Difference between revisions of "Empyema"

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*Stages
 
*Stages
 
*#Exudative - Free-flowing pleural effusion amenable to chest tube drainage; may only last <48hr
 
*#Exudative - 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 - Loculations develop making resolution with single chest tube drainage unlikely
 
*#Organizational - Takes several weeks to develop; "pleural peel" restricts lung expansion
 
*#Organizational - Takes several weeks to develop; "pleural peel" restricts lung expansion
  
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*Complications of [[thoracic trauma|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
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*[[Hemoptysis]]
 
*[[Hemoptysis]]
 
*Recent diagnosis and/or treatment for [[Pneumonia]]
 
*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>
+
*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==
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*[[Tuberculosis]]
 
*[[Tuberculosis]]
 
*[[Pleural Effusion]]
 
*[[Pleural Effusion]]
*[[Wegener's granulomatosis]]
+
*[[Granulomatosis with polyangiitis]] (wegener's)
 
*[[Pulmonary embolism]]
 
*[[Pulmonary embolism]]
  
==Diagnosis==
+
==Evaluation==
 
===Work Up===
 
===Work Up===
 
*CBC
 
*CBC
*CXR
+
*[[CXR]]
 
*[[Thoracentesis]]
 
*[[Thoracentesis]]
 
*Sputum Culture -- Acid Fast Bacilli (If TB suspected)
 
*Sputum Culture -- Acid Fast Bacilli (If TB suspected)
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**LDH >1000 IU/mL
 
**LDH >1000 IU/mL
  
==Treatment==
+
==Management==
 
*Treat underlying disease
 
*Treat underlying disease
*O2 if [[Hypoxemia]]
+
*[[O2]] if [[Hypoxemia]]
 
*Perform [[thoracentesis]] vs. [[chest tube]] if evidence of respiratory distress
 
*Perform [[thoracentesis]] vs. [[chest tube]] if evidence of respiratory distress
 
**May need Video-Assisted Thoracic surgery (VATS)
 
**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}}

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