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    Add as FriendEmpyema Thoracis

    by: Ismail

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    1 : A Respiratory Inflammatory Disease Empyema Thoracis M. Ismail Arif , Sind Medical College, Dow University of Health Sciences.
    2 : A short case history… Mr.Ziaullah 17 year old admitted on 26th jan, with complains of: fever for 2 months chest pain and cough for 20 days….
    3 : HOPC He was in a good state of health 2 months back, when after playing cricket he developed fever of sudden onset without chills rigors and sweating but fever was associated with vomiting and headache. He consulted a local doctor who treated him with some medicines and few injections which did not relieve the fever.
    4 : HOPC continued…. 20 days back patient developed: chest pain, associated with generalized body pain.. The pain aggravated on coughing and sneezing Cough associated with sputum
    5 : Systemic Inquiry of patient Appetite decreased Sleep normal Generalized weakness No complain of Shortness of breath, palpitation and no complain of bowel and micturition disturbance
    6 : Definition of Empyema Thoracis It is the presence/ accumulation of pus between the pleural cavity of the lung Empyema itself is not a disease but it’s a condition complicated by another disease
    7 : Etiology Lung Diseases: Pneumonia ( most common), Lung abscess.. Post traumatic Post operative Rupture of esophagus or subphrenic abscess through the diaphragm Hematogenous spread
    8 : Organisms Staph. Aureus Strep. Pnuemonie Hemophilus influenza Klebsiella pneumonia E.Coli
    9 : Pathological stages Stage 1 – “ Exudative ” Sterile pleural fluid secondary to inflammation. Stage 2 – “ Fibrinopurulent “ Thick opaque fluid, +ve culture (pus), thin fibrin layer.. Stage 3 – “ Organizing “ Presence of thick pus, in growth of capillaries and fibroblasts, and deposition of collagen.. Lung entrapment, decreased expansion
    10 : Clinical Stages Acute stage: Within the first two weeks of onset. Chronic stage: After the first two weeks or with the formation of thick peels or loculations.
    11 : Symptoms And Signs Fever usually high and remittent Pleuritic Chest pain Cough and expectoration Breathlessness Rigors Night Sweating Weight loss Easy Fatigability Decreased expansion of chest of the affected side Decreased breath sounds on auscultation Pleural rub Dull percussion sounds
    12 : Complications Rupture into lung causing bronchopleural fistula and pyopneumothorax Track through the chest wall with the formation of a subcutaneous abscess or sinus which is then called empyema necessitans. Septicemia and septic shock
    13 : Investigations Chest X-ray CT-scan Ultrasound Aspiration of fluid ( thoracentesis or pleuricentesis ) Pleural biopsy, histology and culture to differentiate from tuberculous disease Sputum culture
    14 : Differential Diagnosis Hemothorax Lung Abscess Lung Cancer Pleural Effusion Pneumonia ( Aspiration, Bacterial, Fungal) Tuberculosis
    15 : Management of Empyema Thoracis Control of the infection process by specific antibiotics Drainage of pus from the pleural cavity by: tube thoracostomy, Intra pleural thormbolytic agents, VATS or rib resection. Obliteration of the space and complete re-expansion of the lung by surgical intervention like open thoracostomy + decortication operation, muscle transposition or thoracoplasty.
    16 : Chest Tube (Tube Thoracostomy) Perform tube thoracostomy immediately after empyema thoracis is diagnosed. Position the chest tube in the dependent part of the effusion, in difficult cases use ultrasound or CT guidance Connect the tube to an underwater seal chest drain. The chest tube can be removed once the volume of the pleural drainage is less than 100 mL/24 h, with clearance of the pleural fluid turbidity seen in complicated pleural effusions.
    17 : VATS ( Video Assisted Thoracoscopy Surgery) Thoracoscopy is an alternate therapy for multiloculated empyema thoracis. The loculations in the pleural space can be disrupted with a thoracoscope, and the pleural space can be drained completely. It is minimally invasive and allows direct visualization of the lung and pleura.
    18 : Rib Resection Drainage Open drainage of the pleural space may be used when closed-tube drainage of the pleural infection is inadequate. This procedure is recommended only when the patient is too ill to tolerate decortication. The resection of 1-3 ribs overlying the lower part of the empyema thoracis cavity is performed, a large-bore chest tube is inserted, and the tube is drained into a colostomy bag. Patients have an open wound for a prolonged period of time.
    19 : Thoracotomy And Decortication In decortication, all the fibrous tissue is removed from the visceral pleural peel, and all pus is evacuated from the pleural space. Decortication is not tolerated by critically ill patients. Decortication is the procedure of choice for patients in whom pleural sepsis is not controlled by closed-tube thoracostomy and intrapleural thrombolytic agents. Decortication should not be performed solely to remove the thickened pleural peel as it usually resolves over several months. If the pleura remains thickened with symptom-limiting reduction in pulmonary function after approximately 6 months, decortication can be considered.
    20 : THANK YOU

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