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[Pleural empyema]
1Abteilung für Thorax- und Gefässchirurgie, Universität Ulm.
Abstract:
Thoracic empyema may be based on four different etiologic mechanisms of infection: (1) parapneumonic, (2) posttraumatic, (3) postspecific, (4) postsurgical. According to morphologic processes, three different time-dependent stages may be present: (1) exudative phase, (2) fibrino-purulent phase, (3) organization and pleural peel formation. Diagnosis and pleural puncture are based on the findings of thoracic CT and transthoracic ultrasonography. Thoracocentesis, however--even if performed repeatedly--is not an appropriate treatment of empyema. Chest tube drainage and irrigation of the pleural cavity is appropriate only in stage I and early stage II disease to re-establish total lung inflation and healing without pleural peel formation. Selected stage II cases may benefit from video-assisted debridement, but a 30% conversion rate to open thoracotomy has to be assumed. Residual organized cavities, loculated peels etc. require open thoracotomy and empyemectomy, decortication or combined maneuvers. For treatment quality and outcome it is not only decisive to remove the source of infection but also to reexpand the entire lung without remaining restrictive peels and without relevant leaks.
Insights
Thoracic empyema, an infection in the chest, has four causes and three stages. Treatment depends on the stage, ranging from chest tube drainage to surgery for advanced disease.
Area of Science:
- Pulmonology
- Thoracic Surgery
- Infectious Diseases
Context:
- Thoracic empyema presents with diverse etiologies including parapneumonic, post-traumatic, post-specific, and post-surgical infections.
- The disease progresses through three distinct morphologic stages: exudative, fibrino-purulent, and organization with pleural peel formation.
Purpose:
- This review outlines the etiologic mechanisms, staging, diagnostic modalities, and therapeutic strategies for thoracic empyema.
- To provide a comprehensive overview of thoracic empyema management based on disease stage and morphology.
Summary:
- Diagnosis relies on thoracic CT and ultrasonography, guiding pleural puncture.
- Early-stage empyema (Stage I and early Stage II) may be treated with chest tube drainage and irrigation.
- Advanced or organized empyema necessitates surgical intervention, including video-assisted debridement or open thoracotomy with decortication or empyemectomy.
Impact:
- Optimal treatment requires addressing the infection source and ensuring complete lung reexpansion.
- Effective management aims to prevent restrictive peels and air leaks for improved patient outcomes.
- Understanding the stages and etiologies is crucial for selecting appropriate interventions and improving thoracic empyema treatment efficacy.