Thoracic—Empyema
Concept
Infection localized in the thoracic cavity outside of the lung. May be the result of any neighboring infection (pneumonia, esophageal perforation, bronchopleural fis- tula, recent surgery, subphrenic abscess, generalized sepsis, undrained pleural effusion).
Way Question May be Asked?
“55 y/o male in the ICU with persistent left loculated effu- sion and thoracentesis performed reveals purulent mate- rial. What do you want to do?”
How to Answer?
History
Tobacco use Chest pain Fever
Recent pneumonia or infection h/o Cancer
HIV
Physical Exam
Auscultation of chest Examine for any adenopathy
How to Answer?
Need CXR prethoracentesis/chest tube Look for lesion
Look for air-fluid level (bronchopleural fistula) Need CXR post thoracentesis/chest tube
To confirm complete evacuation of effusion To check for trapped lung, loculations, unexplained
atelectasis (endobronchial lesion) Send fluid for:
Cultures (aerobic, anaerobic, acid fast, fungal) Cytology (r/o malignancy)
LDH, cell count, pH, LDH, glucose CT scan of chest
Adenopathy Loculations Mass lesion Bronchoscopy
If suspect endobronchial lesion Empyema stages:
Exudative < 7 days Fibropurulent 7–14 days Organized > 14 days
Surgical Treatment
Exudative stage—Thoracentesis (usually prior to CT placement)
Chest tube drainage + Abx
Fibropurulent stage—VATS exploration/pleurodesis (pleural biopsy/cytology if sus- pect malignancy) or limited thoracotomy
Organized stage—VATS decortication Open decortication
Rib resection and Eloesser flap (skin sutured to parietal pleura) → used in high risk pt!
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Common Curveballs
Cytology will be positive for malignancy (switch sce- narios)
Empyema will fail treatment with chest tube
Pt will develop bronchopleural fistula post thoraco- tomy
Stains for acid-fast bacilli will be positive
Lung won’t re-expand after chest tube drainage of effu- sion/empyema
Empyema will be the result of some extra-pulmonary process (perforated esophagus, subphrenic abscess, . .)—scenario switch!
Strikeouts
Forgetting PFTs if proceeding towards thoracotomy Describing VATS as an option if you don’t do know
how to do this procedure
Mentioning Eloesser flap if don’t know how to perform it/its indications
Not checking cytology on drained effusion
Not performing bronch for persistently unexpanded lung fields
Strikeouts 121
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