Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content + • 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 pH2. Transitional (fibrinopurulent)-Increase in turbidity, WBC, and LDH-Low glucose and pH-Fibrin deposited thereby fixing the lung3. Chronic organizing-Occurs 7-28 days after disease onset-Exudates thickens, causing further fixation of lung-pH < 7.0-Glucose < 40 mg/dL +++ Epidemiology + • 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%) +++ Symptoms and Signs + • Rarely asymptomatic• Fever, pleuritic chest pain, dyspnea, hemoptysis, cough• Tachycardia, anemia, tachypnea, diminished breath sounds, clubbing +++ Imaging Findings + • Chest film and chest CT:-Pneumonia-Lung abscess-Pleural effusion-Mediastinal shift away if large empyema + • 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 + • Chest CT: May be necessary if loculated• Bronchoscopy: Performed to exclude presence of endobronchial obstruction• Thoracentesis: Diagnostic + • 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 +++ Treatment Algorithm: Empyema + • 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• ... Your MyAccess profile is currently affiliated with '[InstitutionA]' and is in the process of switching affiliations to '[InstitutionB]'. Please click ‘Continue’ to continue the affiliation switch, otherwise click ‘Cancel’ to cancel signing in. Get Free Access Through Your Institution Learn how to see if your library subscribes to McGraw Hill Medical products. Subscribe: Institutional or Individual Sign In Username Error: Please enter User Name Password Error: Please enter Password Forgot Username? Forgot Password? Sign in via OpenAthens Sign in via Shibboleth