Upload
pediatricsmgmcri
View
251
Download
1
Embed Size (px)
Citation preview
PLEURAL EFFUSION &EMPYEMA
Dr.BANUPRIYA
The pleural space lies between the lung and chest wall and normally contains a thin layer of fluid.
Pleural effusion is present when there is an excess quantity of fluid in pleural space.
MECHANICS OF PLEURAL EFFUSION
Increased capillary/pleural membrane permeabiltiy
Increased capillary hydrostatic pressure Decreased intravascular oncotic pressure Lymphatic obstruction Abnormal sites of entry
TRANSUDATIVE EFFUSION –results from alteration in hydrostatic or oncotic pressure of capillaries in parietal pleura
EXUDATIVE EFFUSION- results from change in permeability of capillaries or pleural membranes or from obstruction in lymphatic drainage.
Transudative effusion Nephrotic syndrome Congestive cardiac
failure Hepatic failure PEM Hypothyroidism
Exudative effusion Infections-Pneumonia,lung
abcess,bronchiectasis,TB Malignancy-
Metastasis,leukemia/lymphoma
Collagen vascular diseases-SLE,JRA
Traumatic Drugs-
Amiodarone,bromocriptine Postradiation
Light’s criteria Exudative effusion meet atleast one of the following
criteria,wheras transudative effusions meet none. Pleural fluid protein/serum protein > 0.5 Pleural fluid LDH/serum LDH > 0.6 Pleural fluid LDH-more than two third of serum LDH The above criteria misidentify 25% of transudatesas exudates.
CLINICAL FEATURES
Symptoms depend on the underlying cause of pleural effusion
Commonly presents with pleuritic chest pain(sharp stabbing pain worsened by deep inspiration),dyspnoea,cough
On examination Tachypnea,chest retractions Decreased chest movements on the affected side (hoover’s
sign) Tracheal and mediastinal shift in large effusions
Decreased vocal fremitus and vocal resonance Decreased or absent breath sounds Bronchophony or aegophony above the level of effusion. Dullness on Traube space percussion
CHYLOTHORAX Accumulation of chyle in pleural space. Common causes are -Trauma to thoracic duct -Tumor -Lymphatic obstruction
Pleural fluid characteristics-milky white,high triglyceride levels
Hemothorax Presence of blood in pleural space. Common causes are - Chest wall injuries - Malignancy - Bleeding disorders - Pulmonary infarction
Parapneumonic effusion&empyema
Parapneumonic effusion – sterile pleural effusion with few or no inflammatory cells.It occurs in around 40% of bacterial pneumonias.
Empyema –presence of pus or microorganism in pleural fluid.
Common causative organisms – Staphylococcus aureus,streptococcus pneumoniae,Hemophilus influenza, streptococcus pyogenes
Gram negative organisms and MRSA are more common pathogens in HIV associated empyema.
Anaerobic organisms like bacteroides are common in empyemas following aspiration pneumonia
Atypical organisms like mycoplasma,Chlamydia, viruses,fungi like candida,aspergillus rarely cause empyema.
Although tuberculous effusions are relatively common,tuberculous empyema is quite rare.
PATHOGENESISIt occurs in three stagesExudative stage Clear sterile fluid accumulates in pleural space as a result of
increased pleural and capillary permeability associated with infection
Fibrinopurulent stage Bacterial invasion of pleural space Deposition of fibrin in pleural space leading to septation or
loculations Characterised by presence of turbid fluid or frank pus
Organisational stage ( >14days) Infiltration of fibroblasts in pleural space Thin fibrin membranes transformed into thick pleural
peels,resulting in ‘trapped lung’. More common in staphylococcal empyema Complications like chronic empyema,bronchopleural fistula
and spontaneous perforation through chest wall (empyema necessitans)
Clinical features
Presents with high grade fever with chills,malaise,dyspnoea, pleuritic chest pain.Child prefers to lie on affected side splinting the chest with knees drawn up to the chest.
On examination,in addition to usual findings of pleural effusion,erythema,edema and tenderness of chest wall on affected side may be noted.
INVESTIGATIONS
Chest xray An anteroposterior chestxray should be done in all
children with suspected pleural effusion. Atleast 300ml of fluid should be present to detect effusion clinically and radiographically in AP view.
Lateral decubitus CXR with affected side inferior allows recognition of smaller volumes of fluid.
Xray features- Obliteration of costophrenic and cardiophrenic angles
homogenous opacity of affected hemithorax with mediastinal shift to contralateral side
Ultrasound Helps to differentiate consolidated lung from pleural fluid
especially when there is white out on CXR and clinical signs do not clearly distinguish
Identify pleural thickening and loculated effusions To guide thoracocentesis and chest tube insertion
CT thorax Useful if effusion is minimal or loculated to differentiate effusion from pleural thickness
Thoracocentesis(pleural tap) Indicated if pleural fluid thickness from chest wall more
than 1 cm in lateral decubitus xray and that is of uncertain etiology
Pleural fluid analysis- Gross examination Cell count pH Glucose LDH Protein Gram stain and culture
Lymphocytois-suggestive of tuberculous effusion or malignancy
Pleural fluid ADA > 70IU/L is suggestive of tuberculous effusion.
Biochemical analysis of pleural fluid is unnecessary in case of frank pus.
Blood culture Positive in 10-20% of cases of empyema Sputum,tracheal aspirate and bronchoalveolar lavage sent for
cultures if possible in parapneumonic effusions
Investigations relevant to underlying cause
TREATMENT
• Treatment of underlying cause
• Parapneumonic effusions - appropriate antibiotic therapy and supportive treatment
Simple drainage in case of large effusions and compromised pulmonary function
• Empyema –Antibiotic therapy,supportive treatment and chest tube drainage.
Supportive treatment Adequate oxygenation to maintain spO2>92% Nutrition and adequate hydration
Antibiotic therapy Commonly used antibiotic combinations are cloxacillin and
amikacin Cloxacillin and third generation cephalosporins
In immunocompromised children,cloxacillin and ceftazidime started to cover pseudomonas and other gram negative anaerobes.
If response is poor ,if multiple loculations or putrid smelling pus present,antibiotics for anaerobic cover like clindamycin or metronidazole added.
If MRSA suspected,vancomycin is added.
Treatment is modified based on culture and sensitivity reports.
Parenteral therapy should be continued for 48-72 hrs after abatement of fever and then oral therapy can be used to complete the course.
Antibiotics should be continued till the patient is afebrile and,chest tube drainage is less than 50ml/day.
Duration of antibiotics- 7-14days in case of s.pneumonia or h.influenza
3-4weeks in case of s.aureus
Chest tube drainage Chest drain should be inserted in all children diagnosed
with empyema.Repeated taps are not recommended.
Preferred site for insertion- preferentially in midaxillary line through safe triangle or as suggested by ultrasound
Tube is connected to underwater seal drainage.
Chest drain should be removed if fluid drainage is less than 30ml/day and no residual air or fluid collection noted.
Exercises Early ambulation and breathing exercises are advised to
improve lung expansion ,once toxemia subsides. Chest physiotherapy is not beneficial and not recommended
in children.
Intrapleural fibrinolytic therapy
Instillation of fibrinolytic agents in pleural space via chest drain lyses fibrin strands and clears lymphatic pores ,thus facilitating better drainage.
Agents used – urokinase-proven safe and effective in children
Streptokinase Alteplase
Surgery Considered when empyema fails to resolve despite above
mentioned treatment or in cases of organized empyema(trapped lung)
bronchopleural fistula Options – minithoracotomy and debridement Open decortication Video assisted thoracoscopic adhesiolysis
(VATS)
Complications of empyema Pyopneumothorax Bronchopleural fistula Empyema necessitns Septicemia
THANK YOU