Purulent pleurisy (pleural empyema). Chronic pleural empyema Acute pleural empyema

The disease is a complication of diseases such as: pneumonia, damage to the pleura and lungs, abscess, gangrene, 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 - 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 with unclear etiology.

The disease is associated with the spread of suppuration from neighboring 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 (angina, 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, tubercle bacilli, bacilli). The acute form can occur due to microbial infection and suppuration of effusion during inflammatory processes in the lungs.

Pathogenesis

Any disease has a development mechanism that 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 located in the pleural cavity, and in the secondary form it acts as a complication of another inflammatory-purulent process.

• Primary empyema appears due to a violation of the barrier function of the pleural layers and the introduction of harmful microflora. As a rule, this happens 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, then pyothorax occurs in 25% of patients.
• The secondary form in 80% of cases is a consequence of chronic and acute purulent lesions of the lungs, pneumonia. Initially, pneumonia can occur simultaneously with purulent pleurisy. Another option for the development of the disease 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 lymphatic vessels or hematogenously.

At the same time, the pathogenesis of acute forms of purulent lesions of the pleura is quite complex and is determined by a decrease in the immunobiological reactivity of the body upon penetration of harmful microorganisms. 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 pathologically affects the functioning of the entire body.

Symptoms of pleural empyema

The symptoms of the disorder gradually increase, and exudate accumulates, mechanically squeezing the lungs and heart. This causes organs to shift in the opposite direction and causes respiratory and cardiac problems. 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 occurrence. Let's look at the symptoms of pleural empyema using the example of acute and chronic forms.

Acute inflammation:

• Cough with foul-smelling mucus.
• Chest pain that is relieved by quiet breathing and intensified by taking a deep breath.
• 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:

• Low-grade body temperature.
• Chest pain of an unexpressed nature.
• Chest deformity.

First signs

At an early stage, all forms of purulent process in the pleura have similar symptoms. The first signs appear in the form of cough with sputum, shortness of breath and pain 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 gaps become clogged with fibrin and are compressed by the resulting swelling. In this case, the absorption of exudate from the pleural cavity stops.

That is, the first and main sign of the disease is the accumulation of exudate, swelling and compression of organs. This leads to 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 intoxication of the body. Against this background, dysfunction of vital organs and systems develops.

Acute pleural empyema

The inflammatory process in the pleura, which 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 either primary or secondary.

Symptoms of acute pleural empyema:

• Chest pain that gets worse with inhalation, coughing and changing body position.
• Shortness of breath at rest.
• Blueness of lips, earlobes and hands.
• Increased body temperature.
• Tachycardia over 90 pulse beats per minute.

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

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

Chronic pleural empyema

Long-term accumulation of pus in the chest cavity indicates a congestive inflammatory process requiring medical intervention. Chronic pleural empyema lasts longer than two months, is characterized by 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:

• Low-grade fever.
• Cough with 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, which preserve the purulent cavity and keep the lung in a collapsed state. The gradual resorption of the exudate is accompanied by the deposition of fibrin threads on the pleura, which leads to their gluing and obliteration.

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 according to 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 of only one wall of the pleural cavity.
  • Diaphragmatic.
  • Mediastinal.
  • Apical.
  • Costal.
  • Interlobar.
• Common - the pathological process affects two or more walls of the pleura.
• Total - the entire pleural cavity is affected.

By the nature of the exudate:

• Purulent.
• Serous.
• Serous-fibrous.

According to severity:

• Lungs.
• Moderate weight.
• 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, pleural empyema is included in category J00-J99 of respiratory diseases.

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, the diagnostic auxiliary code for the primary lesion is used to make the final diagnosis.

Types of chronic pyothorax:

1. Limited
   • Apical - in the area of ​​the apex of the lung
   • Basal - on the diaphragmatic surface
   • Mediastinal – facing the mediastinum
   • Parietal - affects 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.

Ensacculated pleural empyema

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

As a rule, this species has a tuberculous etymology, and therefore disintegrates in the lateral pleura or supradiaphragmatically. Ensacculated pyothorax is exudative, with the effusion limited to adhesions between the layers of the pleura. 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.
• Chest pain.

For diagnosis, an ultrasound examination is performed to identify accumulated fluid and radiography. To determine the cause of the disease, a pleural puncture is performed. Treatment takes place in a hospital setting and requires strict bed rest. For therapy, corticosteroid hormones, various physiotherapeutic procedures and a special diet are prescribed.

Complications and consequences

The uncontrolled course of any disease leads to serious complications. The consequences of the purulent process in the pleura pathologically affect the condition of the whole organism. Death accounts for 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, which 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 occur in all organs and systems. But most often these are bronchopleural fistulas, multiple organ failure, bronchiectasis, and 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 outward, it takes the form of open pyopneumothorax. In this case, its course is complicated by a secondary infection, which can be introduced during a diagnostic puncture or during dressings. Prolonged suppuration leads to purulent peritonitis and pericarditis, sepsis, amyloid degeneration of organs and death.

Diagnosis of 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 difficulties.

Let's consider the main methods for identifying 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. Analysis of pleural fluid - allows you to identify the pathogen and determine the nature of the exudate. The material for research is obtained using pleural puncture - thoracentesis.
3. X-ray – used to identify changes characteristic of the disease. The image shows darkening, which corresponds to the spread of purulent contents and a displacement of the mediastinal organs to the healthy side.
4. Ultrasound and CT scans determine the amount of purulent fluid and allow you to specify the location for pleural puncture.
5. Pleurofistulography is a radiography that is performed in the presence of purulent fistulas. A radiopaque contrast agent is injected into the resulting hole and photographs are taken.

Analyzes

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.
• Analysis of pleural fluid.
• Examination of aspirated fluid.
• Bacteriological research.
• Bacterioscopy of a smear with Gram stain.
• 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.

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 parts of the organ filled with exudate.

Tomography - performed after draining 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 and an aspirator are connected to the tomography machine.

• Pleurography is a photograph of the lungs in three projections. Allows you to assess the size of the cavity, the presence of fibrinous deposits, sequestration and the condition of the pleural walls.
• Bronchoscopy - detects tumor lesions of the lungs and bronchial tree, which can be complicated by cancer.
• Fiberoptic bronchoscopy - gives an idea of ​​the nature of the inflammatory process in the bronchi and trachea, which occurs in the acute form of pleural empyema.

Pleural empyema on x-ray

One of the most informative and accessible methods for diagnosing inflammation of the respiratory system is x-ray. Pleural empyema on an x-ray appears as 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 massive infiltration of the lower lobe of the lung is observed, then an x-ray is taken 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. In the image you can see the upper limit of the effusion and assess the degree of lung collapse. The adhesive process significantly changes the radiography. During diagnosis, it is not always possible to identify a purulent cavity, since it can be either in the lung or in the pleura. If purulent pleurisy is accompanied by destruction of the respiratory organs, then deformed parenchyma is visible on the x-ray.

Differential diagnosis

Since the purulent process in the pleura is a secondary disease, differential diagnosis is extremely important to identify it.

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

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. For differentiation, bronchoscopy and puncture of the pleural cavity are used.

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

• Specific lesion of the pleura

We are talking about tuberculous and mycotic lesions, when the pathology precedes empyema. To make the correct diagnosis, exudate studies, puncture biopsy, thoracoscopy and serological tests are performed.

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

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

Algorithm for relieving the disease:

• Cleaning the pleura from pus using drainage or puncture. The earlier the procedure was performed, the lower the risk of complications.
• Use of antibiotic drugs. 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 detoxification 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 indicated for normal restoration of the body.
• If the disease occurs 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 root cause and the individual characteristics of the patient’s body.

The following drugs 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 carried out using aminoglycosides, carbapenems and monobactams. Antibiotics are selected as rationally as possible, taking into account the likely pathogens and based on the results of bacteriological diagnostics.

Traditional treatment

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 and 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.
• Heat 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 the product 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 sit in a water bath for 20-30 minutes. Add honey and aloe to the finished infusion, mix thoroughly and add vegetable oil. The medicine is taken 1-2 spoons 2-3 times a day before meals.

30. Pleural empyema

Empyema is an accumulation of pus in the cavities of the body. Inflammation of the pleural cavity, in which the exudate accumulating in it is purulent in nature, is called pleural empyema.

Empyemas are classified according to the location and extent of inflammation into limited and unlimited. Localized empyemas are divided into apical (in the area of ​​the apex of the lung), basal (in the area of ​​the diaphragmatic surface of the lung), mediastinal (projecting onto the medial surface of the lung facing the mediastinum), and parietal (projecting on the lateral surface of the lung). Unlimited ones are divided into total, subtotal and small.

Acute empyema is accompanied by the presence of general and local symptoms. The onset of the disease is acute: fever appears, the temperature rises to significant levels. Unlimited empyema is accompanied by the appearance of symptoms of intoxication. Involvement of the pleura in the process leads to chest pain, which intensifies with deep inspiration. Often there are complaints of cough with the release of a small amount of sputum, symptoms of respiratory failure. On examination, pronounced diffuse gray cyanosis is determined; patients often take a forced position with the head of the bed raised or sitting. When examining the chest directly, asymmetry is noted in the breathing of the healthy and diseased half of the chest. When determining vocal tremor over the area of ​​inflammatory effusion, it is sharply reduced or not detected, percussion reveals a dull percussion sound. A tympanic percussion sound is detected above the compressed exudate of the lung. Auscultation over purulent discharge reveals the absence of respiratory sounds, and hard breathing is detected over a compressed lung. A general blood test reveals general inflammatory changes - increased ESR, leukocytosis with a shift in the leukocyte formula to the left, and sometimes a decrease in hemoglobin levels is noted. In the biochemical blood test - hypoproteinemia, hypoalbuminemia, dysproteinemia. The area of ​​accumulation of pus is determined on the radiograph as a homogeneous darkening; massive effusion can be suspected based on the presence of an oblique border of the shadow corresponding to the Ellis-Damoise-Sokolov line determined by percussion.

Treatment of the disease is divided into conservative and surgical methods. This is a pleural puncture that provides both a diagnostic and therapeutic effect. In addition to the passive method, there is an active method of washing the pleural cavity - pleural lavage. It is advisable to take vitamin preparations and biogenic stimulants, such as tincture of ginseng and lemongrass. Having diagnosed pleural empyema, it is necessary to immediately begin antibiotic therapy: first with broad-spectrum antibiotics, after clarifying the sensitivity of microorganisms, prescribe the necessary antibiotic in compliance with the principles of antibiotic therapy.

Sheets with further accumulation of purulent masses in the pleural cavity. The disease requires immediate and comprehensive treatment, as otherwise a host of complications may develop.

Brief information about the disease

Pleural empyema (ICD-10 assigned code J86 to this pathology) is a serious disease that is accompanied by inflammation of the pleural layers. At the same time, purulent masses begin to accumulate in the anatomical cavities (the pleural cavity in this case).

Statistics show that men experience this disease three times more often than the fair sex. In most cases, empyema is a complication of other pathologies.

Reasons for the development of the disease

The causes of pleural empyema can be different. If we are talking about the primary form of the disease, then the trigger mechanisms in this case are the activity of pathogenic microorganisms, penetration of blood or air into the cavity, as well as a significant decrease in immunity. Primary empyema (in medicine the disease is also referred to as “purulent pleurisy”) develops when:

• violation of the integrity of the chest due to trauma or injury;
• previous surgical interventions, if they led to the formation of bronchial fistulas;
• thoracoabdominal chest injuries.

Secondary purulent pleurisy develops against the background of other pathologies. The list of them is quite impressive:

• purulent processes in any organ system;
• inflammation of lung tissue;
• abscess formation in lung tissue;
• oncological diseases of the respiratory system;
• spontaneous pneumothorax (violation of the integrity of the pleural cavity);
• inflammation of the appendix;
• peptic ulcer of the stomach and intestinal tract;
• gangrene of the lungs;
• cholecystitis;
• peritonitis;
• formation of ulcers in the liver;
• sepsis;
• osteomyelitis;
• esophageal rupture;
• inflammation of the pericardium;
• inflammatory processes in the pancreas;
• infectious diseases of the respiratory system;
• tuberculosis.

It is worth noting that the disease can be caused by the activation of certain pathogenic microorganisms, in particular pneumococci, streptococci, staphylococci, tubercle bacilli, pathogenic fungi and anaerobic bacteria. Pathogens can enter the tissues of the respiratory system along with the flow of blood and lymph from other organs.

Pleural empyema: classification

Today, there are many schemes that allow you to classify such pathology, because a variety of factors need to be taken into account.

For example, depending on the characteristics and duration of the course, acute and chronic pleural empyema are distinguished. Symptoms of such forms may vary. For example, in an acute inflammatory-purulent process, signs of intoxication come to the fore, and the disease lasts less than a month. If we are talking about a chronic form of the disease, then the symptoms are more blurred, but bother the patient for a long time (more than 3 months).

Depending on the nature of the exudate, empyema can be purulent, specific, putrefactive and mixed. There is a closed form (purulent masses are contained in the pleural cavity and do not come out) and an open form of the disease (the formation of fistulas between the pleura and the lungs, bronchi, and skin is observed, through which exudate circulates).

The volume of pus formed is also taken into account:

• minor empyema - the volume of purulent masses does not exceed 250 ml;
• medium, in which the volume of exudate is 500-1000 ml;
• large empyema - there is an accumulation of a large amount of pus (more than 1 liter).

Depending on the location of the lesion, the pathological process can be either unilateral or bilateral. Of course, all these characteristics are important for creating an effective treatment regimen.

Stages of development of the disease

Today, there are three stages of development of this pathology.

• The first phase is serous. Serous effusion begins to accumulate in the pleural cavity. If at this stage the patient was not provided with appropriate assistance, then the pyogenic flora begins to actively multiply in the serous fluid.
• The second stage is fibrous-serous. Exudate in the pleural cavity becomes cloudy, which is associated with the activity of pathogenic bacteria. Fibrinous plaque forms on the surface of the parietal and visceral layers. Gradually, adhesions form between the sheets. Thick pus accumulates between the leaves.
• The third stage is fibrous. At this stage, the formation of dense adhesions is observed, which constrain the lung. Since the lung tissue does not function normally, it also undergoes fibrotic processes.

Symptoms of pathology

The acute form of pulmonary empyema is accompanied by very characteristic symptoms.

• The patient's body temperature rises.
• There are other symptoms of intoxication, in particular, chills, pain and aching muscles, drowsiness, weakness, and sweating.
• A characteristic sign of empyema is coughing. At first it is dry, but gradually becomes productive. When coughing, sputum of a greenish-yellow, gray or rye hue is released. Often the discharge has an extremely unpleasant odor.
• The list of symptoms also includes shortness of breath - at first it appears only during physical activity, but then it bothers the patient even at rest.
• As the pathology progresses, chest pain appears, which intensifies with exhalation and inhalation.
• Changes in the functioning of the respiratory system also affect the functioning of the heart, causing certain disturbances in its rhythm.
• Patients complain of constant weakness, fatigue, decreased performance, a feeling of weakness, and lack of appetite.
• Disorders of the respiratory system are sometimes accompanied by some external symptoms. For example, the skin on the patient's lips and fingertips becomes bluish.

According to statistics, in approximately 15% of cases the process becomes chronic. However, the clinical picture looks different. There are no symptoms of intoxication, nor is there any increase in temperature. The patient is constantly bothered by a cough. Patients also complain of recurring headaches. If left untreated, various chest deformities develop, as well as scoliosis, which is associated with certain compensatory mechanisms.

Possible complications

Statistics show that properly selected treatment helps to cope with pleural empyema. Complications, however, are possible. Their list is as follows:

• dystrophic changes in the kidneys;
• serious damage to the myocardium, kidneys and some other organs;
• formation of blood clots, blockage of blood vessels;
• multiple organ failure;
• formation of bronchopleural fistulas;
• development of amyloidosis;
• pulmonary embolism associated with thrombosis (requires emergency surgery, as otherwise there is a high probability of death).

As you can see, the consequences of the disease are very dangerous. That is why you should never ignore the symptoms of the disease and refuse the help of a qualified specialist.

Diagnostic measures

Diagnosis of pleural empyema is extremely important. The doctor is faced with the task of not only confirming the presence of pyothorax, but also determining the nature of the pathological process, the extent of its spread, and the causes of its occurrence.

• To begin with, anamnesis is collected and the patient’s medical data is studied. During an external examination of the chest, one may notice some degree of deformation, bulging or smoothing of the intercostal spaces. If we are talking about chronic pleural empyema, then the patient has scoliosis. Very characteristic is drooping of the shoulder and protrusion of the scapula on the affected side.
• Auscultation is required.
• Subsequently, the patient is referred for various studies. Laboratory tests of blood and urine are mandatory, during which the presence of an inflammatory process can be determined. A microscopic examination of sputum and aspirated fluid is performed.
• Exudate samples are used for bacterial culture. This procedure allows you to determine the type and type of pathogen and check the degree of its sensitivity to certain medications.
• Fluoroscopy and radiography of the lungs are informative. In the photographs, the affected areas are darkened.
• Pleurofistulography is a procedure that helps detect fistulas (if any).
• A pleural puncture and ultrasonography of the pleural cavity will also be performed.
• Sometimes the patient is additionally sent for magnetic resonance and/or computed tomography. Such studies help the doctor evaluate the structure and functioning of the lungs, detect the accumulation of exudate and estimate its volume, and diagnose the presence of certain complications.

Based on the data obtained, the doctor selects appropriate medications and draws up an effective treatment regimen.

Therapeutic treatment

Treatment of pleural empyema primarily involves removing purulent masses - this can be done both during puncture and through a full opening of the chest (this method is used only as a last resort).

Since the formation of purulent exudate is to one degree or another associated with the activity of pathogenic microorganisms, broad-spectrum antibiotics in the form of tablets must be introduced into the treatment regimen. Drugs from the group of aminoglycosides, cephalosporins, and fluoroquinolones are considered effective. In addition, sometimes antibacterial agents are injected directly into the pleural cavity to achieve maximum results.

Sometimes patients are prescribed transfusions of protein drugs, for example, special hydrolysates, albumin, purified blood plasma. Additionally, solutions of glucose and electrolytes are introduced, which help restore the body's functioning.

Immunomodulatory therapy is mandatory, as well as taking vitamin complexes - this helps strengthen the functioning of the immune system, which, in turn, contributes to the rapid recovery of the body. It is also carried out. For example, in case of severe fever, antipyretic and non-steroidal anti-inflammatory drugs are used.

After the symptoms of empyema become less severe, patients are recommended physical therapy. Special breathing exercises help strengthen the intercostal muscles, normalize lung function, and saturate the body with oxygen. Therapeutic massage will also be useful, as it also helps clear the lungs of phlegm and improve the body’s well-being. Additionally, therapeutic exercise sessions are conducted. Ultrasound therapy also produces good results. During rehabilitation, doctors recommend that patients undergo restorative sanatorium-resort treatment.

When is surgery necessary?

Unfortunately, sometimes only surgery helps to cope with the disease. Pleural empyema, which is characterized by a chronic course and the accumulation of large amounts of pus, requires surgical intervention. Such methods of therapy can relieve symptoms of intoxication, eliminate fistulas and cavities, straighten the affected lung, remove purulent exudate and sanitize the pleural cavity.

Sometimes a thoracostomy is performed followed by open drainage. Sometimes the doctor decides to remove some areas of the pleura with further decortication of the affected lung. If there are fistulas between the tissues of the pleura, bronchi, lungs and skin, the surgeon closes them. If the pathological process has spread beyond the lungs, the doctor may decide on partial or complete resection of the affected organ.

Traditional medicine

Therapy for such a disease must be comprehensive. And sometimes the use of various herbal remedies is allowed.

• Regular onions are considered effective. Preparing the medicine is simple. Peel a medium-sized onion, rinse and chop. Next, you need to squeeze out the juice and mix it with natural honey (in equal quantities). It is recommended to take the medicine twice a day, one tablespoon at a time. It is believed that the product copes excellently with coughs and facilitates the discharge of sputum.
• At home, you can prepare an effective mucolytic mixture. You need to mix equal amounts of elecampane rhizome, coltsfoot herb, mint, linden flowers and licorice root. Pour 20 g of the plant mixture into a glass of boiling water, then let it brew. After cooling, strain the product and divide it into three equal portions - they should be drunk during the day. Every day you need to prepare fresh medicine.
• Horsetail is also considered effective. 20 g of dry herb (chopped) should be poured into 0.5 liters of boiling water. The container should be covered and left for four hours in a warm place, after which the infusion should be strained. It is recommended to take 100 ml four times a day for 10-12 days.
• There is a medicinal mixture that facilitates the breathing process and helps cope with shortness of breath. It is necessary to mix immortelle grass, dried calendula flowers with currant leaves, tansy and bird cherry in equal quantities. A tablespoon of the mixture is poured into a glass of boiling water and left to infuse. You need to take 2-3 tablespoons three times a day.
• If there are problems with the functioning of the respiratory system, then you need to mix natural honey and fresh radish juice in equal quantities. Herbalists recommend taking the medicine one tablespoon (tablespoon) three times a day.

Of course, you can use home remedies only with the permission of a specialist.

Unfortunately, there are no specific preventive measures. Nevertheless, doctors advise adhering to some rules:

• all inflammatory diseases (especially when they are accompanied by a purulent process) require timely therapy;
• it is important to strengthen the immune system, as this reduces the risk of developing such diseases (you need to try correctly, pierce the body, take vitamins, spend time in the fresh air);
• You should not avoid preventive examinations - the earlier the disease is detected, the less likely it is to develop certain complications.

It is worth noting that in most cases this disease responds well to treatment. It is not for nothing that pleural empyema is considered a dangerous pathology - it should not be ignored. According to statistics, approximately 20% of patients develop certain complications. The mortality rate for this disease ranges from 5 to 22%.

6805 0

Acute purulent pleurisy occurs as a complication of any primary purulent process (as a result of disease or injury), has certain stages of development, features of diagnosis and treatment. In clinical practice, the most commonly accepted term is “pleural empyema.”

Pleural empyema can occur as a result of the spread of a purulent process from surrounding organs and tissues (pneumonia, abscess and gangrene of the lungs, mediastinitis), as well as as a result of direct breakthrough of ulcers of the lung and mediastinum into the pleural cavity.

Lymphogenous spread of purulent infection in patients with peritonitis, cholangitis, retroperitoneal phlegmon can also lead to pleural empyema.

It is believed that the hematogenous route is also possible in the presence of distant purulent foci (abscesses and phlegmon of the lower extremities, osteomyelitis, otitis media).

If in past decades, in the overwhelming majority of cases, pleural empyema was, according to N. R. Paleev (1989), “an unfavorable variant of the course of exudative pleurisy of various genesis and etiology,” but recently pleural empyema due to primary infection has become more and more common pleural cavity in case of wounds and closed chest trauma.

Pleural empyema appears as a complication after planned operations on the breast organs, which is not without reason associated with the uncontrolled use of ineffective antibiotics and the poor immune status of the population as a whole.

Depending on the causes of its occurrence, pleural empyema occurs in different ways (meaning the speed of development, prevalence, degree of intoxication, prognosis, etc.). A relatively slow and benign purulent process in the pleural cavity develops when pathological contents become infected (hydrothorax and hemothorax with chest injuries, with spontaneous pneumothorax, with exudative pleurisy). This process, as a rule, tends to be delimited. When the contents of a lung abscess or gangrene (pyopneumothorax) break into the pleural cavity, intoxication and respiratory failure increase so rapidly that this condition in the literature of past years was designated as pleuropulmonary shock. Most often, most of the pleural layers are affected, and total pleural empyema occurs.

Pleural empyema is divided into:

1) by prevalence (total, limited);

2) by localization - in relation to limited empyema (interlobar, basal, apical, parietal, paramediastinal);

3) by type of pathogen (pneumococcal, staphylococcal, streptococcal, non-clostridial anaerobic, mixed).

As for the third sign, the identification of the non-clostridial anaerobic form of pleural empyema is of greatest clinical importance.

Pleural empyema in its development goes through several stages, the duration and severity of which depends on the mechanism of its occurrence, microbial flora, the initial state of the pleural cavity (free from adhesions, sealed), immune status and age of the patient, as well as the presence of concomitant pathology (diabetes mellitus, tuberculosis ).

The initial stage of infection is characterized by the appearance of fibrinous threads in the serous exudate, hyperemia and infiltration of pleural layers with leukocytes and the deposition of fibrin on them. Subsequently, the exudate becomes purulent. Its heavier and denser elements settle in the posteroinferior sections of the pleural cavity; in the upper sections the exudate is more transparent.

The progressive loss of fibrin leads to the formation of numerous loose adhesions among themselves, as a result of which a single large accumulation of pus turns into multiple, honeycomb-like, encysted cavities with purulent-fibrinous contents of varying viscosity, density and color.

The favorable course of pleural empyema consists of a gradual increase, and then the predominance of reparative processes with the formation of granulation tissue and the pyogenic membrane. Complete evacuation of pus, local exposure to antiseptics in such cases leads to sanitation of the cavity and, if the lung has not lost its elasticity, the cavity is obliterated, and recovery occurs.

In other cases, the prolonged histolytic action of pus leads to the destruction of the elastic layers of the pleura, and the process extends beyond the pleural cavity. The transition to the chest wall is manifested by extensive soft tissue phlegmon and osteomyelitis of the ribs. In the past, surgeons sometimes observed spontaneous drainage of pleural empyema through the chest wall in its thinnest area, not covered by muscle mass (along the mid-axillary line). This phenomenon is called "Empyema necessitatis".

The transition of the purulent process to the lung tissue leads to the destruction of the parenchyma, bronchioles and the formation of bronchopleural fistulas, often multiple (the so-called ethmoid lung is formed). Further lymphogenous spread of infection leads to the appearance of secondary purulent foci in the root of the lung and mediastinum.

Ineffective drainage of even a delimited cavity causes, after 2-3 months, the formation of chronic pleural empyema with a dense fibrous wall, the thickness of which leads to amyloidosis of the liver and kidneys, hepatorenal failure and death.

In the acute stage, the mortality rate (according to 1972 data) was 25% for staphylococcal empyema, 40% for empyema caused by gram-negative flora. Currently, the overall mortality rate with delayed or ineffective treatment can reach 10-15%.

In surviving patients, fibrotic changes in the chest wall of varying severity, atrophy of the intercostal muscles with deformation of the chest and spine occur. These changes are referred to as fibrothorax. Severe fibrothorax is accompanied by severe disturbances in external respiration. Such patients are deeply disabled and often die from an associated acute respiratory disease.

The clinical picture of pleural empyema as a severe complication of diseases and injuries is superimposed on the symptoms of the main pathological process. The most significant signs are a sharp increase in body temperature and its hectic range (over 2°C), an increase in tachycardia, general weakness, sweating, and shortness of breath.

Physical data are not very informative, since they are similar to the main pathological process (weakened breathing, shortened percussion sound, etc.).

X-ray data, at best, may indicate an increase in the amount of free fluid in the pleural cavity, however, against the background of previous serous pleurisy or coagulated hemothorax, these signs are not pathognomonic. The exception is pyopneumothorax due to the breakthrough of a purulent focus into the pleural cavity. This complication has not only the clear clinical picture given above, but also characteristic radiological signs: the appearance of pathological contents in the pleural cavity with a horizontal border and the presence of gases (Fig. 1).

Rice. 1. X-ray of a patient with pleural empyema

Ultrasound examination makes it possible to determine the prevalence of pathological contents, to a certain extent its volume (by the size of the divergence of the layers of the parietal and visceral pleura), as well as its nature (by the presence of echo-negative inclusions, visible fibrin threads) (Fig. 2).

Rice. 2. Ultrasonogram of a patient with pleural empyema

The most informative of all radiological diagnostic methods is CT, which allows you to accurately, down to several cm³, determine the location, volume of encysted purulent accumulations, their total volume and content density (Fig. 3).

Rice. 3. CT scan of a patient with pleural empyema

However, to date, diagnostic puncture of the pleural cavity has been unsurpassed in efficiency and simplicity, allowing not only to establish a diagnosis of purulent pleurisy, but also to determine the nature of the microflora. It should be emphasized that the diagnostic value of microbiological identification of the pathogen increases significantly with the possibility of collecting material for sowing of both ordinary and anaerobic flora.

At the same time, puncture of the pleural cavity is not an effective treatment procedure in the presence of thick, crumbly pus containing a large amount of fibrin and tissue breakdown products. In addition, a complete, but one-time evacuation of liquid pus from the pleural cavity in the context of an ongoing inflammatory process cannot lead to its reverse development, even with the local use of strong antibacterial agents.

In such cases, it is necessary to perform multiple (daily or every few days) punctures of the pleural cavity. The advantages of this method include, firstly, the possibility of developing phlegmon of the soft tissues of the chest wall, and, secondly, longer treatment with the outcome of the process in a chronic form.

The most reasonable method of treating pleural empyema is drainage of the focus of pus accumulation with double-lumen TMMK tubes to rinse the pleural cavity with solutions and antiseptics and constant aspiration of the contents.

Aspiration of the contents of a purulent cavity under the influence of irritation created artificially in the contents collection system and drainages is an active drainage method. In such cases, the liquid part of the contents is forcibly evacuated from the purulent cavity, and the vacuum transmitted to the walls of the cavity contributes to their collapse.

By now, the method has been carefully developed, widely known and, obviously, there is no need to describe its details in detail.

Here it is only worth noting that passive drainage methods, when the contents flow out of the purulent cavity under the influence of gravity (spontaneously), capillarity (tamponing with hygroscopic material) or under the influence of expelling respiratory movements (using Bulau drainage or other valve devices), are less effective compared to active drainage systems.

If the purulent process tends to encyst, the introduction of proteolytic enzymes into the pleural cavity with their exposure for no more than 1-2 hours and subsequent thorough release of the proteolysis product (jet rinsing with an antiseptic solution with three to four times filling and emptying of the pleural cavity) can be successfully used.

As a result of this treatment, the pleural cavity is quickly freed from fibrinous deposits, the solution aspirated from the cavity becomes transparent, the pleural layers cease to be rigid, the cavity collapses and the lung tissue straightens. This entire sequence of reverse development of the process can be visualized by periodically performing fistulography: filling the cavity through the pleural drainage with a water-soluble radiopaque substance and taking radiography at least twice.

The first radiograph is performed when the cavity is filled to its maximum extent, which makes it possible to identify its volume, configuration, nature of the contours (clear, unclear), as well as the presence of bronchopleural fistulas. The second radiograph is performed after connecting the aspiration and evacuation system, which makes it possible to assess the completeness of the evacuation, the adequacy of the position of the drains, as well as the need to correct their position.

The use of the active drainage method allows for recovery in the vast majority of cases. The transition to the chronic stage, requiring the use of traumatic surgical treatment, is observed much less frequently than when using the puncture method.

A very effective therapeutic and diagnostic method is thoracoscopy, which was highly appreciated by G. I. Lukomsky (1976). In his monograph “Nonspecific pleural empyema,” he wrote about thoracoscopy: “It is very tempting to examine in detail the inner surface of the empyema cavity, its boundaries, relief, to try to determine the nature of the pleural layers, their thickness and structure, because, ultimately, it is here that the the answer to the question whether the lung is capable or incapable of expansion.”

Inspection and sanitation of the pleural cavity under visual control is indeed a highly desirable procedure. But this procedure is a one-time procedure, and the use of thoracoscopy still requires the presence of full and long-term drainage of the pleural cavity. Information about the dynamics of the process and the effectiveness of treatment can currently be obtained by using non-invasive methods of radiation diagnostics (ultrasound, CT, fistulography).

At the same time, it should be recognized that thoracoscopy is one of the most effective diagnostic and treatment methods for patients with bronchopleural fistulas that support a purulent inflammatory process in the pleural cavity. Identification of small fistulas, their electrical or laser coagulation during thoracoscopy, laser beam treatment of the empyema cavity can accelerate reparative processes and promote recovery.

In conclusion, it should be emphasized that total pleural empyema, being a severe form of generalized purulent infection, along with widespread peritonitis and total mediastinitis, requires the use of the same complex of intensive therapy, which is carried out according to the principles common to these generalized forms. A detailed description of this complex is given in the relevant sections of the manual.

Pleural empyema (purulent pleurisy, pyothorax) – accumulation of pus or fluid with biological signs of infection in the pleural cavity with involvement of the parietal and visceral pleura in the inflammatory process and secondary compression of the lung tissue.

Etiology of pleural empyema

Pneumonia,

bronchiectasis,

lung abscess

lung gangrene

tuberculosis.

Exudative pleurisy

mediastinitis

pericarditis

osteomyelitis ribs and spine

under the diaphragmatic abscess

liver abscess,

acute pancreatia.

Classification:

According to communication with the external environment, the following are distinguished:

- “closed”, without a fistula (does not communicate with the external environment);

- “open”, with a fistula (there is a connection with the external environment in the form

pleurocutaneous, bronchopleural, bronchopleurocutaneous,

pleuroorgan, bronchopleuroorgan fistula).

According to the volume of damage to the pleural cavity:

Total (on a plain radiograph the lung tissue is not

determined);

Subtotal (only visible on a plain radiograph)

apex of the lung);

Limited (with encystation and mooring of exudate):

apical, parietal paracostal, basal, interlobar,

paramediastinal.

According to etiological factors, they are distinguished:

Para- and metapneumonic;

Due to purulent destructive diseases of the lungs (abscess,

gangrene, bronchiectasis);

Post-traumatic (chest injury, lung injury,

pneumothorax);

Postoperative;

Due to extrapulmonary causes (acute pancreatitis,

subphrenic abscess, liver abscess, inflammation of soft tissues and

bone frame of the chest).

Pathogenesis of pleural empyema

three stages of development

serous,

fibrinous-purulent

stage of fibrous organization.

First stage- occurs with the formation of serous effusion in the pleural cavity.

Fibrinous-purulent stage - In this phase of pleural empyema, due to an increase in the number of bacteria, detritus, and polymorphonuclear leukocytes, the exudate becomes cloudy, acquiring a purulent character. A fibrinous plaque forms on the surface of the visceral and parietal pleura, loose and then dense adhesions appear between the layers of the pleura. The adhesions form limited intrapleural encystations containing an accumulation of thick pus.

In the stage of fibrous organization- the formation of dense pleural cords occurs, which, like a shell, fetter the compressed lung. Over time, non-functioning lung tissue undergoes fibrotic changes with the development of pleurogenic cirrhosis of the lung

Pleural empyema clinic

1. persistently high (up to 39°C and above),

   profuse sweating,

   increasing shortness of breath,

   tachycardia,

   cyanosis of the lips, acrocyanosis.

   endogenous intoxication is pronounced: headaches, progressive weakness, lack of appetite, lethargy, apathy.

There is intense pain on the affected side; stabbing pain in the chest worsens with breathing, movement and coughing.

Volemic and water-electrolyte disorders due to loss of proteins and electrolytes, accompanied by a decrease in muscle mass and weight loss.

Diagnosis of pleural empyema

Typical external signs of a patient with chronic pleural empyema are: a curve of the spine in the healthy direction, a drooping shoulder and a protruding scapula on the affected side.

Percussion sound on the side of purulent pleurisy is dull

radiography fluoroscopy of the lungs- with empyema, the pleura exhibit intense shading.

CT, MRI of the lungs.

Ultrasound of the pleural cavity allows you to detect even a small amount of exudate and determine the location of pleural puncture

Bacteriological and microscopic analysis of pleural effusion allows us to clarify the etiology of pleural empyema.

Treatment of pleural empyema

emptying the pleural cavity of purulent contents

drainage of the pleural cavity,

vacuum aspiration of pus,

pleural lavage,

administration of antibiotics and proteolytic enzymes,

therapeutic bronchoscopy.

2.systemic antibiotic therapy (cephalosporins, aminoglycosides, carbapenems, fluoroquinolones). 3. detoxification, immunocorrective therapy, vitamin therapy, transfusion of protein preparations (blood plasma, albumin, hydrolysates), glucose solutions, electrolytes.

4.breathing exercises, exercise therapy, ultrasound, classic, percussion and vibration chest massage.

When chronic pleural empyema forms, surgical treatment is indicated. In this case, thoracostomy (open drainage), pleurectomy with lung decortication, intrapleural thoracoplasty, closure of bronchopleural fistula, various options for lung resection can be performed.