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.
- Bacterial pneumonia.
- Pulmonary tuberculosis.
- Infection due to haemothorax.
- Rupture of subphrenic abscess through the diaphragm.
- Rupture of lung abscess.
- Staphylococcus aurius.
- Klebsiella pneumonia.
- Mycobacterium tuberculosis.
[A] Systemic features:
- Pyrexia: Usually high & remittent.
- Rigors, sweating, malaise & weight loss.
- Polymorphoneuclear leucocytosis, high CPR.
[B] Local features:
- Pleural pain.
- Cough and sputum- Usually because of underlying lung disease, copious purulent sputum if empyema ruptures into bronchus (Broncho-pleural fistula)
- Clinical signs of fluid in pleural space (restricted chest movement, shifted mediastinum to opposite side, stony dullness on percussion, diminished/absent breath sound.
- X-ray chest: shows
• Homogeneous opacity.
• Costophrenic angle obliteration.
• Mediastinal shifting to opposite side.
• Horizontal level of fluid.
- 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.
- Pus for –
• Culture & sensitivity (Biochemical)
• Bacteriological examination.
• Cytological exam.
• Physical exam.
- Blood for TC, DC, ESR: Neurotrophilic leucocytosis.
[A] Treatment of non-tuberculous emphysema:
- 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.
• Resect the empyema in toto, if the patient is fit and underlying lung is healthy.
• Decorticate if open drainage has been performed.
- Immediately- start anti-tubercular drugs.
- Prednisolone 20-30 mg/day for 6-8 weeks.
- Aspirate pus from the pleural space by a wide bore needle, until it cases to re-accumulate.
- Davidson’s Principles and Practice of Medicine, 21st edition