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[Pleural empyema in mechanically ventilated patients with pneumonia]
A J ten Hagen1, T S van der Werf, J J Ligtenberg
1Afd. Interne Kliniek, Intensive-carebeademing, Academisch Ziekenhuis, Groningen.
Abstract:
Two males aged 41 and 32 years developed pneumonia which responded inadequately to antibiotic treatment and necessitated mechanical ventilation. It was only after surgical and digital opening, drainage of pus pockets and daily pleural lavage that the clinical picture improved. The microorganisms cultured from both patients included Streptococcus milleri, probably acquired by aspiration. Thoracic empyema as a complication of pneumonia is clinically recognised by lack of response to antimicrobial agents. For the diagnosis, ultrasonographic and CT imaging, followed by pleural puncture are used. Simple parapneumonic effusions are managed by drainage with or without rinsing with normal saline, while in advanced empyema, instillations with fibrinolytic agents have proved safe and effective. Sometimes, video-assisted thoracoscopic or conventional surgery is necessary to clear the pleural space, while in complicated cases, extensive surgical procedures are warranted.
Insights
Severe pneumonia unresponsive to antibiotics in two men was successfully treated with surgical drainage and pleural lavage. This highlights the importance of these interventions for thoracic empyema, a serious pneumonia complication.
Area of Science:
- Pulmonology
- Infectious Diseases
- Thoracic Surgery
Background:
- Pneumonia can lead to thoracic empyema, a complex pleural space infection.
- Thoracic empyema often presents with inadequate response to standard antibiotic therapy.
- Early recognition and intervention are crucial for managing empyema.
Observation:
- Two male patients, aged 41 and 32, developed severe pneumonia requiring mechanical ventilation.
- Initial antibiotic treatment was ineffective, indicating a complicated pleural infection.
- Surgical intervention involving pus drainage and daily pleural lavage led to clinical improvement.
Findings:
- Streptococcus milleri was identified as the causative agent in both cases, likely due to aspiration.
- Advanced empyema management may require more than simple drainage, including fibrinolytic agents or surgery.
- Surgical procedures, from video-assisted thoracoscopic surgery to open procedures, are essential for clearing the pleural space in complicated empyema.
Implications:
- This case underscores the necessity of considering surgical intervention for refractory pneumonia with suspected empyema.
- Prompt diagnosis using imaging (ultrasound, CT) and pleural fluid analysis is vital.
- Aggressive management, including surgical drainage and lavage, can be life-saving in advanced thoracic empyema.