Empyema

Introduction The pleural cavity is infected by a purulent pathogen, resulting in the accumulation of purulent exudate, called empyema. According to the extent of the lesion, it is divided into total empyema and localized empyema. Total empyema refers to pus occupying the entire pleural cavity. Localized empyema refers to the accumulation of pus in the lungs between the chest and the diaphragm or the mediastinum, or between the lungs and the lungs, also known as the wrapped empyema. Most of the empyema is secondary, the pathogen is from the intrathoracic or intrathoracic organs or interstitial infections, such as bacterial pneumonia, bronchiectasis, lung abscess or liver abscess, underarm abscess, mediastinal abscess, renal abscess Break into the chest and so on.

Cause

(A) pulmonary infection: about 50% of acute empyema secondary to pulmonary inflammatory lesions. Lung abscess can directly invade the pleura or ulceration to produce acute empyema.

(B) adjacent tissue purulent lesions: mediastinal abscess, underarm abscess or liver abscess, pathogenic bacteria through lymphoid tissue or directly through the invading pleural cavity, can form unilateral or bilateral empyema.

(C) chest surgery: postoperative empyema and bronchopleural fistula or esophageal anastomotic fistula combined. A small percentage is due to intraoperative contamination or postoperative incision infection into the chest.

(4) Chest trauma: After the chest penetrating injury, due to the foreign matter such as shrapnel and clothes debris, the pathogenic bacteria can be brought into the pleural cavity, and often there is a hemothorax, which is easy to form a purulent infection.

(5) sepsis or sepsis: bacteria can reach the chest through the blood circulation to produce empyema, which is more common in infants or frail patients.

(6) Others: such as spontaneous pneumothorax, or other causes of pleural effusion, after repeated puncture or drainage after infection; spontaneous esophageal rupture, mediastinal teratoma infection, can be inserted into the chest can form empyema.

Pathophysiology After infection with bacteria in the pleural cavity, it first causes pleural congestion and edema, edema, loss of luster and lubricity in the visceral and parietal layers. The exudate contains polymorphonuclear neutrophils and fibrin, and the initial stage is a thin clear liquid. Gradually, due to the increase of fibrin, the appearance of pus cells becomes turbid, and the amount of pus increases and increases, so that the lungs are under pressure. Sinking, and pushing the mediastinum to the opposite side, causing disordered breathing cycle. If there is bronchopleural fistula or esophageal anastomotic fistula, tension pus can be formed, and the effect on respiratory and circulatory function is more obvious. At the same time, fibrin is deposited on the surface of the visceral and parietal pleura to form a fibrous membrane. The initial quality is soft and brittle. As the pus becomes thicker, the fibrous membrane becomes more mechanized, thickening and toughness are enhanced, and fibrous sheets are formed, and the lung tissue is fixed and compressed. Limit lung expansion. The pleural cavity infection is extensive and the area is enlarged. The development involves the entire pleura and is a full empyema. If the infection is more limited or the drainage is incomplete, adhesions are formed around the body, so that the pus is limited to a certain range, that is, the localized or encapsulated empyema is formed. The common parts are between the lungs, the diaphragm, the posterior part of the pleural cavity, and the mediastinum. One or more places. Its pressure on the lung tissue and mediastinum is not as severe as that of the whole empyema, and the respiratory cycle function is also less severe than the total empyema. Before the widespread use of antibiotics, the pathogens of empyema were mostly pneumococci and streptococci, and later Staphylococcus aureus was the main cause, and the infection of children under 2 years old was 92%. Patients with bronchial pleural effusion have mixed infections such as anaerobic infection, septic purulent, pus containing necrotic tissue, and have a foul odor. Tuberculosis involving the pleura or cavities can form tuberculous empyema.

an examination

Related inspection

Blood routine lung function check sputum color

The diagnosis of empyema must be done by chest puncture and pus. And for smear microscopy, bacterial culture and antibiotic sensitivity test, according to the selection of effective antibiotic treatment.

Physical examination can be seen in the face, sometimes not lying, the affected side of the chest is weakened, the percussion is voiced and has a slap pain, and the auscultation breath sounds weakened or disappeared. The white blood cell count increased, the neutrophils increased to more than 80%, and the nucleus shifted to the left. Chest x-ray examination varies according to the amount and location of pleural effusion. A small amount of pleural effusion can show the blurred shadow of the disappearance of the rib sinus; when the amount of fluid is too much, the lung tissue is collapsed, and the effusion has a curved shadow with a high outer and inner low; a large amount of effusion causes a uniform blurred shadow on the affected side. The mediastinum is displaced to the healthy side; when the pus is confined between the lungs, or between the lungs and the mediastinum, transverse or chest wall, the localized shadow does not change with the change of body position, the edge is smooth, and sometimes it is difficult to distinguish from the atelectasis. Gastric fluid plane can be seen in patients with bronchopleural fistula or esophageal anastomosis.

Differential diagnosis

According to different pathogens, it can be divided into non-specific empyema and specific empyema.

General bacterial infections are non-specific empyema, tuberculosis or amoeba infection is specific empyema, and can also be directly called tuberculous empyema or amoebic empyema. The empyema caused by the infection of mixed bacteria including anaerobic bacteria is dark gray, thick and stinking, and is called spastic empyema. The course of the disease is acute empyema within 4-6 weeks, and the early stage is mainly a large amount of exudate, which is called exudation period. In this period, the exudate is removed, the infection is controlled, the empyema can be cured, and the lung can be well re-expanded. If the exudate is not removed, a large amount of fibrin is deposited, and the cellulose film is formed into the fibrin stage, and then the cellulose film is mechanicalized to form a fiberboard and calcified, and then enters the empyema stage, which is a chronic empyema. Thoracoscopy is available for early wrapped empyema, open the separation, remove the fibrous membrane on the lung surface, and accurately place the drainage tube. Nutritional support therapy can improve the body's nutritional status and improve the body's resistance. If the treatment of acute empyema is not timely, inappropriate or incomplete, it will be converted to chronic empyema. The pleural hypertrophy of chronic empyema forms fibrous plate, mechanical fixation, thoracic collapse, narrow intercostal space, and limited lung activity, which seriously affects lung function. The formation of a large amount of pus and the consumption of persistent fever make the patient present a consumable condition, and the severe one shows the dyscrasia. Chronic empyema with fiberoptic resection, pleural pneumonectomy or thoracoplasty, pedicled omental filling, pectoralis major or latissimus dorsi flap surgery, thoracoscopic or thoracoscopic assisted small incision pleural fiberboard Stripping is currently the main way to treat chronic empyema in our department. To eliminate the primary pathogenic factors and close the abscess, we must use systemic support therapy before surgery to improve the general condition, correct the negative nitrogen balance and restore the balance of water and electricity.

The diagnosis of empyema must be done by chest puncture and pus. And for smear microscopy, bacterial culture and antibiotic sensitivity test, according to the selection of effective antibiotic treatment. Physical examination can be seen in the face, sometimes not lying, the affected side of the chest is weakened, the percussion is voiced and has a slap pain, and the auscultation breath sounds weakened or disappeared. The white blood cell count increased, the neutrophils increased to more than 80%, and the nucleus shifted to the left. Chest x-ray examination varies according to the amount and location of pleural effusion. A small amount of pleural effusion can show the blurred shadow of the disappearance of the rib sinus; when the amount of fluid is too much, the lung tissue is collapsed, and the effusion has a curved shadow with a high outer and inner low; a large amount of effusion causes a uniform blurred shadow on the affected side. The mediastinum is displaced to the healthy side; when the pus is confined between the lungs, or between the lungs and the mediastinum, transverse or chest wall, the localized shadow does not change with the change of body position, the edge is smooth, and sometimes it is difficult to distinguish from the atelectasis. Gastric fluid plane can be seen in patients with bronchopleural fistula or esophageal anastomosis.

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