Emphyema Thoracis

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Presence of pus in the pleural space. This pus may be as thin as serous fluid or so thick that. It is impossible to aspirate even through a wide-bore needle.

Aetiology:

  1. Bacterial pneumonia.
  2. Pulmonary tuberculosis.
  3. Infection due to haemothorax.
  4. Rupture of subphrenic abscess through the diaphragm.
  5. Rupture of lung abscess.

Common organisms:

  1. Staphylococcus aurius.
  2. Klebsiella pneumonia.
  3. Bacteroids.
  4. Mycobacterium tuberculosis.

Clinical features:

[A] Systemic features:

  1. Pyrexia: Usually high & remittent.
  2. Rigors, sweating, malaise & weight loss.
  3. Polymorphoneuclear leucocytosis, high CPR.

[B] Local features:

  1. Pleural pain.
  2. Breathlessness.
  3. Cough and sputum- Usually because of underlying lung disease, copious purulent sputum if empyema ruptures into bronchus (Broncho-pleural fistula)
  4. Clinical signs of fluid in pleural space (restricted chest movement, shifted mediastinum to opposite side, stony dullness on percussion, diminished/absent breath sound.

Investigations:

  1. X-ray chest: shows
    • Homogeneous opacity.
    • Costophrenic angle obliteration.
    • Mediastinal shifting to opposite side.
    • Horizontal level of fluid.
  2. Aspiration of pus- By a wide-bore needle through an intersotal space over the area of maximum dullness on percussion. The position of empyema should be previously confirmed by radiologically or ultrasonography.
  3. Pus for –
    • Culture & sensitivity (Biochemical)
    • Bacteriological examination.
    • Cytological exam.
    • Physical exam.
  4. Blood for TC, DC, ESR: Neurotrophilic leucocytosis.

Management:

[A] Treatment of non-tuberculous emphysema:

  1. Acute: When the patient is acutely ill and pus is thin in consistency-
    • Water seal drainage: Under the ultrasound guidance insert an intercostals tube into the most dependent part of empyema space and connect to a water sealed drain system.
    • When the pus thickens a short segment of rib is resected the empyema cavity cleared of pus and a wide bore tube inserted to allow prolonged drainage.
    • If the initial aspirate reveals turbid fluid or frank pus or if loculations are on ultrasound, the tube should be put on suction (5-10 cm water), flushed with 20ml normal saline 6 hourly and streptokinase (25oooo U in 100ml normal saline) inserted daily for three days.
    • Antibiotic treatment: Inj ampicillin, Gentamicin, Metronidazole.
  2. Chronic:
    • Resect the empyema in toto, if the patient is fit and underlying lung is healthy.
    • Decorticate if open drainage has been performed.

[B] Treatment:

  1. Immediately- start anti-tubercular drugs.
  2. Prednisolone 20-30 mg/day for 6-8 weeks.
  3. Aspirate pus from the pleural space by a wide bore needle, until it cases to re-accumulate.

Reference:

  1. Davidson’s Principles and Practice of Medicine, 21st edition

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