Complications of chronic empyema

Complications due to chronic toxaemia.—The most common complications are those which arise as the result of a chronic toxaemia ; they include pulmonary osteoarthropathy, amyloid disease and nephritis. The symptoms and joint effusions associated with pulmonary osteoarthropathy usually clear up quickly as soon as the chronic suppuration in the chest has been controlled. It is important to realize that amyloid disease is also reversible, provided that it has not been present over a long period. In many cases the

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Treatment (Empyema)

A chronic empyema can be cured permanently only by obliteration of the cavity. This may occur either as the result of re-expansion of the lung or in consequence of operative mobilization of the chest wall ; in the latter case, the parietal pleura falls inwards to meet and fuse with the visceral layer where it covers the partially collapsed lung. It is obvious that the functional and cosmetic result is much better when the cavity is obliterated by re-expansion of the lung ; plastic operations on the chest wall should therefore be reserved for cases in which complete re-expansion of the lung proves to be impossible.

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Clinical types

Two clinical types of chronic pyogenic empyema may be recognized : (1) "latent", in which drainage has never been performed, either because the diagnosis was not made during the acute stage or because the clinician did not recognize the need for external drainage ; (2) " persistent", in which a cavity persists in spite of external drainage.

Latent empyema.—A patient with a latent empyema may be free from symptoms, and may have been referred for treatment because the signs of an encysted collection of fluid have been discovered on clinical or radiological examination. This applies particularly to those cases in which the pus is sterile as a result of either local or systemic chemotherapy. In other cases the patient complains of persistent fever, chest pain or dyspnoea following an acute respiratory infection. Sometimes the patient notices that, after recovering from an attack of pneumonia, he has not returned to the same state of vigorous health which he enjoyed before his illness. Then, after an interval which varies from a few weeks to several years, he may suffer an acute febrile episode accompanied by pleural pain. If the correct diagnosis is not recognized and appropriate treatment instituted, these symptoms may gradually subside but are liable to recur again and again. As long as a latent empyema persists, it may at any time develop into an empyema necessitatis : the patient will then complain of a tender swelling in the chest wall.

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CHRONIC EMPYEMA

It is obvious that all cases of chronic empyema have passed through an acute stage and that the transition from the acute to the chronic stage is a gradual one, so that there is no clear line dividing the two conditions. Furthermore, the conditions under which an empyema may be reasonably defined as " chronic " are subject to the personal views of individual clinicians; but it is suggested here that the term, chronic, should be applied to those cases in which a cavity persists for more than 3 months after the original pleural effusion.

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Complications of acute empyema

(1)  Bronchopleural fistula.—Fistulae which complicate an acute empyema
almost invariably heal after dependent drainage of the empyema.

(2)   Failure of the lung to re-expand and obliterate the empyema cavity.-—See "Chronic Empyema".

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Empyema complicating diseases other than pneumonia

(1) Secondary to septicaemia or pyaemia.—In patients with a generalized blood infection, the occurrence of pleural pain, dyspnoea or an unexplained deterioration in general condition should lead to a careful investigation for evidence of infection of the pleural space. Fortunately, these cases, which were often bilateral, are now rare, as the result of the widespread use of chemotherapy.

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Possible future advances in treatment

One of the strongest arguments in favour of performing rib resection in all cases of localized empyema is that this provides an opportunity to remove all the fibrin from the cavity. It is now possible to obtain commercially enzymes which are capable of breaking down within the human body the solid constituents of an inflammatory exudate. These enzymes, which are derived from the culture of haemolytic streptococci, are known as streptokinase and streptodornase. The former breaks down fibrin and the latter leads to the

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Control of the drainage tube

The rapid obliteration of an empyema depends more on the maintenance of perfect drainage than on any other factor. Lateral and frontal skiagrams should be taken within 48 hours of surgical drainage. A fluid level in the empyema indicates imperfect drainage ; this may be due to blockage of the tube by fibrin ; in other cases the tube is too long and so projects above the bottom of the cavity, but sometimes it is too short, so that the inner end has been withdrawn from the cavity into the chest wall. In any of these circumstances, the tube must receive immediate and appropriate adjustment.

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Post-operative care

Post-operative care is essentially directed towards obtaining rapid re-expansion of the lung and consequent obliteration of the empyema cavity. The drainage tube should remain connected to a water-seal bottle for a variable period, depending on the size of the empyema and the mobility of the walls of the cavity. In the case of large cavities, re-expansion of the lung will be assisted

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Treatment (Empyema)

Aspiration and chemotherapy

If the presence of a pleural effusion is recognized early, if aspiration produces fluid from which the solid deposit on standing is less than one-third of the total volume, and if the bacteria are sensitive to some antibiotic suitable for intra-pleural injection, there is a reasonable chance that the empyema will be quickly and completely cured by repeated aspiration combined with local chemotherapy. Aspiration must be repeated as often as the fluid re-collects, so that the pleural cavity is kept constantly as dry as possible. At the beginning of treatment this may entail aspiration on alternate days or even daily. At the end of each aspiration the appropriate antibiotic is injected into the empyema, and this should not be omitted until it is found impossible to demonstrate bacteria in a film of the pus on at least two consecutive occasions. It is more satisfactory to rely on microscopic examination of the pus than on cultures, for bacteria may be present and yet fail to grow when incubated on suitable media. In the case of penicillin-sensitive bacteria, it is suggested above that the initial dose should be in the region of 500,000 units, but, subsequently, it is doubtful whether anything is gained by exceeding 100,000 units at each intrapleural injection.

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Comparative and clinical types

Comparative and clinical types

Previously it has been the custom to divide those empyemas which complicate pneumonia into two types : (1) synpneumonic and (2) metapneumonic. In the synpneumonic group the effusion usually formed rapidly and occurred very early in the course of a streptococcal broncho-pneumonia, which was often a sequel to influenza. The patients were already seriously ill from the effects of the pneumonia, and infection of the pleural cavity led to a further deterioration of the general condition, marked by distressing dyspnoea and an increase in fever and pulse rate.    Aspiration  of the thin  pleural fluid containing haemolytic 

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Aetiology and pathology (Empyema)

Because pneumonia is the most common precursor of pyogenic infection of the pleural space, there is a tendency to forget the many other conditions which may lead to suppurative pleurisy.

Infections derived from the lungs

When the lung is the source of the infection, it is always possible that some lesion other than pneumonia—such as bronchogenic carcinoma with secondary suppuration, lung abscess, bronchiectasis or actinomycosis—may be responsible for infecting the pleural cavity. Owing to the great increase in the incidence of

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NON-TUBERCULOUS EMPYEMA THORACIS

Strictly speaking the term, " empyema thoracis", should be confined to the description of a localized collection of pus within the pleural cavity. The early stages of bacterial invasion of the pleural cavity and the consequent formation of fluid which is not localized by adhesions must then be described by some other expression, such as generalized or diffuse suppurative pleurisy with effusion. However, in this chapter, in order to conform with common practice and for the sake of convenience, the terra, empyema, will be used to cover all stages of suppurative pleurisy.

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