M5W9 Empyema

Investigations

Bloods: Blood cultures CRP ECC CXR: Diagnose pneumonia Look for fluid accumulation or a lung abscess Asymmetry Often has an obtuse angle on the liquid, whereas a pleural effusion will have a menisci and be concave In chronic empyema you can get rib crowding and a flattened hemidiaphragm. Thoracentesis: aspiration of the pleural fluid for examination under a microscope and testing Considered an empyema is the pH < 7.2 or the fluid has a glucose level < 40mg/dL USS: Can look for loculations

Aetiology and common causative organisms

Complication of thoracic surgery Rupture of lung abscess Perforation of oesophagus Mediastinitus Bacterial spread of pneumonia *Common bacteria:* • Streptococcus pneumoniae Staphylococcus Aureus

Presentation of an empyema?

Fever cough SOB - lungs cannot fully expand because of the empyema. Pleurisy - chest pain that occurs whilst breathing and is a result of inflammation Fatigue Loss of appetite Weight loss Sepsis (the presence of bacteria in the blood) - severe, life-threatening and requires emergency treatment - Signs of sepsis: high fever, chills, rapid breathing, a fast heart rate, low blood pressure.

What is an empyema?

This is a collection of pus within the pleural cavity Infection in the pleural space There's pus cells and bacteria present. Treat early for a better prognosis

Pathophysiology of a simple and complex empyema

For an empyaemia to occur, it is usually the result of a medical condition. Bacteria/fungi need to get into the pleural space - and an inflammatory response needs to be produced, and pus needs to be produced. *Simple empyema:* This occurs during the early course of the illness where the pus present is free flowing. The treatment for this is to simply drain the pleural cavity. The earlier one is treated, the easier the treatment would be and the fewer complications involved. *Complex empyema:* Here the inflammation is much more severe, If you leave a simple empyema for too long untreated, the chance of it developing into a complex empyema is much greater. Where there is severe inflammation, there are a lot of scars forming in the pleural space. Scar tissue formation results in the cavity to become divided into multiple, smaller cavities - this is called Loculation. Loculation means that the infected areas containing pus become walled off, making it very difficult to drain.

Treatment options for an empyema (Simple and complicated)

IV antibiotics cephalosporins metronidazole penicillin (ampicillin / sulbactam) If allergic to penicillin - clindamycin. Chest drain used to drain pus from the pleural cavity allowing the lungs to expand fully and normally Fluids given (this is because fluids may have been lost as a result of fever and loss of appetite) Paracetamol - given to bring down fever and relieves any pain or discomfort. Treatment in loculated, complex empyema: Euro kinase may be given to break down the loculations

Risk factors

Pneumonia Chest trauma Pre-existing lung disease Immunodeficient