Empyema Thoracic, Shalya Tantra
EMPYEMA THORACIC
Collections of pus (purulent fluid) in the pleural Space is defined as empyema. Empyema is always secondary to pyogenic infections of the neighbouring structures, the mOSt common being lobar pneumonia, bronchopneumonia, lung abscess, tuberculesis; bronchopleural fistula,'oesophageal perfoxration, infected lymph nodes, osteomyelitis of thoracic vertebrae, subphrenic abscess, trauma, osteomyelitis of ribs etc.
The commonly involved organisms are staphylococcus aureus, streptococcus, pneumococcus, pseudomonas, Esch. coli etc. .
As the infections reach the pleural cavity, due to inflammation, protien rich fluid is exudated. This is replaced by fibrin, which causes adhesion of pleural layers at the periphery of collected fluid. Gradually granulation tissue is formed which is than replaced by fibrous tissue. As the empyema is covered by adhesions. The fluid within gradually thickens. Gradually, as the lung is covered by a tough fibrous covering. The affected segment becomes immobile and functionless.
Clinical features-It canbe understood in 3 stages-
(i) Acute empyema
(ii) Subacute empyema
(iii) Chronic empyema.
(i) Acute empyema
(a) Patient is toxic and in shock
(b) Has plueral pain
(c) Respiration 'is shallow and rapid
(d) Presence of fluid in pleura can be understood by stony dullness on percussion, diminished breath sounds, vocal resonance on auscultation, diminished movements of chest wall on the affected side.
(ii) Subacute empyema - This condition oCcurs due to early administration of antibiotics in various lung infections. Persistent fever, delayed resolution of symptoms, prolonged convalescence etc, indicate towards subacute empyema. The clinical signs indicating the presence of fluid in the pleural cavity are manifested.
(iii) Chronic empyema - Failure of identification of acute / subacute empyema or improper/inadequate management of these stages, results in the manifestation of chronic empyema. There are no toxic features, no features of acute empyema, no dyspnoea & no fever.
Management-
The main aim of treatment is to
(a) Control primary infection and its secondary manifestations.
(b) Evacuate infected contents from the empyema sac to prevent chronicity.
(c) To restore the normal functioning of affected lung segment. Thus the main treatments are
(i) Appropriate antibiotics
(ii) Adequate drainage of pus.
Aspiration of pus- Pleuralpuncture is made in the posterior axillary line, at 8‘h or 9lh intercoastal space, The skin at the site is anaesthetised beforehand with 1%local anaesthetic solution. A large needle is introduced and as much fluid as possible, should be aspirated. After aspiratiOn, proper antibiotics should be instilled. If fluid is continuously being formed, continuous closed drainage with interocastal tube should be carried out.
When the pus is too thick, open drainage with resection of a short segment of the rib, usually the 9th or 10th rib (in Paravertebral line) is done. Drainage should be continued till the empyema cavity is completely cleared off the pus. Early removal of drain leads to chronicity.
Collections of pus (purulent fluid) in the pleural Space is defined as empyema. Empyema is always secondary to pyogenic infections of the neighbouring structures, the mOSt common being lobar pneumonia, bronchopneumonia, lung abscess, tuberculesis; bronchopleural fistula,'oesophageal perfoxration, infected lymph nodes, osteomyelitis of thoracic vertebrae, subphrenic abscess, trauma, osteomyelitis of ribs etc.
The commonly involved organisms are staphylococcus aureus, streptococcus, pneumococcus, pseudomonas, Esch. coli etc. .
As the infections reach the pleural cavity, due to inflammation, protien rich fluid is exudated. This is replaced by fibrin, which causes adhesion of pleural layers at the periphery of collected fluid. Gradually granulation tissue is formed which is than replaced by fibrous tissue. As the empyema is covered by adhesions. The fluid within gradually thickens. Gradually, as the lung is covered by a tough fibrous covering. The affected segment becomes immobile and functionless.
Clinical features-It canbe understood in 3 stages-
(i) Acute empyema
(ii) Subacute empyema
(iii) Chronic empyema.
(i) Acute empyema
(a) Patient is toxic and in shock
(b) Has plueral pain
(c) Respiration 'is shallow and rapid
(d) Presence of fluid in pleura can be understood by stony dullness on percussion, diminished breath sounds, vocal resonance on auscultation, diminished movements of chest wall on the affected side.
(ii) Subacute empyema - This condition oCcurs due to early administration of antibiotics in various lung infections. Persistent fever, delayed resolution of symptoms, prolonged convalescence etc, indicate towards subacute empyema. The clinical signs indicating the presence of fluid in the pleural cavity are manifested.
(iii) Chronic empyema - Failure of identification of acute / subacute empyema or improper/inadequate management of these stages, results in the manifestation of chronic empyema. There are no toxic features, no features of acute empyema, no dyspnoea & no fever.
Management-
The main aim of treatment is to
(a) Control primary infection and its secondary manifestations.
(b) Evacuate infected contents from the empyema sac to prevent chronicity.
(c) To restore the normal functioning of affected lung segment. Thus the main treatments are
(i) Appropriate antibiotics
(ii) Adequate drainage of pus.
Aspiration of pus- Pleuralpuncture is made in the posterior axillary line, at 8‘h or 9lh intercoastal space, The skin at the site is anaesthetised beforehand with 1%local anaesthetic solution. A large needle is introduced and as much fluid as possible, should be aspirated. After aspiratiOn, proper antibiotics should be instilled. If fluid is continuously being formed, continuous closed drainage with interocastal tube should be carried out.
When the pus is too thick, open drainage with resection of a short segment of the rib, usually the 9th or 10th rib (in Paravertebral line) is done. Drainage should be continued till the empyema cavity is completely cleared off the pus. Early removal of drain leads to chronicity.
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