Empyema: Difference between revisions
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*Stages | *Stages | ||
*#Exudative - Free-flowing pleural effusion amenable to chest tube drainage; may only last <48hr | *#Exudative - Free-flowing pleural effusion amenable to chest tube drainage; may only last <48hr | ||
*#Fibrinopurulent - Loculations develop making resolution | *#Fibrinopurulent - Loculations develop making resolution with single chest tube drainage unlikely | ||
*#Organizational - Takes several weeks to develop; "pleural peel" restricts lung expansion | *#Organizational - Takes several weeks to develop; "pleural peel" restricts lung expansion | ||
===Causes=== | ===Causes=== | ||
*[[Pneumonia]] | *[[Pneumonia]] (most common) | ||
*Complications of [[thoracic trauma|chest]] or [[abdominal trauma]] | *Complications of [[thoracic trauma|chest]] or [[abdominal trauma]] | ||
*[[Esophageal perforation]] | *[[Esophageal perforation]] | ||
*Extension from lung abscess | *Extension from [[lung abscess]] | ||
*[[Osteomyelitis]] or other near pleural infections | *[[Osteomyelitis]] or other near pleural infections | ||
*[[Hemothorax]], [[chylothorax]], or [[hydrothorax]] that becomes infected | *[[Hemothorax]], [[chylothorax]], or [[hydrothorax]] that becomes infected | ||
==Clinical Features== | ==Clinical Features== | ||
* | *[[Fever]] | ||
** | *[[Shortness of breath]] | ||
*Anorexia | |||
*Night sweats | |||
*Pleuritic [[chest pain]] | |||
*[[Hemoptysis]] | |||
*Recent diagnosis and/or treatment for [[Pneumonia]] | |||
*History of penetrating [[chest trauma]] or [[diaphragmatic injury]]<ref>Barmparas G, DuBose J, Teixeira PG, Recinos G, Inaba K, Plurad D. Risk factors for empyema after diaphragmatic injury: results of a National Trauma Databank analysis. J Trauma. Jun 2009;66(6):1672-6</ref> | |||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
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*[[Tuberculosis]] | *[[Tuberculosis]] | ||
*[[Pleural Effusion]] | *[[Pleural Effusion]] | ||
*[[ | *[[Granulomatosis with polyangiitis]] (wegener's) | ||
*[[Pulmonary embolism]] | *[[Pulmonary embolism]] | ||
==Work Up== | ==Evaluation== | ||
===Work Up=== | |||
*CBC | *CBC | ||
*CXR | *[[CXR]] | ||
*[[Thoracentesis]] | *[[Thoracentesis]] | ||
*Sputum Culture -- Acid Fast Bacilli (If TB suspected) | *Sputum Culture -- Acid Fast Bacilli (If TB suspected) | ||
| Line 45: | Line 42: | ||
*Blood Cultures | *Blood Cultures | ||
== | ===Evaluation=== | ||
*Aspiration of grossly purulent pleural fluid on [[thoracentesis]] and at least 1 of the following:<ref>http://emedicine.medscape.com/article/807499-overview</ref> | *Aspiration of grossly purulent pleural fluid on [[thoracentesis]] and at least 1 of the following:<ref>http://emedicine.medscape.com/article/807499-overview</ref> | ||
**+ Gram stain or culture | **+ Gram stain or culture | ||
| Line 53: | Line 50: | ||
**LDH >1000 IU/mL | **LDH >1000 IU/mL | ||
== | ==Management== | ||
*Treat underlying disease | *Treat underlying disease | ||
*O2 if [[Hypoxemia]] | *[[O2]] if [[Hypoxemia]] | ||
*Perform [[thoracentesis]] vs. [[chest tube]] if evidence of respiratory distress | *Perform [[thoracentesis]] vs. [[chest tube]] if evidence of respiratory distress | ||
**May need Video-Assisted Thoracic surgery (VATS) | **May need Video-Assisted Thoracic surgery (VATS) | ||
*[[Antibiotics]] | *[[Antibiotics]] | ||
**[[Piperacillin-tazobactam]] 3.375-4.5gm q6hr IV or [[imipenem]] 0.5-1gm q6hr | **[[Piperacillin-tazobactam]] 3.375-4.5gm q6hr IV or [[imipenem]] 0.5-1gm q6hr | ||
**Consider adding [[vancomycin]] if | **Consider adding [[vancomycin]] if patient at risk for [[MRSA]] | ||
{{Chest tube size table}} | {{Chest tube size table}} | ||
==Disposition== | |||
*Admit | |||
==See Also== | ==See Also== | ||
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==References== | ==References== | ||
<references/> | |||
[[Category:ID]] | [[Category:ID]] | ||
[[Category: | [[Category:Pulmonary]] | ||
Latest revision as of 22:22, 15 January 2021
Background
- Pleural space infections with + Gram stain/culture OR parapneumonic effusions without pleural fluid sampling
- Stages
- Exudative - Free-flowing pleural effusion amenable to chest tube drainage; may only last <48hr
- Fibrinopurulent - Loculations develop making resolution with single chest tube drainage unlikely
- Organizational - Takes several weeks to develop; "pleural peel" restricts lung expansion
Causes
- Pneumonia (most common)
- Complications of chest or abdominal trauma
- Esophageal perforation
- Extension from lung abscess
- Osteomyelitis or other near pleural infections
- Hemothorax, chylothorax, or hydrothorax that becomes infected
Clinical Features
- Fever
- Shortness of breath
- Anorexia
- Night sweats
- Pleuritic chest pain
- Hemoptysis
- Recent diagnosis and/or treatment for Pneumonia
- History of penetrating chest trauma or diaphragmatic injury[1]
Differential Diagnosis
- Pneumonia
- Sarcoidosis
- Tuberculosis
- Pleural Effusion
- Granulomatosis with polyangiitis (wegener's)
- Pulmonary embolism
Evaluation
Work Up
- CBC
- CXR
- Thoracentesis
- Sputum Culture -- Acid Fast Bacilli (If TB suspected)
- Pulse Ox
- ABG interpretation
- Blood Cultures
Evaluation
- Aspiration of grossly purulent pleural fluid on thoracentesis and at least 1 of the following:[2]
- + Gram stain or culture
- WBC count > 50,000 cells/µL (or polymorphonuclear leukocyte count of 1,000 IU/dL)
- Pleural fluid glucose <60
- pH <7.2
- LDH >1000 IU/mL
Management
- Treat underlying disease
- O2 if Hypoxemia
- Perform thoracentesis vs. chest tube if evidence of respiratory distress
- May need Video-Assisted Thoracic surgery (VATS)
- Antibiotics
- Piperacillin-tazobactam 3.375-4.5gm q6hr IV or imipenem 0.5-1gm q6hr
- Consider adding vancomycin if patient at risk for MRSA
Adult Chest Tube Sizes
| Chest Tube Size | Type of Patient | Underlying Causes |
| Small (8-14 Fr) |
|
|
| Medium (20-28 Fr) |
|
|
| Large (36-40 Fr) |
|
Disposition
- Admit
See Also
References
- ↑ Barmparas G, DuBose J, Teixeira PG, Recinos G, Inaba K, Plurad D. Risk factors for empyema after diaphragmatic injury: results of a National Trauma Databank analysis. J Trauma. Jun 2009;66(6):1672-6
- ↑ http://emedicine.medscape.com/article/807499-overview
- ↑ Inaba Et. al J Trauma Acute Care Surg. 2012 Feb;72(2):422-7.
- ↑ Advanced Trauma Life Support® Update 2019: Management and Applications for Adults and Special Populations.