Empyema: Difference between revisions

Revision as of 20:58, 13 May 2015

Background

Pleural space infections with positive Gram stain or culture OR parapneumonic effusions without pleural fluid sampling
3 stages
- 1. Exudative
  - 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

Pneumonia
Complications of chest or abdominal trauma
Esophageal perforation
Extension from lung abscess
Osteomyelitis or other near pleural infections
Hemothorax, chylothorax, or hydrothorax that becomes infected

Clinical Features

Usually preceded by PNA
- Suspect if symptoms of PNA do not resolve

Differential Diagnosis

Diagnosis

Aspiration of purulent material on thoracentesis and at least 1 of the following:
1. Positive Gram stain or culture
2. Pleural fluid glucose <40
3. pH <7.1
4. LDH >1000

Treatment

Treat underlying disease
Perform thoracentesis versus chest tube if evidence of respiratory distress
Antibiotics
- Piperacillin-tazobactam 3.375-4.5gm q6hr IV or imipenem 0.5-1gm q6hr
- Consider adding vancomycin if pt at risk for MRSA

Adult Chest Tube Sizes

Chest Tube Size	Type of Patient	Underlying Causes
Small (8-14 Fr)	Most spontaneous pneumothorax (primary and secondary) Most iatrogenic pneumothorax	Alveolar-pleural fistulae (small air leak) Iatrogenic air
Medium (20-28 Fr)	Traumatic pneumothorax Traumatic hemothorax ("any acute hemothorax visible on chest radiograph")^[1]^[2] Pneumothorax on mechanical ventilation Non-traumatic tension pneumothorax Malignant effusion	Trauma/bleeding (hemothorax/hemopneumothorax) Bronchial-pleural fistulae (large air leak) Malignant fluid
Large (36-40 Fr)	Empyema	Thick pus

Source

Tintinalli

Authors:

[1] Inaba Et. al J Trauma Acute Care Surg. 2012 Feb;72(2):422-7.

[2] Advanced Trauma Life Support® Update 2019: Management and Applications for Adults and Special Populations.

[1]

[2]

@@ Line 9: / Line 9: @@
 ***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
 **Suspect if symptoms of PNA do not resolve
-*Diagnostic criteria
-**Aspiration of purulent material on thoracentesis and at least 1 of the following:
+==Differential Diagnosis==
-***1. Positive Gram stain or culture
-***2. Pleural fluid glucose <40
+==Diagnosis==
-***3. pH <7.1
+*Aspiration of purulent material on [[thoracentesis]] and at least 1 of the following:
-***4. LDH >1000
+*#Positive Gram stain or culture
+*#Pleural fluid glucose <40
+*#pH <7.1
+*#LDH >1000
 ==Treatment==
 *Treat underlying disease
-*Perform thoracentesis versus chest tube drainage if e/o respiratory distress
+*Perform [[thoracentesis]] versus [[chest tube]] if evidence of respiratory distress
-*Abx
+*[[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 pt at risk for [[MRSA]]
+{{Chest tube size table}}
 ==See Also==
-*[[Pleural Effusion]]
+*[[Pleural effusion]]
 ==Source==