Pleural empyema is an inflammation of the pleural leaflets, accompanied by the formation of purulent exudate in the pleural cavity. Disease occurs with chills, persistently high or hectic temperature, profuse sweating, tachycardia, shortness of breath, weakness. Diagnosis is carried out on the basis of X-ray data, ultrasound of the pleural cavity, the results of thoracocentesis, laboratory examination of exudate, peripheral blood analysis. Treatment of acute pleural empyema includes drainage and sanitation of the pleural cavity, massive antibiotic therapy, detoxification therapy; with chronic empyema, thoracostomy, thoracoplasty, pleurectomy with lung decortication can be performed.
The term “empyema” in medicine is used to denote the accumulation of pus in natural anatomical cavities. So, gastroenterologists in practice have to deal with empyema of the gallbladder (purulent cholecystitis), rheumatologists – with joint empyema (purulent arthritis), otolaryngologists – with empyema of the paranasal sinuses (purulent sinusitis), neurologists – with subdural and epidural empyema (accumulation of pus under or above the dura mater). In practical pulmonology, empyema of the pleura (pyothorax, purulent pleurisy) is understood as a type of exudative pleurisy that occurs with an accumulation of purulent effusion between the visceral and parietal pleural leaves.
Causes of pleural empyema
In almost 90% of cases, pleural empyema is secondary in origin and develops during the direct transition of the purulent process from the lung, mediastinum, pericardium, chest wall, subdiaphragmatic space.
1. Most often, pleural empyema occurs in acute or chronic infectious pulmonary processes:
- lung abscess,
- lung gangrene,
- suppurated lung cyst,
- spontaneous pneumothorax,
- exudative pleurisy , etc.
In some cases, pleural empyema is complicated by the course of mediastinitis, pericarditis, osteomyelitis of the ribs and spine, subdiaphragmatic abscess, liver abscess, acute pancreatitis.
2. Metastatic empyema of the pleura is caused by the spread of infection by hematogenic or lymphogenic pathways from distant purulent foci (for example, in acute appendicitis, angina, sepsis, etc.).
3. Post-traumatic purulent pleurisy, as a rule, is associated with lung injuries, chest wounds, rupture of the esophagus.
4. Postoperative empyema of the pleura may occur after resection of the lungs, esophagus, cardiac surgery and other operations on the organs of the thoracic cavity.
There are three stages in the development of pleural empyema: serous, fibrinous-purulent and the stage of fibrous organization.
- The serous stage proceeds with the formation of a serous effusion in the pleural cavity. Timely initiated antibacterial therapy allows to suppress exudative processes and promotes spontaneous resorption of fluid. In the case of inadequately selected antimicrobial therapy, the growth and reproduction of pyogenic flora begins in the pleural exudate, which leads to the transition of pleurisy to the next stage.
- Fibrinous-purulent stage. In this phase of pleural empyema, due to an increase in the number of bacteria, detritus, polymorphonuclear leukocytes, the exudate becomes cloudy, acquiring a purulent character. Fibrinous plaque forms on the surface of the visceral and parietal pleura, loose and then dense adhesions appear between the pleural leaves. The accretions form limited intrapleural osumkovaniya containing an accumulation of thick pus.
- The stage of fibrous organization. There is the formation of dense pleural mooring, which, like a shell, fetter the compressed lung. Over time, non-functioning lung tissue undergoes fibrous changes with the development of pleurogenic cirrhosis of the lung.
Classification of pleural empyema
Depending on the etiopathogenetic mechanisms, disease is distinguished:
- metapneumonic and parapneumonic (developed in connection with pneumonia),
According to the duration of the course, pleural empyema can be acute (up to 1 month), subacute (up to 3 months) and chronic (over 3 months). Taking into account the nature of the exudate, purulent, putrefactive, specific, mixed pleural empyema is isolated. The causative agents of various forms of pleural empyema are nonspecific pyogenic microorganisms (streptococci, staphylococci, pneumococci, anaerobes), specific flora (Mycobacterium tuberculosis, fungi), mixed infection.
According to the criterion of localization and prevalence of pleural empyema, there are:
- unilateral and bilateral;
- subtotal, total, delimited: apical (apical), paracostal (parietal), basal (naddiaphragmatic), interlobular, paramediastinal.
By volume of purulent exudate:
- small – in the presence of 200-500 ml of purulent exudate in the pleural sinuses;
- average – with an accumulation of 500-1000 ml of exudate, the boundaries of which reach the angle of the scapula (VII intercostal space);
- large – when the amount of effusion is more than 1 liter.
The pyothorax can be closed (not communicating with the environment) and open (in the presence of fistulas – bronchopleural, pleurocutaneous, bronchopleural, pleuropulmonary, etc.). Open empyema of the pleura is classified as a pyopneumothorax.
Symptoms of pleural empyema
Acute pyothorax manifests with the development of a symptom complex, including chills, persistently high (up to 39 ° C and above) or hectic temperature, profuse sweating, increasing shortness of breath, tachycardia, lip cyanosis, acrocyanosis. Endogenous intoxication is pronounced: headache, progressive weakness, lack of appetite, lethargy, apathy.
There is an intense pain syndrome on the side of the lesion; stabbing pains in the chest increase with breathing, movements and coughing. Pain can radiate to the shoulder blade, the upper half of the abdomen. With closed empyema of the pleura, the cough is dry, in the presence of bronchopleural communication – with the separation of a large amount of fetid purulent sputum. Patients with pleural empyema are characterized by a forced position – half-sitting with an emphasis on the hands located behind the trunk.
Due to the loss of proteins and electrolytes, volemic and water-electrolyte disorders develop, accompanied by a decrease in muscle mass and weight loss. The face and the affected half of the chest become pasty, peripheral edema occurs. Against the background of hypo- and dysproteinemia, dystrophic changes in the liver, myocardium, kidneys and functional multiple organ failure develop. With pleural empyema, the risk of thrombosis and PE increases sharply, leading to the death of patients. In 15% of cases, acute pleural empyema turns into a chronic form.
Diagnostics of pleural empyema
Recognition of the pyothorax requires a comprehensive physical, laboratory and instrumental examination. Examination of a patient with empyema of the pleura reveals a lag of the affected side of the chest during breathing, an asymmetric enlargement of the chest, expansion, smoothing or bulging of the intercostals. Typical external signs of a patient with chronic pleural empyema are scoliosis with a bend of the spine to the healthy side, a lowered shoulder and a protruding shoulder blade on the side of the lesion.
The percussive sound on the side of purulent pleurisy is blunted; in the case of total empyema of the pleura, absolute percussive dullness is determined. During auscultation, breathing on the side of the pyothorax is sharply weakened or absent. The data of instrumental diagnostics complement the physical picture:
- X-ray. Polypositional radiography and lung fluoroscopy with pleural empyema reveal intense shading. To clarify the size, shape of the closed empyema of the pleura, the presence of fistulas, pleurography is performed with the introduction of a water-soluble contrast into the pleural cavity. To exclude destructive processes in the lungs, CT and MRI of the lungs are indicated.
- Sonography. In the diagnosis of pleural empyema limited, the information content of ultrasound of the pleural cavity is great, which allows you to detect even a small amount of exudate, determine the place of pleural puncture.
- Evaluation of exudate. The decisive diagnostic value in pleural empyema is assigned to the puncture of the pleural cavity, with the help of which the purulent nature of the exudate is confirmed. Bacteriological and microscopic analysis of pleural effusion makes it possible to clarify the etiology of pleural empyema.
Treatment for pleural empyema
Sanitation of the pleural cavity
With purulent pleurisy of any etiology, the general principles of treatment are adhered to. Great importance is attached to the early and effective emptying of the pleural cavity from purulent contents. This is achieved by drainage of the pleural cavity, vacuum aspiration of pus, pleural lavage, administration of antibiotics and proteolytic enzymes, therapeutic bronchoscopy. Evacuation of purulent exudate helps to reduce intoxication, straightening of the lung, soldering of pleural leaves and elimination of the pleural empyema cavity.
Simultaneously with the local administration of antimicrobials, massive systemic antibiotic therapy (cephalosporins, aminoglycosides, carbapenems, fluoroquinolones) is prescribed. Detoxification, immunocorrective therapy, vitamin therapy, transfusion of protein preparations (blood plasma, albumin, hydrolysates), glucose solutions, electrolytes are carried out. In order to normalize homeostasis, reduce intoxication and increase the immune-resistant capabilities of the body, blood UFOs, plasmapheresis, plasmocytopheresis, hemosorption are performed.
During the period of exudate resorption, procedures are prescribed to prevent the formation of pleural adhesions – respiratory gymnastics, physical therapy, ultrasound, classical, percussion and vibration chest massage.
Surgical treatment is indicated for the formation of chronic pleural empyema. In this case, thoracostomy (open drainage), pleurectomy with lung decortication, intrapleural thoracoplasty, closure of the bronchopleural fistula, various options for lung resection can be performed.
Prognosis and prevention
Complications of pleural empyema may include bronchopleural fistulas, septicopyemia, secondary bronchiectasis, amyloidosis, multiple organ failure. The prognosis for pleural empyema is always serious, the mortality rate is 5-22%. Prevention of pleural empyema consists in timely antibiotic therapy of pulmonary and extrapulmonary infectious processes, careful asepsis during surgical interventions on the thoracic cavity, achieving rapid expansion of the lung in the postoperative period, increasing the overall resistance of the body.
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