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  • Pyothorax: Pus within pleural cavity, usually thick, creamy, malodorous

    • Etiology includes:

    • -In setting of pneumonia, lung abscess, bronchiectasis, it is referred to as parapneumonic (60%)

      -Postsurgical (20%)

      -Post-traumatic (10%)

      -Less common causes include esophageal rupture and other chest wall or mediastinal infections

    • 3 temporal phases:

    • 1. Acute exudative

      -Sterile low viscosity pleural fluid

      -Low WBC count and lactic dehydrogenase (LDH)

      -Normal glucose

      -Normal pH

      2. Transitional (fibrinopurulent)

      -Increase in turbidity, WBC, and LDH

      -Low glucose and pH

      -Fibrin deposited thereby fixing the lung

      3. Chronic organizing

      -Occurs 7-28 days after disease onset

      -Exudates thickens, causing further fixation of lung

      -pH < 7.0

      -Glucose < 40 mg/dL

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Epidemiology

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  • • Most organisms are anaerobic bacteria: bacteroides, fusobacterium, peptococcus

    Staphylococcus is cause in > 90% of children under 2 years; common cause in adults also

    E coli, Pseudomonas cause 66% of aerobic, gram-negative empyemas

    • Rarely fungi and Entamoeba histolytica can cause empyemas

    • Average number of bacterial species isolated: 3.2 per patient

    Incidence of complications with Staph pneumonias in adults:

    • -Abscess (25%)

      -Empyema (15%)

      -Effusion (30%)

    Incidence of complications with Staph pneumonias in kids:

    • -Abscess (50%)

      -Empyema (15%)

      -Pneumatocele (35%)

      -Effusion (55%)

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Symptoms and Signs

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  • • Rarely asymptomatic

    • Fever, pleuritic chest pain, dyspnea, hemoptysis, cough

    • Tachycardia, anemia, tachypnea, diminished breath sounds, clubbing

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Imaging Findings

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  • Chest film and chest CT:

    • -Pneumonia

      -Lung abscess

      -Pleural effusion

      -Mediastinal shift away if large empyema

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  • • Thoracentesis is diagnostic

    • -In early empyema, pleural fluid may not be purulent

      -pH < 7.0

      -Glucose < 40 mg/dL

      -LDH > 1000 U/L

      -Suggests evolving empyema despite negative Gram stain and culture

      -Frank pus usually develops later in empyema development

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  • Chest CT: May be necessary if loculated

    Bronchoscopy: Performed to exclude presence of endobronchial obstruction

    Thoracentesis: Diagnostic

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  • • Goals:

    • -Control infection

      -Remove purulent material with lung reexpansion

      -Eliminate underlying disease process

    • Options:

    • -Repeated thoracentesis

      -Chest tube drainage

      -Rib resection with open drainage

      -Decortication and empyemectomy

      -Thoracoplasty

      -Muscle flap closure

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Treatment Algorithm: Empyema

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  • • Clear thoracentesis

    • -Check Gram stain and culture

      -If positive, thoracentesis/chest tube

      -If negative, check pH, glucose, LDH; chest tube if indicated

    • Pus on thoracentesis

    • -Place chest tube

      -Convert to open drainage

      -Perform sinogram: No cavity, then withdraw tube; small cavity, evaluate how well drained—if well drained, then slowly advance tube—if not well drained, then consider rib resection, thoracoscopy, or new chest tube; large cavity, if well drained, slowly advance tube—if no reexpansion, consider decortication—if not well drained, consider early decortication, rib resection, or Eloesser procedure

    • Residual spaces, continued sepsis: Consider open drainage procedures 10-14 days after chest tube (allows time for pleural fusion

    • Rib resection: Of short segments of 1-3 ribs in dependent portion

    • Eloesser procedure: Simple rib resection and open flap drainage

    • Creation of U-shape flap: Chest wall sewn to parietal pleura with rib resection

    • ...

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