Difference between revisions of "Empyema"

(Created page with "==Background== *Empyema is pus in the pleural space **Pleural space infections with positive Gram stain or culture OR **Parapneumonic effusions without pleural fluid sampling *3 ...")
 
 
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==Background==
 
==Background==
*Empyema is pus in the pleural space
+
*Pleural space infections with + Gram stain/culture '''OR''' parapneumonic effusions without pleural fluid sampling
**Pleural space infections with positive Gram stain or culture OR
+
*Stages
**Parapneumonic effusions without pleural fluid sampling
+
*#Exudative - Free-flowing pleural effusion amenable to chest tube drainage; may only last <48hr
*3 stages
+
*#Fibrinopurulent - Loculations develop making resolution with single chest tube drainage unlikely
**1. Exudative
+
*#Organizational - Takes several weeks to develop; "pleural peel" restricts lung expansion
***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
 
  
==Causes==
+
===Causes===
#Pneumonia
+
*[[Pneumonia]]
#Complications of chest or abdominal trauma
+
*Complications of [[thoracic trauma|chest]] or [[abdominal trauma]]
#Esophageal perforation
+
*[[Esophageal perforation]]
#Extension from lung abscess
+
*Extension from [[lung abscess]]
#Osteomyelitis or other near pleural infections
+
*[[Osteomyelitis]] or other near pleural infections
#Hemothorax, chylothorax, or hydrothorax that becomes infected
+
*[[Hemothorax]], [[chylothorax]], or [[hydrothorax]] that becomes infected
  
==Diagnosis==
+
==Clinical Features==
*Usually preceded by PNA
+
*[[Fever]]
**Suspect if symptoms of PNA do not resolve
+
*[[Shortness of breath]]
*Diagnostic criteria
+
*Anorexia
**Aspiration of purulent material on thoracentesis and at least 1 of the following:
+
*Night sweats
***1. Positive Gram stain or culture
+
*Pleuritic [[chest pain]]
***2. Pleural fluid glucose <40
+
*[[Hemoptysis]]
***3. pH <7.1
+
*Recent diagnosis and/or treatment for [[Pneumonia]]
***4. LDH >1000
+
*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>
  
==Treatment==
+
==Differential Diagnosis==
 +
*[[Pneumonia]]
 +
*[[Sarcoidosis]]
 +
*[[Tuberculosis]]
 +
*[[Pleural Effusion]]
 +
*[[Granulomatosis with polyangiitis]] (wegener's)
 +
*[[Pulmonary embolism]]
 +
 
 +
==Evaluation==
 +
===Work Up===
 +
*CBC
 +
*[[CXR]]
 +
*[[Thoracentesis]]
 +
*Sputum Culture -- Acid Fast Bacilli (If TB suspected)
 +
*Pulse Ox
 +
*[[ABG interpretation]]
 +
*Blood Cultures
 +
 
 +
===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 drainage if e/o respiratory distress
+
*[[O2]] if [[Hypoxemia]]
*Abx
+
*Perform [[thoracentesis]] vs. [[chest tube]] if evidence of respiratory distress
**Piperacillin-tazobactam 3.375-4.5gm q6hr IV or imipenem 0.5-1gm q6hr
+
**May need Video-Assisted Thoracic surgery (VATS)
**Consider adding vancomycin if pt at risk for MRSA
+
*[[Antibiotics]]
 +
**[[Piperacillin-tazobactam]] 3.375-4.5gm q6hr IV or [[imipenem]] 0.5-1gm q6hr
 +
**Consider adding [[vancomycin]] if patient at risk for [[MRSA]]
 +
 
 +
{{Chest tube size table}}
  
 
==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 15:31, 12 October 2019

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