Pleura empyema (Purulent pleurisy)

Description:

Pleura empyema — accumulation of purulent exudate in a pleural cavity with a secondary compression of pulmonary fabric at pleurisy.
Classification.
On localization:
1. Unilateral or bilateral
2. Limited (localized in any part of the pleural cavity surrounded with pleural unions); subtotal (the empyema is limited to two or three anatomic walls of a pleural cavity, for example costal and phrenic, or mediastinal, phrenic and costal; total (purulent exudate fills all pleural cavity)
3. Basal or paramediastinal
For the reason:
1. The metapneumonic, developed in the outcome pneumonia
2. Parapneumonic, arisen along with pneumonia
3. Postoperative, arisen as a surgery complication on bodies chest or an upper part of an abdominal cavity
On a current:
1. Acute (disease duration — to 8 weeks)
2. Chronic (duration — more than 8 weeks)
By quantity of an exudate distinguish a small pyothorax — accumulation of exudate in pleural sine (the number of 200-500 ml); an average pyothorax — accumulation of exudate to a shovel corner in the VII mezhreberye (the number of 500-1000 ml); the big pyothorax — accumulation of exudate is higher than a shovel corner (quantity more than 1 liter).
Frequency — about 320 on 100 000 population in the industrial countries.

Pleura Empyema symptoms (Purulent pleurisy):

Acute empyema of a pleura. Cough with expectoration. Long and frequent fits of coughing with department of a large number of a phlegm demonstrate existence of bronchopleural fistula. Thorax pain is minimum expressed at quet breathing, sharply amplifies during a full deep breath. Asthma. Disturbance of voice trembling or clear egophony. The stupid or dulled percussion sound on the party of defeat, the upper bound of dullness corresponds to Ellis-Damuazo-Sokolov's line. Easing or lack of breath at auscultation over area of an exudate. Bronchial breath over the squeezed lung, adjacent to an exudate. Erubescence arises only at break of pus from an empyema cavity under skin. The general state progressively worsens: weakness, appetite loss, weight loss, gektichesky body temperature, frequent pulse.

Chronic empyema of a pleura. Body temperature can be subfebrile or normal, at disturbance of outflow of pus becomes gektichesky. Cough with an otkhozhdeniye of a purulent phlegm. Deformation of a thorax on the party of defeat because of narrowing of intercostal spaces. At children scoliosis develops. Percussion data depend on a cavity degree of admission pus, respiratory noise over a cavity are not listened.

Pleura Empyema reasons (Purulent pleurisy):

Vozbuditeli:stafilokokki, pneumococci, facultative and strict anaerobes.
Direct way of penetration of an infection:
1. Lung injury
2. Thorax wounds
3. Rupture of a gullet
4. Break of abscess, gangrene of a lung, cavity
5. Pneumonia
6. Tuberculosis
7. Progressing of bacterial damage of lungs (abscess or bacterial destruction)
8. Bronchiectasias
9. A resection of lungs and other operations on bodies of a thorax
10. Pheumothorax
11. Acute mediastinites
12. Osteomyelites of edges and vertebrae
Indirect way of penetration of an infection:
1. Subphrenic abscess
2. Acute pancreatitis
3. Liver abscesses
4. Inflammation of soft tissues and bone framework of a chest wall
5. Idiopathic empyema.

Treatment of the Empyema of a pleura (Purulent pleurisy):

General principles:
Treatment of a basic disease.
Early full removal of exudate from a pleural cavity by means of a puncture or at drainage.
Raspravleniye easy use of continuous aspiration.
LFK.
Rational antibioticotherapia.

Conservative therapy. Early acute empyemas — are necessary repeated pleurocenteses with aspiration of purulent exudate and an adequate antibioticotherapia (clindamycin, цефтриаксон in combination with metronidazole; it is possible to appoint aminoglycosides, monobaktama, karbapenema). Washing of a pleural cavity with introduction of antibiotics, proteolytic enzymes. The immunostimulating therapy.  Ural federal district blood. Infusional therapy and partial parenteral food. The created empyemas with dense purulent exudate — the indication to the long closed drainage.

Surgical treatment.

Acute empyemas. Free empyemas of a pleura — constant washing of a pleural cavity through two tubes, in 2–3 days suck away contents through both tubes and try to obtain a full raspravleniye of a lung. The wide thoracotomy with a resection of edges, a toilet of a pleural cavity and the subsequent drainage is shown in the presence of big sequesters and clots in a pleural cavity. In the presence of bronchial fistula — a tamponade of the corresponding bronchial tube. At inefficiency of above-mentioned actions the early decortication of a lung is shown.

Chronic empyema.  Sanitation of an empyema through a drainage with active aspiration. In the presence of bronchial fistula: the same + bronchial tube tamponade. At inefficiency — surgical treatment: репневмолиз, a lung decortication, a scraping of a piogenic layer to the fibrous capsule, sewing up of bronchial fistula or a resection of an affected area of a lung. At a tubercular empyema the volume of operation is increased — carry out a total parietal pleurectomy.
The forecast at timely treatment favorable, at a chronic empyema can be adverse.