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    Pleural effusion

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    Pleural Effusion

    Uploaded by

    NARUTO

    Copyright:

    © All Rights Reserved
    Download as PPT, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as ppt, pdf, or txt
    of 22

     EMPYEMA

    Pneumothorax

    TABINDAH REHMAN , GROUP 2, SEM 7


    EMPYEMA

    DEFINITION

     Empyema or Purulent Pleurisy: Empyema is an


    accumulation of pus in the pleural space
     Most often associated with pneumonia due to Staphylococcus
    aureus & Streptococcus pneumoniaea
     The relative incidence of Haemophilus influenzae empyema
    has decreased (Hib vaccination)
     Also produced by rupture of a lung abscess into the pleural
    space, by contamination introduced from trauma or thoracic
    surgery or by mediastinitis or the extension of intra-
    abdominal abscesses
    EPIDEMIOLOGY

     Most frequently encountered in infants & preschool children

     Predisposing factors: preceding history of pustules, blunt


    trauma to the chest, viral infection, severe malnutrition,
    contiguous extension
    PATHOLOGY

     Empyema has 3 stages: exudative, fibrinopurulent, and


    organizational

     Exudative stage: 1-3 days

     Fibrinopurulent stage: 4-14 days

     Organizational stage: After 14 days


    PATHOLOGY

     Exudative stage: fibrinous exudate forms on the pleural surfaces

     Fibrinopurulent stage: fibrinous septa form, causing loculation of


    the fluid & thickening of the parietal pleura

     If the pus is not drained, it may dissect through the pleura into lung
    parenchyma, producing bronchopleural fistulas and
    pyopneumothorax, or into the abdominal cavity or through the chest
    wall (empyema necessitatis)

     Organizational stage: fibroblast proliferation; pockets of loculated


    pus develop into thick-walled abscess cavities or the lung may
    collapse & become surrounded by a thick, inelastic envelope (peel)
    CLINICAL MANIFESTATIONS

     The initial signs & symptoms are primarily those of bacterial pneumonia

     Children treated with antibiotic agents may have an interval of a few days
    between the clinical pneumonia phase & the evidence of empyema

     Most patients are febrile (fever may be absent in immunocompromised


    patients), develop increased work of breathing or respiratory distress &
    often appear more ill

     Physical findings are identical to those for uncomplicated parapneumonic


    effusion & the 2 conditions are differentiated only by thoracentesis
    DIAGNOSIS

     The effusion is empyema if bacteria are present on Gram


    staining, the pH is <7.20, glucose<40 mg/dl and LDH>1000
    IU/L and there are >100,000 neutrophils/µL

     Cultures of the fluid must always be performed

     Blood cultures also have a high yield



    COMPLICATIONS

    1. Bronchopleural fistulas

     Usually respond to adequate drainage, nutritional support &


    sealing of the open communication over the lung surface

     Prolonged bronchopleural fistulas (>2-3 weeks) requires


    decortication, lobectomy or thoracoplasty
     COMPLICATIONS
    2. Pyopneumothorax
    3. Purulent pericarditis & pulmonary abscesses
    4. Peritonitis from extension through the diaphragm & osteomyelitis of
    the ribs
    5. Septic complications: meningitis, arthritis
    6. Septicemia is often encountered in H. influenzae and pneumococcal
    infections
    7. Peel: may restrict lung expansion and may be associated with persistent
    fever and temporary scoliosis
    8. Empyema necessitans
    9. Gastropleural fistula
    TREATMENT

     Systemic antibiotics

     Staphylococcus aureus: cloxacillin & aminoglycoside or 3 gen


    cephlosporin & aminoglycoside
     Gram-ve organism: cefotaxim & aminoglycoside

     Gram stain inconclusive: cefotaxim & cloxacillin

     Resistant Staphylococcus: vancomycin, teicoplanin & linezolid

     Thoracentesis
    TREATMENT

     Chest tube drainage with or without a fibrinolytic agent

    Indications for surgical treatment:

    a) Pleural thickening

    b) Loculated empyema

    c) Non-expansion of lungs with intercostal drainage

    d) Bronchopeural fistula

    1. Video-assisted thorascopic surgery: effective in lysis of adhesions in


    multiloculted effusions & removal of fibrinous material from pleural cavity

    2. Open decortication: significant pleural thickening


    TREATMENT

     The long-term clinical prognosis for adequately treated


    empyema is excellent & follow-up pulmonary function studies
    suggest that residual restrictive disease is uncommon, with or
    without surgical intervention
    PNEUMOTHORAX

    PNEUMOTHORAX
    DEFINITION

     Accumulation of extra pulmonary air within the chest, most


    commonly from leakage of air from within the lung

    ETIOLOGY
    Closed pneumothorax Open pneumothorax
    -Pulmonary disease Invasive pleural &
    Foreign body pulmonary procedures
    RDS Chest trauma
    Respiratory infections
    Bronchial asthma Spontaneous pneumothorax
    Cystic fibrosis Idiopathic (ruptured
    Chemical pneumonitis subpleural blebs)
    Diffuse lung disease Familial
    Tumors
    -Iatrogenic
    Mechanical ventilation
    Central venous catheterization
    PATHOGENESIS

     The tendency of the lung to collapse is balanced in the normal resting


    state by the inherent tendency of the chest wall to expand outward,
    creating negative pressure in the intrapleural space

     When air enters the pleural space, the lung collapses

     In simple pneumothorax, intrapleural pressure is atmospheric, and the


    lung collapses up to 30%.

     In complicated, or tension pneumothorax, continuing leak causes


    increasing positive pressure in the pleural space, with further
    compression of the lung, contralateral shift of mediastinal structures
    & decreases in venous return and cardiac output
    CLINICAL MANIFESTATIONS

     Sudden onset

     Dyspnea, pain, & cyanosis

     Trachea & heart may be shifted toward the unaffected side

     Hyperinflation & reduced movements on affected side

     Respiratory distress with retractions

     Decreased vocal fremitus & vocal resonance

     Markedly decreased breath sounds and a tympanitic percussion note


    over the involved hemithorax
     When fluid is present, there is usually a sharply limited area of
    tympany above a level of flatness to percussion
    CLINICAL MANIFESTATIONS

     Succussion splash: to rule out hydropneumothorax

     Coin test

     Friction test
    DIAGNOSIS

     By radiographic examination

     When the possibility of diaphragmatic hernia is being


    considered, a small amount of barium may be necessary to
    demonstrate that it is not free air but is a portion of the
    gastrointestinal tract that is in the thoracic cavity

     Ultrasound can also be used to establish the diagnosis


    TREATMENT

     Extent of the collapse & nature and severity of the underlying


    disease
     A small (<5%) or even moderate-sized pneumothorax in an
    otherwise normal child may resolve without specific treatment,
    usually within about 1 wk
     Needle aspiration: tension pneumothorax & primary spontaneous
    pneumothorax
     If the pneumothorax is recurrent, secondary or under tension or there
    is >5% collapse: chest tube drainage
     Pneumothorax complicating malignancy: chemical pleurodesis or
    surgical thoracotomy
    TREATMENT

     Closed thoracotomy: adequate to reexpand the lung in most patients

     Chemical pleurodesis: recurrent pneumothoraces; introduction of


    talc, doxycycline, or iodopovidone into the pleural space

     Open thoracotomy: plication of blebs, closure of fistula, stripping of


    the pleura and basilar pleural abrasion; Stripping and abrading the
    pleura leaves raw, inflamed surfaces that heal with sealing adhesions

     VATS: preferred therapy for blebectomy, pleural stripping, pleural


    brushing and instillation of sclerosing agents; less morbidity than
    with open thoracotomy

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