Empyema of the pleura

Inflammatory lesions of pleural sheets, or empyema of the pleura - is a pathology that is accompanied by the formation of a purulent exudate.

Consider the causes, pathogenesis, signs of the disease and complications, the main methods of diagnosis and treatment.

[1], [2], [3], [4], [5], [6]

Causes of the pleural empyema

The disease is a complication of diseases such as: pneumonia, damage to the pleura and lungs, abscess, gangrene, the transition of inflammation from neighboring and distant inflammatory foci.

Very often, the disorder is caused by the formation of serous exudate in the pleural cavity, which gradually takes the form of pus. This leads to intoxication of the body and aggravates the course of the disease.

Various diseases of the respiratory system cause a number of pathological consequences, diagnosis, and whose treatment is significantly complicated. The causes of pleural empyema are divided into three groups, consider them:

1. Primary
   • Post-trauma - chest injuries, injuries, thoracoabdominal injuries.
   • Postoperative - pathology with / without bronchial fistula.
2. Secondary
   • Diseases of the sternum organs - pneumonia, gangrene and abscess of the lungs, cysts, spontaneous pneumothorax, lung cancer, secondary suppuration.
   • Diseases of the retroperitoneal space and abdominal cavity - peritonitis, cholecystitis, appendicitis, ulcerative lesions of the duodenum and stomach, abscesses.
   • Metastatic pyotorax is a purulent process of any localization complicated by infection and sepsis (phlegmon, osteomyelitis).
3. Cryptogenic empyema with non-etiologic etiology.

The disease is associated with the spread of suppuration from neighboring tissues and organs (lungs, chest wall, pericardium). This occurs with such diseases as:

• Pericarditis.
• Transfer of infection with lymph and blood from other foci of inflammation (tonsillitis, sepsis).
• Abscess of the liver.
• Osteomyelitis of the ribs and spine.
• Cholecystitis.
• Pancreatitis.
• Pericarditis.
• Mediastinitis.
• Pneumothorax.
• Injuries, injuries, complications after operations.
• Pneumonia, gangrene and lung abscess, tuberculosis and other infectious diseases of the respiratory system.

The main factor for the development of the disease is a decrease in the protective properties of the immune system, ingestion into the pleural cavity of blood or air and microbial flora (pyogenic cocci, tubercle bacilli, bacilli). The acute form can arise due to microbial infection and suppuration of effusion in inflammatory processes in the lungs.

[7], [8], [9], [10], [11], [12]

Pathogenesis

Any disease has a developmental mechanism that is accompanied by a certain symptomatology. The pathogenesis of pyotorax is associated with a primary inflammatory disease. In the primary form of the disease, inflammation is in the pleural cavity, and in the secondary - it is a complication of another inflammatory-purulent process.

• Primary empyema appears due to a violation of the barrier function of pleural sheets and the introduction of a harmful microflora. As a rule, this happens with open chest injuries or after operations on the lungs. In the development of pathology, an important role is played by primary surgical care. If it is provided in the first hours of malaise, then pyothorax occurs in 25% of patients.
• Secondary form in 80% of cases is a consequence of chronic and acute purulent lung lesions, pneumonia. Initially, pneumonia can occur simultaneously with purulent pleurisy. Another variant of the development of the disease is the spread of the inflammatory process to the pleura from the tissues of adjacent organs and the chest wall. In rare cases, the disorder provokes purulent and inflammatory diseases of the abdominal organs. Malicious microorganisms penetrate the abdomen into the pleura through the lymphatic vessels or the hematogenous way.

In this case, the pathogenesis of acute fores of purulent lesions of the pleura is rather complicated and is determined by a decrease in the immunobiological reactivity of the organism with the penetration of harmful microorganisms. In this case, the changes can gradually increase with the development of pleurisy (fibrinous, fibrinous-purulent, exudative) or acutely. The severe form of purulent intoxication causes disturbances in the functions of the endocrine organs, which affects the work of the whole organism pathologically.

[13], [14], [15], [16], [17]

Symptoms of the pleural empyema

The symptoms of the disorder gradually increase, and the exudate accumulates, mechanically squeezing the lungs and the heart. This causes displacement of the organs in the opposite direction and causes disturbances in respiratory and cardiac activity. Without timely and proper treatment, purulent contents break through the bronchi and skin, causing external and bronchial fistulas.

The clinical picture of the disease depends on its type and cause of appearance. Consider the symptoms of pleural empyema by the example of acute and chronic form.

Acute inflammation:

• Cough with sputum separation with an unpleasant odor.
• Pain in the chest, which weakens with quiet breathing and intensifies with a deep breath.
• Cyanosis - on the skin of the lips and hands appears a blue tint, indicating a lack of oxygen.
• Shortness of breath and rapid aggravation of general condition.

Chronic empyema:

• Subfebrile body temperature.
• Cough with purulent sputum.
• Pain in the chest is not expressed.
• Deformation of the chest.

First signs

At an early stage, all forms of purulent process in the pleura have a similar symptomatology. The first signs are manifested in the form of a cough with separation of sputum, shortness of breath and pain in the chest, fever and intoxication.

At the initial stage, a part of the exudate that has accumulated in the chest cavity is absorbed and only fibrin remains on the walls of the pleura. Later, the lymphatic cracks are clogged with fibrin and squeezed by the puffiness that appears. In this case, the absorption of exudate from the pleural cavity ceases.

That is, the first and main sign of the disease is accumulation of exudate, puffiness and squeezing of organs. This leads to a displacement of the mediastinal organs and a sharp disruption of the functions of the cardiovascular and respiratory system. In the acute form of pyotorax, the inflammation pathologically progresses, increasing intoxication of the body. Against this background dysfunction of vital organs and systems develops.

[18], [19], [20]

Acute Pleural Empyema

The inflammatory process in the pleura, which lasts no longer than one month, is accompanied by accumulation of pus and symptoms of septic intoxication - this is an acute empyema. The disease is closely related to other lesions of the bronchopulmonary system (gangrene and lung abscess, pneumonia, bronchiectasis). Piotrax has a broad microbial spectrum, pleural damage can be either primary or secondary.

Symptoms of acute pleural empyema:

• Pain in the chest, worse when inhaled, coughing and changing the position of the body.
• Shortness of breath at rest.
• Cyanosis of the lips, earlobes and hands.
• Increased body temperature.
• Tachycardia over 90 beats per minute.

Treatment should be comprehensive. In the early stages of therapy, the contents of the pleura should be removed to spread the lung and obturate fistulas. If the empyema is common, then the contents are removed with the help of thoracocentesis, and then drained. The most effective method of sanitation is the regular washing of the pleural cavity with an antiseptic solution with broad-spectrum antibiotics and proteolytic enzymes.

With progressive empyema, various pathological complications and inefficiency of drainage, surgical treatment is performed. The patients are shown a wide thoracotomy and an open sanation, after which the thoracic cavity is drained and sutured.

[21], [22], [23], [24], [25], [26]

Chronic pleural empyema

A prolonged accumulation of pus in the chest cavity is indicated by a stagnant inflammatory process requiring medical intervention. Chronic pleural empyema lasts longer than two months, characterized by penetration into the pleural cavity of the infectious agent and is a complication of the acute form. The main causes of the disease are the mistakes made in the treatment of acute pyotorax and other features of the disease.

Symptoms:

• Subfebrile temperature.
• Cough with purulent sputum.
• Deformation of the chest from the lesion due to narrowing of the intercostal spaces.

Chronic inflammation leads to the formation of thick cicatricial adhesions, which retain the purulent cavity, and keep the lung in a sleeping state. Gradual resorption of exudate is accompanied by the deposition of filaments of fibrin on the pleura sheets, which leads to their gluing and obliteration.

[27], [28], [29], [30], [31], [32]

Forms

Pythorax can be either bilateral or one-sided, but the latter form is more common.

Since there are many forms and types of inflammatory changes in the pleura, a special classification has been developed. The empyema of the pleura is divided according to etiology, the nature of complications and prevalence.

On the etiology:

• Infectious - pneumococcal, streptococcal, staphylococcal.
• Specific - actinomycotic, tubercular, syphilitic.

Duration:

• Sharp - up to two months.
• Chronic - more than two months.

By prevalence:

• Constricted (limited) - inflammation only on one wall of the pleural cavity.
  • Diaphragmatic.
  • Mediastinal.
  • The apical.
  • The costal.
  • The interlobar.
• Common - the pathological process struck two or more walls of the pleura.
• Total - the entire pleural cavity is affected.

By the nature of the exudate:

• Purulent.
• Serous.
• Serous fibrous.

By the severity of the current:

• Lungs.
• Of moderate severity.
• Heavy.

Diseases can be classified according to the cause and nature of the inflammatory process and a number of other characteristics characteristic of the ailment.

According to the international classification of diseases of the 10th revision, empyema of the pleura enters the category J00-J99 of respiratory diseases.

Let's consider more detailed a code on mb 10:

J85-J86 Purulent and necrotic conditions of the lower respiratory tract

• J86 Pythothrace
  • Empyema of the pleura
  • The destruction of the lungs (bacterial)
• J86.0 Pythothax with fistula
• J86.9 Pythorax without fistula
  • Piopevneumotorax

Since pyothorax is a secondary disease, the diagnostic code for the final diagnosis uses an auxiliary primary lesion code.

Types of chronic pyotorax:

1. Limited
   • Apical - in the region of the apex of the lung
   • Basal - on the diaphragm surface
   • Mediastinal - facing the mediastinum
   • Pristenochnye - affect the lateral surface of the organ
2. Unlimited
   • Small
   • Total
   • Subtotal

Depending on the type of disease, the patient's age and other individual characteristics of his body, treatment is selected. Therapy is aimed at restoring the normal functioning of the respiratory system.

Impaired empyema of the pleura

A limited form of purulent-inflammatory process is characterized by localization in a certain part of the pleural cavity with an environment of pleural coalescence. The drained empyema of the pleura can be multi-chambered and single-chambered (apical, interlobar, basal, parietal).

As a rule, this species has a tuberculous etymology, therefore it decomposes in the lateral part of the pleura or supra-diaphragmatic. The drained pyotorax is exudative, while the effusion is limited by adhesions between the pleura sheets. Pathology involves the transition of acute inflammation to chronic and is accompanied by symptoms such as:

• A sharp decrease in the protective properties of the immune system.
• Degenerative changes in the structure of connective tissue and massive splices.
• Strong cough with separation of phlegm.
• Pain in the chest.

For diagnosis, an ultrasound is performed to identify the accumulated fluid and X-ray. To determine the cause of the disease, do a pleural puncture. Treatment takes place in a hospital and assumes a strict bed rest. For therapy, corticosteroid hormones, various physiotherapy procedures and a special diet are prescribed.

[33]

Complications and consequences

The uncontrolled course of any disease leads to serious complications. The consequences of the purulent process in the pleura have a pathological effect on the state of the whole organism. The lethal outcome is about 30% of all cases and depends on the form of the disease and its underlying cause.

Very often purulent pleurisy takes a chronic form, which is characterized by a prolonged course and painful symptoms. Breakthrough pus through the chest wall outward or into the lungs leads to the formation of a fistula that connects the pleural cavity with the lungs or the external environment. But the most dangerous consequence is sepsis, that is, the penetration of the infection into the circulatory system and the formation of purulent-inflammatory foci in various organs.

Regardless of its shape, piothorax entails a number of serious consequences. Complications are manifested by all organs and systems. But most often these are bronchopleural fistulas, multi-organ failure, bronchiectasis, septicopyemia. The disease can result in perforation of the lung and the accumulation of pus in the soft tissues of the chest wall.

Since the purulent exudate does not dissolve on its own, it can break through the lungs into the bronchi or through the thorax and skin. If the purulent inflammation is revealed outside, it takes the form of an open pyopneumotorax. In this case, its course is complicated by a secondary infection that can be brought in during a diagnostic puncture or with dressings. Prolonged suppuration results in purulent peritonitis and pericarditis, sepsis, amyloid organ degeneration and death.

[34], [35], [36], [37]

Diagnostics of the pleural empyema

Many methods are used to recognize purulent pleurisy. Diagnosis of pleural empyema is based on the symptomatology of the disease and, as a rule, does not present difficulties.

Consider the main methods for identifying the disease in the early stages, determining its prevalence and nature:

1. Analysis of blood and urine - show pronounced leukocytosis with a significant shift of the leukocyte formula.
2. Analysis of pleural fluid - allows you to identify the pathogen and determine the nature of the exudate. The material for the study is obtained with the help of a pleural puncture - thoracocentesis.
3. Radiography - is used to identify the characteristic changes in the ailment. In the picture, a darkening is determined, which corresponds to the spread of purulent contents and the displacement of the mediastinal organs to the healthy side.
4. Ultrasound and CT - determine the amount of purulent fluid and allow you to specify the place for pleural puncture.
5. Pleurofistulography - X-ray, which is carried out in the presence of purulent fistula. A radiopaque preparation is injected into the resulting hole and images are taken.

[38], [39], [40]

Analyzes

In addition to instrumental diagnostic methods, laboratory tests are used to detect the disease. Analyzes are necessary to determine the pathogen, the stage of empyema and other features of the inflammatory process.

Analyzes for the detection of purulent pleurisy:

• General analysis of blood and urine.
• Pleural fluid analysis.
• Investigation of aspirated liquid.
• Bacteriological study.
• Bacterioscopy of the smear with Gram staining.
• Determination of pH (with a pyotorax below 7.2)

Laboratory diagnostics is carried out at all stages of treatment and allows to trace the effectiveness of the chosen therapy.

[41], [42], [43]

Instrumental diagnostics

For effective treatment of a purulent-inflammatory disease, it is necessary to conduct a lot of research. Instrumental diagnosis is necessary to determine the nature of inflammation, its location, the stage of spread and other features of the course.

Basic instrumental methods:

• Polypozitsionnaya roentgenoscopy - localizes the lesion, determines the degree of collapse of the lung, the nature of the displacement of the mediastinum, the amount of exudate and other pathological changes.
• Lateroscopy - determines the vertical dimensions of the affected cavity and makes it possible to assess the state of the basal parts of the body filled with exudate.

Tomography - is performed after drainage of the pleural cavity from pus. If the organ is collapsed by more than ¼ of its volume, then the interpretation of the results obtained is difficult. In this case, a drainage device and an aspirator are connected to the tomography apparatus.

• Pleurography is a picture of the lungs in three projections. It allows to estimate cavity size, presence of fibrinous strata, sequestration and condition of pleural walls.
• Bronchoscopy - reveals tumor lesions of the lungs and bronchial tree, which can be complicated by cancer.
• Fibrobronchoscopy - gives an idea of the nature of the inflammatory process in the bronchi and trachea, which occur in the acute form of pleural empyema.

Empyema of the pleura on the roentgenogram

One of the most informative and accessible methods for diagnosing inflammation of the respiratory system is X-ray. The empyema of the pleura on the roentgenogram looks like a shadow, which is most often located in the lower parts of the lung. This sign indicates the presence of fluid in the body. If there is a massive infiltration of the lower lobe of the lung, then the x-ray is carried in the prone position on the affected side. Thus, the exudate is distributed along the chest wall and is clearly visible in the picture.

If the ailment is complicated by bronchopleural fistula, then there is an accumulation of air in the pleural cavity. In the image, you can see the upper border of the effusion and assess the degree of collapse of the lung. Significantly changes the radiography - adhesive process. During the diagnosis, it is not always possible to identify a purulent cavity, since it can be in the lung or in the pleura. If purulent pleurisy is accompanied by destruction of the respiratory organs, then on the roentgenogram the deformed parenchyma is visible.

[44], [45]

Differential diagnosis

Since a purulent process in the pleura is a secondary disease, differential diagnosis is extremely important for its detection.

• Pneumonia

Acute empyema is often a complication of pneumonia. If the displacement of the mediastinum is detected during the study, this indicates a pyothorax. In addition, partial expansion and swelling of the intercostal spaces, painful sensations during palpation, weakened breathing are observed. Of decisive importance is tomography, puncture and multiaxial fluoroscopy.

• Abscess of the lung

The purulent process in the pleura is similar in its x-ray and clinical picture with an abscess. For differentiation, bronchography is used. During the study, the displacement of the bronchial branches and their deformation is determined.

• Atelectasis of the lung

Diagnosis is complicated by the fact that the obturation form of the disease can be accompanied by an effusion into the pleural cavity and squeezing a part of the lung with pleural fluid. For differentiation, bronchoscopy and puncture of the pleural cavity are used.

• Tumors of the lungs

Oncology is characterized by peripheral shading of the pulmonary field and transition to the chest wall. To detect purulent pleurisy, a transthoracic biopsy of the lung tissue is performed.

• Specific lesions of the pleura

This is a tuberculous and mycotic lesion, the pathology code precedes the empyema. To establish the correct diagnosis, exudate, puncture biopsy, thoracoscopy and serological tests are performed.

In addition to the above described diseases, do not forget about differentiation with diaphragmatic hernias and cysts.

[46], [47], [48], [49], [50],

Treatment of the pleural empyema

To eliminate the purulent process in the lungs, only modern and effective methods are used. Treatment of pleural empyema is aimed at restoring the normal functioning of the respiratory system and the body. The main task of therapy is emptying of the pleural cavity from purulent contents. Treatment is carried out in a hospital with strict adherence to bed rest.

Disease management algorithm:

• Cleaning the pleura from the pus with drainage or puncture. The earlier the procedure was performed, the lower the risk of complications.
• The use of antibiotic drugs. In addition to the general course of taking the medicine, antibiotics are used to wash the pleural cavity.
• The patient is prescribed vitamin therapy, immunostimulating and detoxification treatment. Possible the use of protein preparations, UV of blood, hemosorption.
• In the process of recovery for normal recovery of the body shows diet, therapeutic exercises, physiotherapy, massages and ultrasound therapy.
• If the disease occurs in an advanced chronic form, then the treatment is performed surgically.

Drug treatment of pleural empyema

Treatment of a purulent-inflammatory disease is a long and complex process. The effectiveness of therapy is largely determined by the drugs used. Medicines are selected based on the form of the disorder, the nature of the course, the root cause and individual characteristics of the patient's body.

For treatment appoint such drugs:

• Aminoglycosides - Amikacin, Gentamicin
• Penicillins - Benzylpenicillin, Piperacillin
• Tetracyclines - Doxycycline
• Sulfonamides - Co-trimoxazole
• Cephalosporins - Cefalexin, Ceftazidime
• Lincosamides - Clindamycin, Lincomycin
• Quinolones / fluoroquinolones - Ciprofloxacin
• Macrolides and azalides - Oleandomycin

To aspirate the purulent contents, antibiotic therapy with aminoglycosides, carbapenems and monobactams is performed. Antibiotics are selected as rationally as possible taking into account probable pathogens and based on the results of bacteriological diagnosis.

[51], [52], [53]

Alternative treatment

In addition to conservative therapy, unconventional methods are used to eliminate pyothorax. Alternative treatment is based on the use of herbal remedies that are safe for the human body, have a minimum of side effects and contraindications.

• Mix the onion juice with honey in a 1: 1 ratio. Take 1-2 spoons 2 times a day after meals. The medicine has anti-infective properties.
• Remove from the fresh cherries bones and chop the pulp. The medicine should be taken on ¼ cup 2-3 times a day after eating.
• Preheat the olive oil and rub it on the affected side. You can make an oil compress and leave it for the night.
• Mix in equal proportions honey and black radish juice. Take 1-2 spoon 3 times a day.
• Take a glass of aloe juice, a glass of vegetable oil, linden flowers, birch buds and a glass of lime honey. Dry ingredients pour boiling water and let it brew for 20-30 minutes. In the ready-made infusion, add honey and aloe, carefully mix and add vegetable oil. The medicine is taken 1-2 tablespoons 2-3 times a day before meals.

[54], [55], [56], [57], [58]

Herbal Treatment

Alternative therapies are related to non-traditional therapies, but are quite popular, since they only use natural medicines. Herbal treatment is successful due to the medicinal properties of plants and minimal contraindications.

• Take the fruits of anise, licorice root and althea and mix them with pine buds and sage leaves in a 2: 2: 2: 1: 1 ratio. Pour a couple of spoons of the mixture with boiling water and let it brew for 5-6 hours. Once the infusion is ready, it must be filtered and taken 1 spoon 4-6 times a day.
• 50 g of horsetail pour 500 ml of boiling water and let it brew for 3-4 hours. The medicine is taken for ½ cup 3-4 times a day.
• Mix in equal proportions licorice root, marshweed grass, St. John's wort, elecampane root, mother-and-stepmother leaves and pour boiling water. The mixture should be infused for 5-6 hours, after which it must be filtered and take ½ cup before each meal.

Homeopathy with pleural empyema

Another unconventional method of treatment of purulent and inflammatory processes in the respiratory system is homeopathy. Any homeopathic preparations are selected only by a doctor, after a thorough examination of the patient. Consider the popular means for treating pleural empyema:

• Asclepias tuberose 3X, 3 - eliminates dry cough, minimizes painful sensation with right-sided lesion.
• Ranunculus bulbozus 3, 6 - used for left-sided lesions, relieves pain, increased weakness, heaviness in breathing and movement.
• Cantaris 3, 6, 12 - is prescribed in the serous form of pyotorax. It alleviates fits of weakness, intense thirst, excessive sweating.
• Millefolium 2X, 3X - helps at the stage of remission of acute inflammation, when the amount of exudate does not decrease.
• Sulfur 6-12 - minimizes purulent processes in the pleural cavity, increases the reactivity of the body.

Operative treatment

The chronic form of lung empyema suggests therapy only by surgical methods. Surgical treatment is performed with ineffectiveness of drug therapy. Let's consider the basic methods of operation with pyotorax:

• Decortication of the lung

Removal of densified fibrous tissue on the membrane of the lung and pleura, which interferes with the spreading of the organ. The main task of the operation is to release the lung from scars and adhesions that cover the visceral pleura and create conditions for the restoration of the organ. Decortication is performed in chronic empyema, lasting from 3-6 months.

• Plevrrectomy

Removal of the parietal pleura from the costal surface of the sternum. The purpose of the surgical intervention is the recovery and recovery of the pleural cavity. The operation is performed only with chronic empyema and can be combined with lung decortication.

• Thoracoplasty

Removal of a part of the ribs for depressing and mobilizing the chest wall. The operation eliminates the persistent residual of the purulent contents of the empyema.

• Intrapleural thoracoplasty - a purulent cavity is opened with the help of complete excision of the ribs, intercostal spaces and parietal pleural scarring.
• Extrapulural thoracoplasty is a subperiosteal resection without opening the pleural cavity. The falling chest wall ensures the contraction and contraction of the lung tissue.

Thoracoplasty is used in the long course of pyotorax and in the event that other surgical options can not be performed.

Prevention

To prevent the development of complications of inflammatory diseases of the respiratory system, it is very important to timely treat. Prevention of purulent processes in the pleural cavity is based on the successful treatment of primary ailments that can be transformed into empyema. Let's consider the basic preventive recommendations:

• Prevention of acute respiratory infections and colds. This will avoid the entry of pathogenic microflora into the mucosa of the respiratory tract and the pleural cavity. Even a slight form of cold should be treated.
• If there is a suspicion of pneumonia, then you need to do a chest x-ray and start treatment. Untimed or incorrect therapy increases the risk of pathological complications, in the form of suppuration and accumulation of exudate in the pleura.
• Strengthening the immune system, healthy diet and physical activity, allow you to maintain health at a high level and protect against inflammatory diseases of the respiratory system.
• Smoking and alcoholism can cause pulmonary tuberculosis, the neglected form of which provokes purulent pleurisy. Give up bad habits for health.

[59], [60], [61], [62], [63]

Forecast

The outcome of any disease depends on the results of his treatment. The prognosis of pyotorax is based on early diagnosis and therapy of the disease. If the treatment started on time and was consistent with the medical recommendations, the prognosis for recovery is positive. The lack of therapy leads to an aggravation of an already pathological process. This will help lead to respiratory failure, disruption in the work of the entire body and even death.

The empyema of the lungs is a secondary disease, the course of which depends on its underlying cause. Purulent inflammation is accompanied by painful symptoms, leads to the destruction of the respiratory system and impaired functioning of other organs and systems. Patients who have suffered this disease, for 2-3 years are on dispensary supervision.

[64], [65], [66]