EMPYEMA THORACISEMPYEMA THORACIS

Dr. Ashraf A. Esmat Dr. Ashraf A. Esmat

A.Prof.Cardio-thoracic surgeryA.Prof.Cardio-thoracic surgery

Cairo universityCairo university

DefinitionDefinition

Accumulation of Pus in the Pleural cavityAccumulation of Pus in the Pleural cavity..

It comes from the greek word It comes from the greek word empyeinempyein ,which ,which means :pus –producing (suppurates)means :pus –producing (suppurates)..

AetiologyAetiology

Lung diseases:Lung diseases: Pneumonia (the most common cause)Pneumonia (the most common cause)

Lung abscessLung abscess.. Subphrenic abscess.Subphrenic abscess. Post traumatic.Post traumatic. Iatrogenic.Iatrogenic. Post-operative.Post-operative. Blood spread .Blood spread .

OrganismsOrganisms

The most common:The most common: Staph.aureus .(90% of causes in infants & Staph.aureus .(90% of causes in infants &

children)children) Strept.pneuomonie.Strept.pneuomonie. H.influenzae.H.influenzae.

Pathological StagesPathological Stages

Acute (exudative) stage:Acute (exudative) stage: Pleura fills with thin fluid that shows one or Pleura fills with thin fluid that shows one or

more of these criteria; more of these criteria;Ph < 7.4Ph < 7.4Glucose <40 mg/dlGlucose <40 mg/dlLDH> 1000 iu/dlLDH> 1000 iu/dlProtein > 2.5 gm/dlProtein > 2.5 gm/dlSp.gravity >1.018Sp.gravity >1.018

Stages (cont.)Stages (cont.)

Fibrinopurulent stage:Fibrinopurulent stage:

Thick,Opaque fluid with positive culture Thick,Opaque fluid with positive culture (pus) and Deposition of thin fibrin layer over (pus) and Deposition of thin fibrin layer over the pleura. the pleura.

Progressive loculation and formation of Progressive loculation and formation of pouches in the pleura.pouches in the pleura.

Stages (cont.)Stages (cont.)

Organizing Stage:Organizing Stage:

Presence of very thick pus .Presence of very thick pus .

Thick Inelaastic peel over both pleurae Thick Inelaastic peel over both pleurae causing entrapment of the lung.causing entrapment of the lung.

Clinical stagesClinical stages

Acute stage :Acute stage :

within the first 2 weeks of the onset.within the first 2 weeks of the onset.

Chronic Stage :Chronic Stage :

after 2 weeks or with the formation of the after 2 weeks or with the formation of the thick peel and loculations.thick peel and loculations.

Causes of chronicityCauses of chronicity::

Inadequate Tube Drainage.Inadequate Tube Drainage.

Chronic pulmonary Disease( T.B. or Fungal Chronic pulmonary Disease( T.B. or Fungal Infection)Infection)

Immunosupressed patients.Immunosupressed patients.

Presence of Foreign body within the pleural Presence of Foreign body within the pleural space.space.

Symptoms & signsSymptoms & signs

Fever Fever Cough & Expectoration.Cough & Expectoration. Pleuretic chest pain.Pleuretic chest pain. Easy fatiguability.Easy fatiguability. Loss of weight.Loss of weight. Night sweating.Night sweating.

ComplicationsComplications

Rupture into the lung; Rupture into the lung;

BronchoPleural fistulaBronchoPleural fistula Spread to the subcutaneous tissue;Spread to the subcutaneous tissue;

Empyema NiscitanesEmpyema Niscitanes Septicaemia & septic shock.Septicaemia & septic shock.

InvestigationsInvestigations

Chest X-ray.Chest X-ray.

C-T scan.C-T scan.

UltrasonographyUltrasonography

ThoracentesisThoracentesis

ManagementManagement

Control of the Infection process.Control of the Infection process.

Drainage of pus form the pleura.Drainage of pus form the pleura.

Obliteration of the space & complete Re-Obliteration of the space & complete Re-expansion of the Lung.expansion of the Lung.

Drainage of EmpyemaDrainage of Empyema

Intercostal tube thoracostomy.Intercostal tube thoracostomy.

Intrapleural instillation of streptokinase .Intrapleural instillation of streptokinase .

V.A.T.S.V.A.T.S.

Rib Resection Drainage.Rib Resection Drainage. Eloesser Flap .Eloesser Flap .

Tube thoracostomyTube thoracostomy

IndicationsIndications

TechniqueTechnique

When to removeWhen to remove

When to convert to open drainageWhen to convert to open drainage

Intrapleural StreptokinaseIntrapleural Streptokinase

IndicationsIndicationsAcute or fibrino purulent stageAcute or fibrino purulent stagePresence of loculations.Presence of loculations. Incomplete drainage after tube insertionIncomplete drainage after tube insertion Contraindications:Contraindications:Chronic stageChronic stagePost-operative empyemaPost-operative empyemaEmpyema with BPF.Empyema with BPF.

TechniqueTechnique

Streptokinase 25000 iu in 50 cc of 0.9% Streptokinase 25000 iu in 50 cc of 0.9% saline solution.saline solution.

Clamp the tube for 6 hours.Clamp the tube for 6 hours.

Open the clamp and connect tube to suctionOpen the clamp and connect tube to suction

Video Assisted ThoracoscopyVideo Assisted Thoracoscopy

IndicationsIndications

TechniqueTechnique

LimitationsLimitations

complicationscomplications

Rib Resection DrainageRib Resection Drainage

Indication Indication

TechniqueTechnique

LimitationsLimitations

Eloesser Flap DrainageEloesser Flap Drainage

Indication.Indication.

Technique.Technique.

Advantage.Advantage.

Disadvantage.Disadvantage.

Reexpansion of the lung & Reexpansion of the lung & obliteration of the spaceobliteration of the space Decortication.Decortication.

Muscle Transposition.Muscle Transposition.

Thoracoplasty.Thoracoplasty.

DecorticationDecortication

Indications.Indications.

Technique.Technique.

Postoperative care.Postoperative care.

ThoracoplastyThoracoplasty

Conventional alexander .Conventional alexander .

Tailoring thoracoplasty.Tailoring thoracoplasty.

THANK YOUTHANK YOU

GOOD LUCKGOOD LUCK