empyema dr yusuf imran
DESCRIPTION
Empyema orTRANSCRIPT
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PAEDIATRIC EMPYEMA THORACIS
CAUSES AND MANAGEMENT
By – Dr. Yusuf Imran
J.N Medical College
AMU-Aligarh (INDIA)
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INTRODUCTION
Empyema is the accumulation of pus in the space
between the lung and pleural space that occurs when
an infection spreads from the lungs.
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DEFINITION
It is the presence/accumulation of pus between the pleural cavity of the lung.
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STAGES
While this disease evolves in a continuum, it has been divided into 3
distinct stages by the American Thoracic Society
1. Exudative- in which a sterile exudate low in cellular count
accumulates in the pleural space.
2. Fibrinopurulent- in which frank pus is present with an increase in
white cells.
3. Organised- fibroblast proliferation leads to the formation of thick peel
and potential lung entrapment, whereby the pleural space is
characterised by a very thick exudate with heavy sediment.
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DIFFERENTIATION OF PLEURAL FLUID
TRANSUDATE EMPYEMA
Appearance Clear Cloudy or purulent
Cell count (per mm3) <1000Often >50,000 (cell count has
limited predictive value)
Cell type Lymphocytes, monocytesPolymorphonuclear leukocytes
(neutrophils)
Lactate dehydrogenase <200 U/L >1000 U/L
Pleural fluid/serum LDH ratio
<0.6 >0.6
Protein >3g Unusual CommonPleural fluid/serum protein
ratio<0.5 >0.5
Glucose Normal Low (<40 mg/dL)
pH Normal (7.40-7.60) <7.10
Gram stain NegativeOccasionally positive (less than one-third of cases)
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ETIOLOGY OF EMPYEMA
1. Common cause is pulmonary infection as a result of aerobic bacteria such as :
Streptococcus pneumonia, Staph aureus, E coli, Klebsiella pneumoniae, Hemophilus influenzae.
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2. Chest Trauma (blunt chest wound, chest surgery, lung abscess, or a ruptured esophagus )
3. Septicemia ( very rare blood borne infection )
4. Subdiaphragmatic causes as liver abscess.
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Pneumococcal infection remains the most common
isolated cause in developed countries, with
Staphylococcus aureus the predominant pathogen in the
developing world.
Prevalence of S.pneumaoniae has decreased from 66 to
27 %.
S aureus has become the most common organism
isolated, with 78 % of those being resistant to methicillin.
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PATHOPHYSIOLOGY
The pleural space usually contains a small amount of fluid
(0.3ml/kg of body weight), which is absorbed and secreted
in equilibrium via the lymphatic drainage system.
This circulatory system can cope with a substantial
increase in fluid production; however disruption of this
balance can lead to fluid accumulation and an associated
pleural effusion.
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Infection in the lung activates an immune response and
stimulates pleural inflammation.
Pleural vasculature becomes more permeable and
inflammatory cells and bacteria leak into the pleural space
causing pleural fluid infection and formation of pus
resulting in the classical empyema.
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CLINICAL HISTORY
Risk factors should be determined on admission, and may include-
History of chronic illness.
Congenital or chromosomal abnormality.
Anatomic or functional asplenia .
Immuno-compromise .
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Previous invasive pneumococcal disease (IPD).
Vaccination status .
Prematurity .
Parental smoking history .
History of recurrent infections in the child
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CLINICAL PRESENTATION AND EXAMINATION
Fever, malaise, tachypnoea are the presenting signs.
Cough may be absent in the early part of the pneumonic
process caused by Streptococcus pneumoniae but
develops as the disease advances.
Chest pain and diarrhoea.
Children often lie on the affected side to minimise pain
and to improve ventilation and perfusion matching. They
may have a scoliosis to the affected side.
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Chest examination typically reveals
• Decreased unilateral chest expansion with reduced breath
sounds on auscultation.
• Stony dull percussion.
Typically, a persistent fever despite 48 hours of
appropriate antibiotic treatment, together with a change in
physical signs should alert the clinician to the possible
development of pleural fluid as a complication of
pneumonia .
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INVESTIGATIONS
IMAGING –
A) Chest X-ray (CXR) –
blunting of the costophrenic angle and pleural shadowing;
B) Ultrasound - it is the best technique to differentiate
pleural fluid and consolidation, estimate effusion size and
grade complexity, demonstrate the presence of fibrinous
septations and guide chest drain placement.
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C) Computerised Tomography (CT) -
Child fails to respond to treatment and there is concern
that an abscess has developed.
Presentation is atypical
Concerns that the child may have other pathology such
as a tumour.
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INVESTIGATIONS CONT… BLOOD TESTS –
A) Microbiology -The yield of isolating causative bacteria from
blood cultures is low, probably due to prior antibiotic use.
B) Full blood count -White blood cells (WBC), particularly
neutrophils, are raised at initial presentation and return to normal
once the pleural space and lung parenchyma are sterilised.
There is no role for routine WBC testing to monitor disease.
Reduction of fever pattern is the most useful sign to indicated
disease improvement.
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MANAGEMENT AIM OF TREATMENT :
To resolve clinical symptoms. Prevent further progression of empyema, Sterilise the pleural cavity, Reduce fever, Shorten hospital stay Re-expand the lung with return to normal function.
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A) SUPPORTIVE THERAPY-
Supplemental oxygen. Fluid replacement. Antipyretics. Analgesia. Early mobilisation and encouragement of deep breathing
and coughing.
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B) ANTIBIOTICS –
The choice is dependent on local bacterial causes of community acquired pneumonia and local antibiotic policy.
It is recommended that the initial empirical choice of antibiotics should cover at least Streptococcus pneumoniae and Staphylococcus aureus.
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Macrolides should be used when Mycoplasma pneumoniae is thought to be the causative organism.
Change to oral antibiotics once a child has been afebrile for 24 hours.
Length of oral antibiotic treatment varies from at least 1 week to 6 weeks.
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C). DRAINAGE OF PLEURAL FLUID –
The options available for definitive drainage are:
Chest drain insertion alone or with instillation of fibrinolytics
Video assisted thoracoscopic surgery (VATS)
Open thoracotomy
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INDICATIONS FOR PLEURAL CAVITY DRAINAGE –
Moderate to severe respiratory distress,
Large pleural effusion
Ongoing sepsis.
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TREATMENT FAILURE AND COMPLICATIONS
Persistent fever.
Incorrect antibiotic choice.
Failure of the antibiotics to penetrate the infected lung tissue or
cavity.
A CT scan is indicated for persistent fever which is not reducing
and a rise in WBC and C-reactive protein, to exclude a pulmonary
abscess .
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Persistent lobar collapse is unusual and is in an
indication for a bronchoscopy to exclude a foreign body.
Cavitary necrosis, necrotising pneumonia and
pneumatocoeles may be present on CT scans and are
often a complication of empyema .
A bronchopleural fistula occurs occasionally following the
insertion of a chest drain or surgery for the treatment of
empyema
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DISCHARGE AND FOLLOW UP No oxygen requirement and has been on oral antibiotics for 24
hours then he/she can be discharged .
Oral antibiotics should be continued for at least one week and
may be continued for up to 6 weeks .
A repeat chest X-ray should be done at 4 to 6 weeks post
discharge to confirm changes are resolving; most CXR are not
completely normal at this time point.
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THANK YOU By – Dr. Yusuf ImranJ.N Medical College
AMU-Aligarh (INDIA)