Pleural empyema

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

Let's consider the causes, pathogenesis, signs of the disease and complications, the main methods of diagnosis and treatment.

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Causes pleural empyema

The disease is a complication of such diseases 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 respiratory diseases cause a number of pathological consequences, the diagnosis and treatment of which are significantly complicated. The causes of pleural empyema are divided into three groups, let's consider them:

1. Primary
   • Post-traumatic – chest wounds, trauma, thoracoabdominal injuries.
   • Postoperative – pathology with/without bronchial fistula.
2. Secondary
   • Diseases of the sternum organs – pneumonia, gangrene and lung abscess, 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 pyothorax is a purulent process of any localization, complicated by infection and sepsis (phlegmon, osteomyelitis).
3. Cryptogenic empyemas of unclear etiology.

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

• Pericarditis.
• Transfer of infection with lymph and blood from other foci of inflammation (tonsillitis, sepsis).
• Liver abscess.
• Osteomyelitis of the ribs and spine.
• Cholecystitis.
• Pancreatitis.
• Pericarditis.
• Mediastinitis.
• Pneumothorax.
• Injuries, wounds, 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, the entry of blood or air into the pleural cavity and microbial flora (pyogenic cocci, tuberculosis bacilli, bacilli). The acute form can occur due to microbial infection and suppuration of effusion during inflammatory processes in the lungs.

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Pathogenesis

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

• Primary empyema occurs due to a disruption of the barrier function of the pleural sheets and the introduction of harmful microflora. As a rule, this occurs with open chest injuries or after lung surgery. Primary surgical care plays an important role in the development of pathology. If it is provided in the first hours of illness, pyothorax occurs in 25% of patients.
• The 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 disease development is the spread of the inflammatory process to the pleura from the tissues of neighboring organs and the chest wall. In rare cases, the disorder is provoked by purulent and inflammatory diseases of the abdominal organs. Harmful microorganisms penetrate from the abdominal cavity into the pleura through the lymphatic vessels or hematogenously.

In this case, the pathogenesis of the acute form of purulent pleural lesion is quite complex and is determined by a decrease in the immunobiological reactivity of the body when harmful microorganisms penetrate. In this case, changes can increase gradually with the development of pleurisy (fibrinous, fibrinous-purulent, exudative) or acutely. A severe form of purulent intoxication causes dysfunction of the endocrine organs, which has a pathological effect on the functioning of the entire body.

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Symptoms pleural empyema

The symptoms of the disorder gradually increase, and the exudate accumulates, mechanically squeezing the lungs and heart. This causes the organs to shift in the opposite direction and causes respiratory and cardiac dysfunction. Without timely and proper treatment, the 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. Let's consider the symptoms of pleural empyema using the example of acute and chronic forms.

Acute inflammation:

• Cough with the production of sputum with an unpleasant odor.
• Chest pain that is relieved by calm breathing and intensified by deep inhalation.
• Cyanosis – a blue tint appears on the skin of the lips and hands, indicating a lack of oxygen.
• Shortness of breath and rapid deterioration of the general condition.

Chronic empyema:

• Subfebrile body temperature.
• Cough with the separation of purulent sputum.
• Chest pain of a vague nature.
• Chest deformity.

First signs

At an early stage, all forms of purulent process in the pleura have similar symptoms. The first signs are cough with sputum, shortness of breath and painful sensations in the chest, fever and intoxication.

At the initial stage, part of the exudate accumulated in the chest cavity is absorbed and only fibrin remains on the walls of the pleura. Later, the lymphatic slits become clogged with fibrin and are compressed by the resulting edema. At this point, the absorption of exudate from the pleural cavity ceases.

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

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Acute pleural empyema

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

Symptoms of acute pleural empyema:

• Chest pain that intensifies when inhaling, coughing, and changing body position.
• Shortness of breath at rest.
• Blueness of the lips, earlobes and hands.
• Elevated body temperature.
• Tachycardia over 90 beats per minute.

Treatment should be comprehensive. In the early stages of therapy, it is necessary to remove the contents of the pleura to straighten the lung and obturate the fistulas. If the empyema is widespread, the contents are removed using thoracocentesis and then drained. The most effective method of sanitation is considered to be regular lavage of the pleural cavity with an antiseptic solution with broad-spectrum antibiotics and proteolytic enzymes.

In case of progressive empyema, various pathological complications and ineffective drainage, surgical treatment is performed. Patients are shown wide thoracotomy and open sanitation, after which the chest cavity is drained and sutured.

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Chronic pleural empyema

Long-term accumulation of pus in the chest cavity indicates a congestive inflammatory process that requires medical intervention. Chronic empyema of the pleura lasts longer than two months, is characterized by the penetration of an infectious agent into the pleural cavity and is a complication of the acute form. The main causes of the disease are errors made in the treatment of acute pyothorax and other features of the disease.

Symptoms:

• Subfebrile temperature.
• Cough with the separation of purulent sputum.
• Deformation of the chest on the affected side due to narrowing of the intercostal spaces.

Chronic inflammation leads to the formation of thick cicatricial adhesions that preserve the purulent cavity and keep the lung in a collapsed state. Gradual resorption of exudate is accompanied by the deposition of fibrin threads on the pleural sheets, which leads to their gluing and obliteration.

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Forms

Pyothorax can be either bilateral or unilateral, 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. Pleural empyema is divided by etiology, nature of complications and prevalence.

By etiology:

• Infectious – pneumococcal, streptococcal, staphylococcal.
• Specific – actinomycosis, tuberculosis, syphilitic.

By duration:

• Acute – up to two months.
• Chronic – more than two months.

By prevalence:

• Encapsulated (limited) – inflammation only on one wall of the pleural cavity.
  • Diaphragmatic.
  • Mediastinal.
  • Apical.
  • Rib.
  • Interlobar.
• Widespread – the pathological process has affected 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 severity of the course:

• Lungs.
• Moderate severity.
• Heavy.

Diseases can be classified depending on the cause and nature of the inflammatory process and a number of other signs characteristic of the disease.

According to the International Classification of Diseases, 10th revision, empyema of the pleura is included in the category J00-J99 diseases of the respiratory system.

Let's take a closer look at the ICD 10 code:

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

• J86 Pyothorax
  • Empyema of the pleura
  • Lung destruction (bacterial)
• J86.0 Pyothorax with fistula
• J86.9 Pyothorax without fistula
  • Pyopneumothorax

Since pyothorax is a secondary disease, an auxiliary code for the primary lesion is used to make a final diagnosis.

Types of chronic pyothorax:

1. Limited
   • Apical - in the region of the apex of the lung
   • Basal - on the diaphragmatic surface
   • Mediastinal - facing the mediastinum
   • Parietal - 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 organs.

Encapsulated pleural empyema

A limited form of purulent-inflammatory process is characterized by localization in a certain part of the pleural cavity surrounded by pleural adhesions. Encapsulated empyema of the pleura can be multi-chamber and single-chamber (apical, interlobar, basal, parietal).

As a rule, this type has a tuberculous etymology, therefore it disintegrates in the lateral part of the pleura or supradiaphragmatically. Encapsulated pyothorax is exudative, while the effusion is limited by adhesions between the pleural sheets. The 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 tissues and massive adhesions.
• Severe cough with sputum production.
• Chest pain.

For diagnostics, an ultrasound examination is performed to detect accumulated fluid and X-ray. To determine the cause of the disease, a pleural puncture is performed. Treatment is carried out in a hospital setting and involves strict bed rest. Corticosteroid hormones, various physiotherapeutic procedures and a special diet are prescribed for therapy.

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Complications and consequences

Uncontrolled progression of any disease leads to serious complications. The consequences of the purulent process in the pleura have a pathological effect on the condition of the whole organism. The fatal 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 long course and painful symptoms. The breakthrough of pus through the chest wall to the outside 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 infection into the circulatory system and the formation of purulent-inflammatory foci in various organs.

Regardless of its form, pyothorax entails a number of serious consequences. Complications manifest themselves on the part of all organs and systems. But most often these are bronchopleural fistulas, multiple organ failure, bronchiectasis, septicopyemia. The disease can lead to perforation of the lung and accumulation of pus in the soft tissues of the chest wall.

Since purulent exudate does not resolve on its own, pus may break through the lungs into the bronchi or through the chest and skin. If purulent inflammation opens up, it takes the form of open pyopneumothorax. In this case, its course is complicated by a secondary infection, which can be introduced during diagnostic puncture or dressings. Long-term suppuration leads to purulent peritonitis and pericarditis, sepsis, amyloid degeneration of organs and death.

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Diagnostics pleural empyema

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

Let's look at the main methods for detecting the disease in the early stages, determining its prevalence and nature:

1. Blood and urine tests show pronounced leukocytosis with a significant shift in the leukocyte formula.
2. Pleural fluid analysis – allows to identify the pathogen and determine the nature of the exudate. The material for the study is obtained using pleural puncture – thoracentesis.
3. Radiography is used to detect changes characteristic of the disease. The image shows a darkening that corresponds to the spread of purulent contents and the displacement of the mediastinal organs to the healthy side.
4. Ultrasound and CT scans determine the amount of purulent fluid and allow for a more precise location for pleural puncture.
5. Pleurofistulography is an X-ray that is performed in the presence of purulent fistulas. A radiopaque agent is injected into the resulting opening and images are taken.

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Tests

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

Tests to detect purulent pleurisy:

• General blood and urine analysis.
• Pleural fluid analysis.
• Examination of aspirated fluid.
• Bacteriological examination.
• Bacterioscopy of a smear with Gram staining.
• Determination of pH (with pyothorax below 7.2)

Laboratory diagnostics are carried out at all stages of treatment and allow us to monitor the effectiveness of the chosen therapy.

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Instrumental diagnostics

For effective treatment of purulent-inflammatory disease, it is necessary to conduct many studies. Instrumental diagnostics are necessary to determine the nature of inflammation, its localization, stage of spread and other features of the course.

Basic instrumental methods:

• Polypositional fluoroscopy – localizes the lesion, determines the degree of lung collapse, the nature of the mediastinal displacement, the amount of exudate and other pathological changes.
• Lateroscopy – determines the vertical dimensions of the affected cavity and makes it possible to assess the condition of the basal sections of the organ filled with exudate.

Tomography – 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 obtained results is difficult. In this case, drainage and an aspirator are connected to the tomography apparatus.

• Pleurography is a three-projection image of the lungs. It allows one to evaluate the size of the cavity, the presence of fibrinous deposits, sequesters, and the condition of the pleural walls.
• Bronchoscopy – reveals tumor lesions of the lungs and bronchial tree, which may be complicated by cancer.
• Fiberoptic bronchoscopy provides an idea of the nature of the inflammatory process in the bronchi and trachea that occurs in the acute form of pleural empyema.

Empyema of the pleura on radiograph

One of the most informative and accessible methods of diagnosing inflammation of the respiratory organs is an X-ray. Empyema of the pleura on an X-ray 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 organ. If there is massive infiltration of the lower lobe of the lung, then the X-ray is performed in a lying position on the affected side. Thus, the exudate is distributed along the chest wall and is clearly visible on the image.

If the disease is complicated by a bronchopleural fistula, then an accumulation of air is observed in the pleural cavity. The image shows the upper border of the effusion and assesses the degree of lung collapse. The adhesion process significantly changes the radiography. During diagnostics, it is not always possible to detect a purulent cavity, since it can be both in the lung and in the pleura. If purulent pleurisy is accompanied by destruction of the respiratory organs, then the radiograph shows deformed parenchyma.

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Differential diagnosis

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

• Pneumonia

Acute empyema is a very common complication of pneumonia. If a shift in the mediastinum is detected during the examination, this indicates pyothorax. In addition, partial expansion and bulging of the intercostal spaces, painful sensations during palpation, and weakened breathing are observed. Tomography, puncture, and multi-axis fluoroscopy are of decisive importance.

• Lung abscess

The purulent process in the pleura is similar in its radiological and clinical picture to an abscess. Bronchography is used for differentiation. During the study, the displacement of the bronchial branches and their deformation are determined.

• Atelectasis of the lung

Diagnosis is complicated by the fact that the obstructive form of the disease may be accompanied by effusion into the pleural cavity and compression of part of the lung by pleural fluid. Bronchoscopy and puncture of the pleural cavity are used for differentiation.

• Lung tumors

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

• Specific pleural lesion

We are talking about tuberculosis and mycotic lesions, when the pathology precedes empyema. To establish the correct diagnosis, exudate studies, puncture biopsy, thoracoscopy and serological tests are carried out.

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

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Treatment 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 organs and the body. The main goal of therapy is to empty the pleural cavity from purulent contents. Treatment is carried out in a hospital setting with strict adherence to bed rest.

Algorithm for disease management:

• Cleaning the pleura from pus by drainage or puncture. The earlier the procedure is performed, the lower the risk of complications.
• Use of antibiotics. In addition to the general course of medication, antibiotics are used to wash the pleural cavity.
• The patient is required to be prescribed vitamin therapy, immunostimulating and detoxifying treatment. It is possible to use protein preparations, ultraviolet irradiation of blood, hemosorption.
• During the recovery process, diet, therapeutic exercises, physiotherapy, massages and ultrasound therapy are recommended for normal restoration of the body.
• If the disease is in an advanced chronic form, then treatment is carried out surgically.

Drug treatment of pleural empyema

Treatment of 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 underlying cause and the individual characteristics of the patient's body.

The following medications are prescribed for treatment:

• Aminoglycosides – Amikacin, Gentamicin
• Penicillins – Benzylpenicillin, Piperacillin
• Tetracyclines – Doxycycline
• Sulfonamides - Co-trimoxazole
• Cephalosporins – Cephalexin, Ceftazidime
• Lincosamides – Clindamycin, Lincomycin
• Quinolones/Fluoroquinolones – Ciprofloxacin
• Macrolides and Azalides - Oleandomycin

For aspiration of purulent contents, antibiotic therapy is performed using aminoglycosides, carbapenems and monobactams. Antibiotics are selected as rationally as possible, taking into account probable pathogens and based on the results of bacteriological diagnostics.

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Folk remedies

In addition to conservative therapy, non-traditional methods are used to eliminate pyothorax. Traditional 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 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 the pits from fresh cherries and chop the pulp. The medicine should be taken ¼ cup 2-3 times a day after meals.
• Warm up some olive oil and rub it on the affected side. You can make an oil compress and leave it overnight.
• Mix honey and black radish juice in equal proportions. Take 1-2 spoons 3 times a day.
• Take a glass of aloe juice, a glass of vegetable oil, linden flowers, birch buds and a glass of linden honey. Pour boiling water over the dry ingredients and let it brew in a water bath for 20-30 minutes. Add honey and aloe to the finished infusion, mix thoroughly and add vegetable oil. Take 1-2 spoons of the medicine 2-3 times a day before meals.

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Herbal treatment

Traditional methods of treatment are considered non-traditional therapy, but are quite popular, as they involve the use of only natural medicines. Herbal treatment is successful due to the healing properties of plants and minimal contraindications.

• Take anise fruits, licorice root and marshmallow and mix them with pine buds and sage leaves in a ratio of 2:2:2:1:1. Pour boiling water over a couple of spoons of the mixture and let it brew for 5-6 hours. Once the infusion is ready, strain it and take 1 spoon 4-6 times a day.
• Pour 500 ml of boiling water over 50 g of horsetail and let it brew for 3-4 hours. The medicine is taken ½ cup 3-4 times a day.
• Mix equal parts of licorice root, marsh cudweed, St. John's wort, elecampane root, coltsfoot leaves and pour boiling water over it. The mixture should be left to infuse for 5-6 hours, after which it should be strained and taken ½ cup before each meal.

Homeopathy for empyema of the pleura

Another unconventional method of treating purulent and inflammatory processes in the respiratory organs is homeopathy. Any homeopathic drugs are selected only by a doctor, after a thorough examination of the patient. Let's consider popular remedies for the treatment of pleural empyema:

• Asclepias tuberose 3X, 3 – eliminates dry cough, minimizes pain in case of right-sided lesions.
• Ranunculus bulbosus 3, 6 – used for left-sided lesions, relieves pain, increased weakness, heaviness when breathing and moving.
• Cantharis 3, 6, 12 – prescribed for serous pyothorax. Relieves attacks of weakness, intense thirst, increased sweating.
• Millefolium 2X, 3X – helps at the stage of subsiding acute inflammation, when the amount of exudate does not decrease.
• Sulfur 6-12 – minimizes purulent processes in the pleural cavity, increases the body’s reactive abilities.

Surgical treatment

The chronic form of pulmonary empyema requires only surgical treatment. Surgical treatment is performed when drug therapy is ineffective. Let's consider the main surgical methods for pyothorax:

• Decortication of the lung

Removal of compacted fibrous tissue on the lung membrane and pleura, which prevents the organ from straightening. The main goal of the operation is to free the lung from scars and adhesions covering the visceral pleura and create conditions for the restoration of organ function. Decortication is performed for chronic empyema lasting 3-6 months.

• Pleurectomy

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

• Thoracoplasty

Removal of a portion of the ribs to retract and mobilize the chest wall. The operation eliminates persistent residual purulent contents of the empyema.

• Intrapleural thoracoplasty – the purulent cavity is opened by complete excision of the ribs, intercostal spaces and parietal pleural scars.
• Extrapleural thoracoplasty is a subperiosteal resection without opening the pleural cavity. The recessed chest wall guarantees the collapse and compression of the lung tissue.

Thoracoplasty is used in cases of prolonged pyothorax and in cases where other surgical options cannot be performed.

Prevention

To prevent the development of complications of inflammatory diseases of the respiratory organs, it is very important to carry out treatment in a timely manner. Prevention of purulent processes in the pleural cavity is based on the successful treatment of primary diseases that can transform into empyema. Let's consider the main preventive recommendations:

• Prevention of acute respiratory viral infections and colds. This will prevent pathogenic microflora from entering the mucous membrane of the respiratory tract and pleural cavity. Even a mild form of cold should be treated.
• If pneumonia is suspected, a chest X-ray should be taken and treatment should be started. Untimely or incorrect therapy increases the risk of pathological complications, such as suppuration and accumulation of exudate in the pleura.
• Strengthening the immune system, healthy eating and physical activity help maintain high levels of health and protect against inflammatory diseases of the respiratory system.
• Smoking and alcoholism can cause pulmonary tuberculosis, the advanced form of which provokes purulent pleurisy. Give up bad habits to maintain health.

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Forecast

The outcome of any disease depends on the results of its treatment. The prognosis of pyothorax is based on early diagnosis and treatment of the disease. If the treatment began on time and corresponded to the doctor's recommendations, then the prognosis for recovery is positive. The absence of therapy leads to an aggravation of the already pathological process. This can lead to respiratory failure, disruptions in the functioning of the entire body and even death.

Empyema of the lungs is a secondary disease, the course of which depends on its primary cause. Purulent inflammation is accompanied by painful symptoms, leads to the destruction of the respiratory organs and disruption of the functioning of other organs and systems. Patients who have suffered from this disease are under dispensary observation for 2-3 years.

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