Empyema def., causes, symptoms, signs, complications and treatment

Here, we are going to discuss Empyema , regarding  definition , aetiology , clinical picture , investigations , complications and management of that emergency .
Definition
It is an accumulation of pus in the pleural sac. The fluid usually is thick and has the appearance of frank pus. 
As previously stated pleural fluid with a pH of less than 7.2 strongly suggests an empyema.

Causes of Empyema 

- pneumonia, bronchopneumonia lung abscess.
- Subphrenic abscess.
- Mediastinal infection .

Clinical Picture 
C/P of the cause +

Symptoms

General : Severe Headache , Fever , Malaise from Toxaemia 

Local    :  - Cough , Dyspnea .
               - Chest pain : • dull aching Pain • pleural stitching pain. 

Signs :

Toxic facies, fever .
Local examination :
Inspection  :  Diminished movement of the affected side .
Palpation    :  - Mediastinal shift to the opposite side
                     - TVF  on the affected side .
Percussion  :  Stony dullness .
Auscultation :  --- intensity of breath sounds or diminished air entery .

Complications of Empyema

1- Pulmonary fibrosis
2- Bronchopleural fistula: Pus cells destroy the lung parenchyma --> connection between pleura & bronchus so pus gets from pleural space to bronchus --> cough
with expectoration related to posture (cavitary lung $).
3- Amyloidosis kidney --> Nephrotic $
4- Empyema necessitans --> intercostals swelling giving expansileimpulse on cough (it is necessary to be drained)
5- Septicaemia

Investigations:
1- X-ray  : opacity of effusion, encysted empyema may present.
2- Aspiration :  culture & sensitivity.

Treatment of empyema:

1- Antibiotics with high doses according to culture and sensitivity.
2- Intercostal tube for free drainage.
If no response :
1- Antibiotics
2- Open drainage :  Rib reiection ± hole in the pleura with dissection of adhesions within the pleural cavity .
Empyema
3- Decortication :  removal of pleura if open drainage is failed .

An empyema almost always requires chest tube drainage as well as antibiotic therapy.
If the fluid itself is non infected with a relatively low WBC count and a pH of more than 7.2 the empyema may resolve with systemic antimicrobial therapy and tube drainage.
However after several days without adequate drainage, most empyemas become loculated, so that tube drainage is not effective and rib resection is necessary to allow
open drainage.

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