Difference between revisions of "Empyema"

(Background)
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==Background==
 
==Background==
*Pleural space infections with positive Gram stain or culture OR parapneumonic effusions without pleural fluid sampling
+
*Pleural space infections with + Gram stain/culture '''OR''' parapneumonic effusions without pleural fluid sampling
 
*Stages
 
*Stages
*#Exudative
+
*#Exudative - Free-flowing pleural effusion amenable to chest tube drainage; may only last <48hr
*#*Free-flowing pleural effusion amenable to chest tube drainage; may only last <48hr
+
*#Fibrinopurulent - Loculations develop making resolution w/ single chest tube drainage unlikely
*#Fibrinopurulent
+
*#Organizational - Takes several weeks to develop; "pleural peel" restricts lung expansion
*#*Loculations develop making resolution w/ single chest tube drainage unlikely
+
 
*#Organizational
+
==Presentation==
*#*Takes several weeks to develop; "pleural peel" restricts lung expansion
+
*Fever
 +
*Shortness of breath
 +
*Anorexia
 +
*Night sweats
 +
*Pleuritic chest pain
 +
*Hemoptysis
 +
*Recent dx and/or treatment of [[Pneumonia]]
 +
*History of penetrating chest trauma or diaphragmatic injury<ref>Barmparas G, DuBose J, Teixeira PG, Recinos G, Inaba K, Plurad D. Risk factors for empyema after diaphragmatic injury: results of a National Trauma Databank analysis. J Trauma. Jun 2009;66(6):1672-6</ref>
  
 
===Causes===
 
===Causes===
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==Differential Diagnosis==
 
==Differential Diagnosis==
 +
*[[Pneumonia]]
 +
*[[Sarcoidosis]]
 +
*[[Tuberculosis]]
 +
*[[Pleural Effusion]]
 +
*[[Wegener Granulomatosis]]
 +
*[[Pulmonary embolism]]
 +
 +
==Work Up==
 +
*CBC
 +
*CXR
 +
*[[Thoracentesis]]
 +
*Sputum Culture -- Acid Fast Bacilli (If TB suspected)
 +
*Pulse Ox
 +
*[[ABG interpretation]]
 +
*Blood Cultures
  
 
==Diagnosis==
 
==Diagnosis==
*Aspiration of purulent material on [[thoracentesis]] and at least 1 of the following:
+
*Aspiration of grossly purulent pleural fluid on [[thoracentesis]] and at least 1 of the following:<ref>http://emedicine.medscape.com/article/807499-overview</ref>
*#Positive Gram stain or culture
+
**+ Gram stain or culture
*#Pleural fluid glucose <40
+
**WBC count > 50,000 cells/µL (or polymorphonuclear leukocyte count of 1,000 IU/dL)
*#pH <7.1
+
**Pleural fluid glucose <60
*#LDH >1000
+
**pH <7.2
 +
**LDH >1000 IU/mL
  
 
==Treatment==
 
==Treatment==
 
*Treat underlying disease
 
*Treat underlying disease
*Perform [[thoracentesis]] versus [[chest tube]] if evidence of respiratory distress
+
*O2 if [[Hypoxemia]]
 +
*Perform [[thoracentesis]] vs. [[chest tube]] if evidence of respiratory distress
 +
**May need Video-Assisted Thoracic surgery (VATS)
 
*[[Antibiotics]]
 
*[[Antibiotics]]
 
**[[Piperacillin-tazobactam]] 3.375-4.5gm q6hr IV or [[imipenem]] 0.5-1gm q6hr
 
**[[Piperacillin-tazobactam]] 3.375-4.5gm q6hr IV or [[imipenem]] 0.5-1gm q6hr
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==See Also==
 
==See Also==
 
*[[Pleural effusion]]
 
*[[Pleural effusion]]
 +
*[[Pneumonia]]
 +
*[[Sarcoidosis]]
 +
*[[Tuberculosis]]
  
==Source==
+
==References==
*Tintinalli
+
<ref></ref>
  
 
[[Category:ID]]
 
[[Category:ID]]
 
[[Category:Pulm]]
 
[[Category:Pulm]]

Revision as of 15:37, 8 June 2015

Background

  • Pleural space infections with + Gram stain/culture OR parapneumonic effusions without pleural fluid sampling
  • Stages
    1. Exudative - Free-flowing pleural effusion amenable to chest tube drainage; may only last <48hr
    2. Fibrinopurulent - Loculations develop making resolution w/ single chest tube drainage unlikely
    3. Organizational - Takes several weeks to develop; "pleural peel" restricts lung expansion

Presentation

  • Fever
  • Shortness of breath
  • Anorexia
  • Night sweats
  • Pleuritic chest pain
  • Hemoptysis
  • Recent dx and/or treatment of Pneumonia
  • History of penetrating chest trauma or diaphragmatic injury[1]

Causes

Clinical Features

  • Usually preceded by PNA
    • Suspect if symptoms of PNA do not resolve

Differential Diagnosis

Work Up

Diagnosis

  • Aspiration of grossly purulent pleural fluid on thoracentesis and at least 1 of the following:[2]
    • + Gram stain or culture
    • WBC count > 50,000 cells/µL (or polymorphonuclear leukocyte count of 1,000 IU/dL)
    • Pleural fluid glucose <60
    • pH <7.2
    • LDH >1000 IU/mL

Treatment

Adult Chest Tube Sizes

Chest Tube Size Type of Patient Underlying Causes
Small (8-14 Fr)
  • Alveolar-pleural fistulae (small air leak)
  • Iatrogenic air
Medium (20-28 Fr)
  • Bronchial-pleural fistulae (large air leak)
  • Malignant fluid
Large (36-40 Fr)
  • Bleeding (Hemothorax/hemopneumothorax)
  • Thick pus

See Also

References

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refs with no name must have content

  1. Barmparas G, DuBose J, Teixeira PG, Recinos G, Inaba K, Plurad D. Risk factors for empyema after diaphragmatic injury: results of a National Trauma Databank analysis. J Trauma. Jun 2009;66(6):1672-6
  2. http://emedicine.medscape.com/article/807499-overview