Difference between revisions of "Empyema"

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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
*3 stages
+
*Stages
**1. 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 with single chest tube drainage unlikely
**2. Fibrinopurulent
+
*#Organizational - Takes several weeks to develop; "pleural peel" restricts lung expansion
***Loculations develop making resolution w/ single chest tube drainage unlikely
 
**3. Organizational
 
***Takes several weeks to develop; "pleural peel" restricts lung expansion
 
  
 
===Causes===
 
===Causes===
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==Clinical Features==
 
==Clinical Features==
*Usually preceded by PNA
+
*[[Fever]]
**Suspect if symptoms of PNA do not resolve
+
*[[Shortness of breath]]
 +
*Anorexia
 +
*Night sweats
 +
*Pleuritic [[chest pain]]
 +
*[[Hemoptysis]]
 +
*Recent diagnosis and/or treatment for [[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>
  
 
==Differential Diagnosis==
 
==Differential Diagnosis==
 +
*[[Pneumonia]]
 +
*[[Sarcoidosis]]
 +
*[[Tuberculosis]]
 +
*[[Pleural Effusion]]
 +
*[[Granulomatosis with polyangiitis]] (wegener's)
 +
*[[Pulmonary embolism]]
  
==Diagnosis==
+
==Evaluation==
*Aspiration of purulent material on [[thoracentesis]] and at least 1 of the following:
+
===Work Up===
*#Positive Gram stain or culture
+
*CBC
*#Pleural fluid glucose <40
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*[[CXR]]
*#pH <7.1
+
*[[Thoracentesis]]
*#LDH >1000
+
*Sputum Culture -- Acid Fast Bacilli (If TB suspected)
 +
*Pulse Ox
 +
*[[ABG interpretation]]
 +
*Blood Cultures
  
==Treatment==
+
===Evaluation===
 +
*Aspiration of grossly purulent pleural fluid on [[thoracentesis]] and at least 1 of the following:<ref>http://emedicine.medscape.com/article/807499-overview</ref>
 +
**+ 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
 +
 
 +
==Management==
 
*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
**Consider adding [[vancomycin]] if pt at risk for [[MRSA]]
+
**Consider adding [[vancomycin]] if patient at risk for [[MRSA]]
  
 
{{Chest tube size table}}
 
{{Chest tube size table}}
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==See Also==
 
==See Also==
 
*[[Pleural effusion]]
 
*[[Pleural effusion]]
 +
*[[Pneumonia]]
 +
*[[Sarcoidosis]]
 +
*[[Tuberculosis]]
  
==Source==
+
==References==
*Tintinalli
+
<references/>
  
 
[[Category:ID]]
 
[[Category:ID]]
[[Category:Pulm]]
+
[[Category:Pulmonary]]

Latest revision as of 08:03, 9 September 2016

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 with single chest tube drainage unlikely
    3. Organizational - Takes several weeks to develop; "pleural peel" restricts lung expansion

Causes

Clinical Features

Differential Diagnosis

Evaluation

Work Up

Evaluation

  • 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

Management

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

  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