Side Effects:Immunological reaction, Fever , Local pleural pain, Hemorhage,
Occasionally, ARDS
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Human
Recombinant DNase
5mg 3days
38. Video Assisted Thoracoscopic Surgery (VATS)
Minimally invasive
Less pain
Short recovery time.
Safe and effective
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40. Open Drainage
• Patient unfit for decortication.
• Resecting ribs and inserting tube over lower part of empyema.
• If converted to open drainage earlier pneumothorax.
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42. Prognosis
long-term survival - good if prompt treatment is initiated.
Mortality
15%–2O%
Delay in drainage increase mortality from 3.4% to 16%.
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43. Take home message
Empyema is presence of pus in the pleural space.
Urgent chest drain for empyema or a complicated parapneumonic effusion
Prolonged course of antibiotics needed to treat empyema.
If NO improvement with antibiotics and drainage of the pleural space,
surgery or fibrinolytics should be Considered.
Mortality is approximately 15% to 20%.
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