Empyema of the pleura

Empyema of the pleura (purulent pleurisy, pyotorax) - accumulation of pus in the pleural cavity with secondary compression of the lung tissue. Direct path of infection; Trauma of the lung, injury of the chest wall, rupture of the esophagus (posttraumatic empyema), pneumonia, tuberculosis, abscess or gangrene of the lung, bronchiectasis, lung resection, pneumothorax. The most frequent are para- and metapneumonic empyema. Indirect path of infection: subdiaphragmatic abscess, acute pancreatitis, liver abscesses, inflammation of soft tissues and bone structure of the chest wall. Pathogens: staphylococci, pneumococci, facultative and obligate anaerobes (Pseudomonas aeruginosa). As a result of inflammation, there is hyperemia and leukocyte infiltration of pleural sheets, further deposition of fibrin, clinically manifested by the appearance of pleural friction noise and pain disappearing with the continued accumulation of fluid in the pleural cavity. Gradually the pleural sheets thicken, moorings are formed, contributing to the organization of the cavity of the empyema, one- or two-sided, limited or total, more often located basally, less often paramediastically.

Complications. Perforation inward with the formation of bronchopleural fistula, less often outward, through the intercostal spaces - accumulation of pus in the soft tissues of the chest wall (empyema necessitatis), septicopyemia.

Symptoms, course. The clinical picture is masked by the symptoms of pneumonia, therefore, with metapneumonic empyema, its signs after the light interval are more easily recognized than in post-pneumonic empyema, shaded by the current pneumonia. The shortening of percussion sound, the disappearance of respiratory noises, and weakened vocal tremor are also determined. X-ray examination of standing reveals basal obscuration with a horizontal level with putrefactive infection or bronchopleural fistula - pyopneumothorax. Redness of the skin is observed only when pus breaks out of the cavity of the empyema under the skin. The general condition progressively worsens as a result of a purulent-resorptive fever: weakness, loss of appetite, weight loss, hectic temperature, frequent pulse, high leukocytosis with a shift of the formula to the left, hypo and dysproteinemia.

Treatment. Already at the beginning of treatment of a patient with pneumonia complicated by pleural effusions, one should foresee the possibility of developing purulent pleurisy, so rational selection of antibiotics and timely drainage of the pleural cavity are necessary. Selection of antibiotics is carried out by analysis of sputum with Gram stain. Based on the results of coloring, select the appropriate antibiotics, the early application of which promotes resorption of pleural effusion. The decision to drain the pleural cavity is based on an evaluation of the type of fluid obtained from pleural puncture. The presence of pus serves as an imperative indication to drainage along the puncture needle with the help of a trocar, through the lumen of which a drainage tube is connected to the Bylau system. Through the drainage tube, the empyema cavity is washed with antiseptics followed by a daily dose of antibiotics. Especially dangerous empyema of the pleura in the elderly and those weakened by protracted pneumonia. Hospitalization emergency in the surgical department, even with a suspected pleural ampia.

The prognosis for timely treatment is favorable.