CAUSATIVE ORGANISMS

The commonest organism seen in the tropical countries is staphylococcus aureus. Other organisms reported are S. pneumoniae, Klebsiella aerogenes, S. faecalis and methicillin-resistant Staph. aureus. The commonest organism reported in western studies is Streptococcus pneumoniae. Frank tuberculous empyema is rare, occurring in only about 2 percent cases of tuberculous pleurisy

PATHOPHYSIOLOGY

Para-pneumonic effusions that occur in first 48 to 72 hours are small, sterile polymorphonuclear leucocytes (PMNS) predominant exudate with pleural fluid pH more than 7.30, glucose more than 60 mg/dl and LDH less than 500 IU/L .

This is the exudative stage. The fibrinopurulent stage is marked by bacterial invasion and lasts from 4 to 14 days. In this stage, there is fibrin deposition in pleura. This is marked by septations, loculations and thickening of pleural fluid. After 14 days the pus organizes to form an inelastic “peel” that restricts lung expansion and is impermeable to drugs. This is the organizational stage and is seen most commonly with Staph aureus. An ET may get complicated by bronchopleural fistula, parenchymal necrosis or empyema necessitates.

Figs 5.38A to C: Empyema thoracic (A) Five-year-old boy presented with pyrexia, breathlessness, cough.

Examination revealed bulging of left hemithorax, reduced breath sound and stoney dull note on percussion overleft hemithorax. (B) X-ray chest revealed opaque left hemithorax with shifting of trachea to right side (C) Intercostal chest drainage ICD with wide bore chest tube

PRESENTATION

ET can have a pneumonia like presentation where there is high fever, cough, breathlessness and abdominal and chest pain. Any pneumonia that is not responding to 48 hours of parenteral antibiotic therapy should be suspected to be having ET.

Another presentation is like that of a space-occupying lesion hampering normal respiratory movement and causing bulging of the hemithorax. On examination there is decreased movement and air entry, dullness on percussion, mediastinal shift and later scoliosis.

INVESTIGATIONS

1. Chest radiograph - erect (PA or AP): The earliest evidence is the obliteration of the costophrenic angle. Later the meniscus sign develops and with further increase in fluid, there is mediastinal shift and finally the entire hemithorax may be white – out. As pleural thickening ensues, scoliosis appears with concavity towards the affected hemithorax. A lateral chest radiograph not required routinely.

2. Ultrasonography: USG has emerged as an extremely useful tool to diagnose small amounts of pleural effusion and to guide further interventions. It gives information regarding the size and thickness of the effusion as well demonstrates pleural thickening. It can be used as a guide to thoracocentesis and drainage.

3. CAT scan: is done only if a surgery (apart from intercostals drainage) is contemplated.

4. Pleural fluid examination: Should be done to do a gram staining and culture and sensitivity.

Routinely, biochemical examination is not required.

MANAGEMENT

1. Antimicrobial therapy: Empirically the patient is started on intravenous cloxacillin (50 mg/

kg/dose, Q6H) along with an aminoglycoside and benzyl penicillin (1 Lac units/kg/dose, Q6H). The further treatment depends on the sensitivity pattern and clinical response. The

A B C

IV antibiotics are continued till the fever subsides, respiratory distress improves and the pleural drainage becomes non-purulent.

2. Intercostal Chest drainage (ICD): A wide bore chest tube should be inserted to drain the fluid. Thoracocentesis (needle aspiration) has no therapeutic role in managing empyema. At times, more than one ICD needs to be done because of loculations or BPF.

3. Surgery: Decortication is the most popular mode of surgery that is done throughout the world. It is supposed to give an opportunity for the lung to expand, to do pleural toilet and to tackle BPF. Another mode of surgery is Video Assisted Thoracoscopic Surgery (VATS).

While it is applicable for the fibrinopurulent stage, its exact status in the management of ET is yet to be defined.

4. Fibrinolytic agents (urokinase, streptokinase): Though studied more extensively, the cost factor and inability to use them with hypersensitive patients and BPF has limited their use.

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