Pleural Empyema
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PLEURAL EMPYEMA
THE PLEURA the visceral pleura the parietal pleura
The pleural is the serous membrane lining of two complete and independent pleural sacs or potential cavities. Each extends into the neck,the retrosternal area,and the costophrenic sinuses,and also into the interlobar fissures.
Familiarity with these ramifications of the pleural cavity can be important,unwitting violation of the pleural space,with its special anatomic and physiologic attributes,can be followed by serious consequences.
The visceral pleura
The visceral pleura is thinner,remarkably elastic,and intimately attached to the underlying lung by intrapulmonary fibrous prolongations of the deeper layer of connective tissue . It is supplied by the bronchial arteries.Sensory fibers are absent in the visceral.
The parietal pleura
The parietal pleura is thicker and easily separable from the thoracic wall because of the loose layer of areolar tissue separating it from the endothoracic fascia.It is supplied by the intercostal arteries. Sensory nerve endings are present in the costal and diaphragmatic parietal pleura.
Physiologic Characteristics
Subatmospheric in the normally nonexistent pleural space.the elastic recoil of the lung produces intrapleural negative pressures of –6 to –12cm.H2O during inspiration,and –4 to –8cm. H2O during expiration.
The secreting and absorbing surface of the pleura are substantial.Using special techniques,a rate of formation of 600 to 1000ml.of fluid per day has been observed in patients,and equal volume has been noted to be reabsorbed.
As we know,pleural cavities is potential,the accumulation of air in the pleural cavity is called pneumothorax. An accumulation of blood in the pleural cavities is called hemothorax. A collection of purulent fluid in the pleural space is called pleural empyema.
Etiology of pleural empyema These infections were commonly due to Streptococcus or Pneumococcus pneumoniae; Today gram-negative and anaerobic organism Organisms are common Tuberculous empyema resurgence.
causes of has had
empyema. a recent
Infectious process An empyema may occur by direct contamination of the pleural space through wounds of the chest (trauma or surgery) by hematologic spread (bacteremia or sepsis), by direct extension from lung parenchymal infection (parapneumonic or postpneumonic)
by rupture of an intrapulmonary abscess or infected cavity by extension from the mediastinum (esophageal perforation). Most often, empyemas are the result of a primary infectious process in the lung.
Classification They may be classified into three categories based on the chronicity of the disease process. The acute phase is characterized by pleural effusion of low viscosity and cell count.
The transitional or fibrinopurulent phase, which can begin after 48 hours, is characterized by an increase in white blood cells in the pleural effusion. The effusion is turbid, begins to loculate, and is associated with fibrin deposition on visceral and parietal pleura and progressive lung entrapment.
The organizing or chronic phase occurs after as little as 1 to 2 weeks and is associated with an ingrowth of capillaries and fibroblasts into the pleural rind and inexpansible lung.
Diagnosis
Symptoms Most patients with acute or transitional phase empyema present with symptoms of their primary lung infection (cough, fever, sputum production), followed by symptoms of pleural effusion (chest pain and dyspnea) and systemic illness (anorexia, malaise, and sweats). Fever from empyema can be very high. Without intervention, a septic course will ensue.
Chest x-ray demonstrates a pleural effusion; chest Computed tomography (CT) scan may demonstrate a complicated effusion with loculations and a heterogeneous appearance to the effusion. thoracentesis :It is confirmed by needle aspiration of the empyema with the demonstration of pus.
Gram stain (organisms), cell count (polymorphonuclear leukocytic predominance in bacterial empyema and lymphocytic predominance in tuberculous empyema), chemistries, (protein, LDH, amylase, and glucose) and pH (<7.3) all can be useful in making the diagnosis.
大量脓胸
少量脓胸
中量脓胸
Treatment Objectives of treatment control of the primary infection and its secondary manifestation. evacuation of the purulent contents of the empyema sac and eradication of sac ,to prevent chronicity. re-expansion of the underlying lung to restore function.
Treatment of empyema is dependent on its phase, but involves the identification and systemic treatment (antibiotics) of the causative organism and full drainage of the pleural space
antibiotics thoracentesis:If the purulent fluid is very thin. Tube thoracostomy may be indicated for pleural drainage if thoracentesis fails or the empyema has progressed beyond its earliest stages. Chest tube insertion, however, can be ineffective if the empyema has become loculated or organized . Full lung expansion and the prevention of complications is the goal of the procedural intervention
Chronic empyema is the result of failure to recognize or properly treat acute pneumonia or acute empyema, or failure of earlier intervention, and usually is associated with lung entrapment by a thick pleural peel or fibrothorax. This process can begin as early as 1 to 2 weeks and as late as 6 weeks after the onset of the acute illness.
The open surgical approaches for chronic empyema include variations of an open thoracostomy with rib resection or full thoracotomy with empyema evacuation and lung decortication.
Open drainage
Empyema evacuation and decortication Occasionally, pleuropneumonectomy is indicated in empyema with underlying destroyed lung (tuberculosis or bronchiectasis).
An intercostal tube
Decortication the pleura
Thanks ！
THE PLEURA the visceral pleura the parietal pleura
The pleural is the serous membrane lining of two complete and independent pleural sacs or potential cavities. Each extends into the neck,the retrosternal area,and the costophrenic sinuses,and also into the interlobar fissures.
Familiarity with these ramifications of the pleural cavity can be important,unwitting violation of the pleural space,with its special anatomic and physiologic attributes,can be followed by serious consequences.
The visceral pleura
The visceral pleura is thinner,remarkably elastic,and intimately attached to the underlying lung by intrapulmonary fibrous prolongations of the deeper layer of connective tissue . It is supplied by the bronchial arteries.Sensory fibers are absent in the visceral.
The parietal pleura
The parietal pleura is thicker and easily separable from the thoracic wall because of the loose layer of areolar tissue separating it from the endothoracic fascia.It is supplied by the intercostal arteries. Sensory nerve endings are present in the costal and diaphragmatic parietal pleura.
Physiologic Characteristics
Subatmospheric in the normally nonexistent pleural space.the elastic recoil of the lung produces intrapleural negative pressures of –6 to –12cm.H2O during inspiration,and –4 to –8cm. H2O during expiration.
The secreting and absorbing surface of the pleura are substantial.Using special techniques,a rate of formation of 600 to 1000ml.of fluid per day has been observed in patients,and equal volume has been noted to be reabsorbed.
As we know,pleural cavities is potential,the accumulation of air in the pleural cavity is called pneumothorax. An accumulation of blood in the pleural cavities is called hemothorax. A collection of purulent fluid in the pleural space is called pleural empyema.
Etiology of pleural empyema These infections were commonly due to Streptococcus or Pneumococcus pneumoniae; Today gram-negative and anaerobic organism Organisms are common Tuberculous empyema resurgence.
causes of has had
empyema. a recent
Infectious process An empyema may occur by direct contamination of the pleural space through wounds of the chest (trauma or surgery) by hematologic spread (bacteremia or sepsis), by direct extension from lung parenchymal infection (parapneumonic or postpneumonic)
by rupture of an intrapulmonary abscess or infected cavity by extension from the mediastinum (esophageal perforation). Most often, empyemas are the result of a primary infectious process in the lung.
Classification They may be classified into three categories based on the chronicity of the disease process. The acute phase is characterized by pleural effusion of low viscosity and cell count.
The transitional or fibrinopurulent phase, which can begin after 48 hours, is characterized by an increase in white blood cells in the pleural effusion. The effusion is turbid, begins to loculate, and is associated with fibrin deposition on visceral and parietal pleura and progressive lung entrapment.
The organizing or chronic phase occurs after as little as 1 to 2 weeks and is associated with an ingrowth of capillaries and fibroblasts into the pleural rind and inexpansible lung.
Diagnosis
Symptoms Most patients with acute or transitional phase empyema present with symptoms of their primary lung infection (cough, fever, sputum production), followed by symptoms of pleural effusion (chest pain and dyspnea) and systemic illness (anorexia, malaise, and sweats). Fever from empyema can be very high. Without intervention, a septic course will ensue.
Chest x-ray demonstrates a pleural effusion; chest Computed tomography (CT) scan may demonstrate a complicated effusion with loculations and a heterogeneous appearance to the effusion. thoracentesis :It is confirmed by needle aspiration of the empyema with the demonstration of pus.
Gram stain (organisms), cell count (polymorphonuclear leukocytic predominance in bacterial empyema and lymphocytic predominance in tuberculous empyema), chemistries, (protein, LDH, amylase, and glucose) and pH (<7.3) all can be useful in making the diagnosis.
大量脓胸
少量脓胸
中量脓胸
Treatment Objectives of treatment control of the primary infection and its secondary manifestation. evacuation of the purulent contents of the empyema sac and eradication of sac ,to prevent chronicity. re-expansion of the underlying lung to restore function.
Treatment of empyema is dependent on its phase, but involves the identification and systemic treatment (antibiotics) of the causative organism and full drainage of the pleural space
antibiotics thoracentesis:If the purulent fluid is very thin. Tube thoracostomy may be indicated for pleural drainage if thoracentesis fails or the empyema has progressed beyond its earliest stages. Chest tube insertion, however, can be ineffective if the empyema has become loculated or organized . Full lung expansion and the prevention of complications is the goal of the procedural intervention
Chronic empyema is the result of failure to recognize or properly treat acute pneumonia or acute empyema, or failure of earlier intervention, and usually is associated with lung entrapment by a thick pleural peel or fibrothorax. This process can begin as early as 1 to 2 weeks and as late as 6 weeks after the onset of the acute illness.
The open surgical approaches for chronic empyema include variations of an open thoracostomy with rib resection or full thoracotomy with empyema evacuation and lung decortication.
Open drainage
Empyema evacuation and decortication Occasionally, pleuropneumonectomy is indicated in empyema with underlying destroyed lung (tuberculosis or bronchiectasis).
An intercostal tube
Decortication the pleura
Thanks ！
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