National clinical guidelines “pleural empyema” Working group for the preparation of the text of clinical guidelines. Pleural empyema (Purulent pleurisy, Pyothorax) Chronic pleural empyema ICD code 10

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 therapy. 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%.

Compiled and edited by V.V. Lishenko, Associate Professor of the Department of Surgery and Innovative Technologies, VTsERM A.M. Nikiforova Ministry of Emergency Situations of Russia, head of the department of purulent pulmonary surgery of the hospital surgery clinic of the Military Medical Academy in the period 1991-1998.

Zolotarev D.V., Candidate of Medical Sciences, Head of the Department of Purulent Thoracic Surgery of the Moscow City Clinical Hospital No. 23 named after Medsantrud, Moscow Healthcare Department; senior researcher at the Scientific Research Institute "Surgical Infection" of the Research Center of the State Budgetary Educational Institution of Higher Professional Education First Moscow State Medical University named after. I.M. Sechenov of the Ministry of Health of Russia, employee of the department of purulent pulmonary surgery of the Military Medical Academy in the period 1996-1999.

Skryabin S.A., Head of the Department of Thoracic Surgery, Murmansk Regional Clinical Hospital named after. P.G. Balandina.

Popov V.I., Doctor of Medical Sciences, head of the department of purulent pulmonary surgery of the Military Medical Academy in the period 1998-2005.

Kochetkov A.V., Doctor of Medical Sciences, Professor, Chief Surgeon of the VTsERM named after. A.M. Nikiforova, employee of the purulent pulmonary department of the clinic named after. P.A. Kupriyanov Military Medical Academy in the period 1982-1986.

Egorov V.I., Candidate of Medical Sciences, Head of the Center for Purulent Pulmonary Surgery in St. Petersburg.

Deinega I.V., Zaitsev D.A., Velikorechin A.S.

Consultants: Professor Chepcheruk G.S. Professor Akopov A.L.

CODE ICD 10

J86.0 Pyothorax with fistula

J86.9 Pyothorax without fistula

Definition

Pleural empyema is a purulent (putrefactive) inflammation that develops in the pleural cavity involving the parietal and visceral pleura in the pathological process.

Etiology and pathogenesis

The development of purulent or putrefactive inflammation in the pleural cavity in the vast majority of cases is preceded (except for breakthroughs of ulcers from the lung, mediastinum, etc. into the pleura) by a primary non-bacterial exudative reaction of the pleura (non-infectious exudative pleurisy). This is due to the increased permeability of the blood and lymphatic capillaries of the cortical layers of the lungs, involved in the perifocal inflammatory reaction in various pathological processes, primarily in the pulmonary parenchyma, as well as in injuries to the lung and chest wall. The accumulation of exudate in the pleural cavity is facilitated by swelling of the mesothelial layer, blockage of the absorption surfaces of the pleura by fibrin deposits on it.

Often, a predisposing factor for the development of pleural empyema is the presence of uninfected pleurisy of another origin - infectious-allergic (rheumatic, rheumatoid), pleurisy with collagenosis (systemic lupus erythematosus, periarteritis nodosa), with post-embolic pulmonary infarction, carcinomatosis and mesothelioma of the pleura. Fluid in the pleural cavity can accumulate due to circulatory failure and chylothorax. A pronounced exudative reaction is observed when blood leaks into the pleural cavity (so-called hemopleuritis) with closed injuries to the chest.

The penetration of microorganisms into pleural exudate - “infection of pleurisy” - occurs in various ways. Lymphogenous infection of the pleural cavity is associated with retrograde flow of tissue fluid during inflammatory processes in the pulmonary parenchyma (pneumonia, bronchitis, purulent bronchitis, hilar abscesses of the lungs), purulent processes in the abdominal cavity (peritonitis, pancreatitis, subphrenic abscess).

Some researchers identify a hematogenous route of infection into the pleural cavity (sepsis, septic embolism of the vessels of the pulmonary circulation), but in these cases it is impossible to reliably

exclude the parapneumonic nature of pleurisy and pleural empyema due to lymphogenous infection of the pleural contents. Direct infection of the pleural cavity with the development of pleural empyema, when microorganisms penetrate into the pleural cavity from the environment with air, foreign bodies, wounding projectiles, is typical for open chest injuries, including surgical interventions on the organs of the chest cavity. In this case, the exudative reaction is caused by trauma to the pleura, irritation by the shed blood, and the infectious process itself. In these cases, some authors call pleural empyema primary.

The direct route of infection of the pleural cavity is indicated when subcortically located abscesses of the pulmonary parenchyma break into it. The entry of a large amount of abscess contents into the pleural cavity causes a violent exudative reaction, and the resorption of microbial toxins by the intact pleura in the early stages of the development of the process leads to the development of infectious-toxic shock. The same mechanism for the development of an infectious process in the pleural cavity is observed with gangrene of the lung, when large areas of the pulmonary parenchyma along with the visceral pleura are exposed to putrefactive decay. Constant microbial invasion and the prevalence of the process (involvement of all parts of the pleura, including the parietal) determine the particular severity of pleural empyema with this mechanism of occurrence.

The further development and nature of the infectious process in the pleural cavity after the penetration of microorganisms into it depends on many factors, but the condition of the local

And general immunity, type of pathogen.

IN The etiological structure of pleural empyema, according to recent studies, is dominated by staphylococci, streptococci, Pseudomonas aeruginosa, and Proteus. In more than a third of cases, these microorganisms are in association with numerous types of non-clostridial anaerobic microflora (bacteroides, fusobacteria, peptostreptococci). In the initial stages of the development of the disease, there is, as a rule, an increase in the exudative reaction of the pleura, which, along with inhibition of resorption due to a block of tissue structures in the deep layers of the pleura as a result of inflammation, causes the accumulation of fluid in the pleural cavity. The high content of fibrinogen in pleural exudate leads to the formation of significant fibrinous deposits on the walls of the pleural cavity and the formation of dense detritus, mainly in its lower parts. With pronounced reactivity of the body, neutrophilic leukocytes and macrophages migrate into the pleural cavity, the processes of phagocytosis increase and the exudate quickly transforms into purulent. Over time, the exudative phase of inflammation turns into a proliferative one: granulations are formed on the pleural layers, which subsequently form adhesions (moorings). Availability of large quantities

pleural moorings, the predominance of the proliferative reaction over the exudative one causes a more favorable course of pleural empyema. This is due to the delimitation of the pathological process. With a significant decrease in the body's reactivity and suppression of reparative processes, the purulent or putrefactive process spreads, empyema becomes total, which in the absence of timely assistance leads to the rapid death of the patient.

Often, the development of pleural empyema occurs against the background of a moderate decrease in local and general immunity, which causes the torpidity of the process: there is a significant amount of fibrinous deposits on the pleural layers, the adhesions between them are loose, the granulations are flaccid, and the formation of mature connective tissue is delayed. Such features of the inflammatory reaction determine the tendency towards a chronic course of the process, when new foci of purulent inflammation appear in the thickness of the organizing fibrinous masses.

However, the most common reason for the transition of an acute purulent process to a chronic one is the constant infection of the pleural cavity in the presence of its communication with the focus of purulent destruction in the lung (abscess, gangrene), in the presence of a purulent process in the tissues of the chest and ribs (osteomyelitis, chondritis), with the formation of various type of fistulas - bronchopleural, pleuropulmonary.

It should be emphasized that purulent exudate from the pleural cavity is not resorbed. The purulent process presented to its natural course inevitably ends with a breakthrough of the abscess into the bronchial tree or outward when the tissues of the chest wall melt (empyema necessitatis). Rarely, with a small volume of purulent exudate, it can be delimited by powerful adhesions and persist for a long time (years). Such outcomes, as a rule, do not lead to recovery, since natural sanitation of the pleural cavity in these cases is impossible and, after a certain period of clinical well-being, a relapse of purulent inflammation occurs again.

Despite the listed features of the course of the inflammatory process in the pleural cavity, there are also general specific manifestations of the disease. These include, first of all, dysfunction of external respiration associated with the exclusion from breathing of the pulmonary parenchyma compressed by exudate on the affected side, and if the mediastinum is displaced, on the opposite side. Often the cause of life-threatening respiratory disorders is a total collapse of the lung when a pulmonary abscess breaks into the pleural cavity with the formation of a valve mechanism (tension pyopneumothorax). In the later stages from the onset of the disease, the severity of respiratory disorders is determined by two factors: the degree of lung collapse (the volume of the empyema cavity) and the state of the pulmonary parenchyma, since a long stay of the lung in a collapsed state against the background of purulent damage to the visceral pleura leads to profound irreversible sclerotic changes

lung tissue (pleurogenic cirrhosis of the lung). Another characteristic general, systemic manifestation of the purulent-inflammatory process in the pleural cavity is intoxication associated with the resorption of microbial toxins, which, at high levels, leads to severe multiple organ failure in the acute period (toxic nephritis, myocarditis), and subsequently leads to amyloidosis.

Thus, the key links in the pathogenesis of pleural empyema are:

1. The presence of fluid in the pleural cavity as a result of the development of a primary pathological process (non-bacterial pleurisy, hydrothorax) or trauma.

2. Infection of the pleural cavity and the development of purulent inflammation, the course of which is determined by the state of the body’s resistance and the virulence of the microflora.

1. According to communication with the external environment

Empyema of the pleura

	Closed			Open
				communicated (communicated externally
	not communicated communicated externally			external environment))
	external environment)

With pleurocutaneous fistula - with bronchopleural fistula

With bronchopleurocutaneous fistula - with pleuroorgan fistula - with bronchopleurocutaneous fistula

Ethmoidal lung (discussed issue)

2. By volume

Empyema of the pleura

Total		Subtotal		Demarcated
During Rg study		Determined only		When mooring
lung tissue is not
		apex of the lung		exudate
determined

By localization

By pathogenesis

- parapneumonic;

Due to purulent-destructive lung diseases;

- post-traumatic;

- postoperative.

3. Most authors distinguish by the duration of the pathological process acute, subacute and chronic pleural empyema. However, this division of pleural empyema only according to the duration of the disease, and in some cases, the presence of morphological signs of chronic inflammation (formation of mature connective tissue) is conditional. In some patients with pronounced reparative abilities, rapid fibrotization of fibrinous layers on the pleura occurs, while in others these processes are so suppressed that adequate fibrinolytic therapy makes it possible to “cleanse” the pleural layers even in the long term (6-8 weeks) from the onset of the disease. Thus, as a classification sign of acute or chronic pleural empyema (in the presence of a lung), one should apparently use morphological changes not in the pleura, but in the pulmonary parenchyma (pleurogenic cirrhosis of the lung), which serve as a criterion for assessing treatment results and determine adequate volume of surgical intervention. A sign of the development of chronic

pleural empyema after pneumonectomy should be considered the presence of pathological processes - bronchial fistulas, osteomyelitis of the ribs and sternum, purulent chondritis, foreign bodies - making it impossible to eliminate the purulent process in the residual cavity without additional surgery. Thus, to cure chronic pleural empyema, radical surgical intervention is required; for acute pleural empyema, cure can be achieved without radical surgery (pleurectomy with decortication, combined with resection of the lung, ribs, sternum, etc.).

At the same time, using the duration of the disease as a oriented criterion (up to 1 month - acute, up to 3 months - subacute, over 3 months - chronic) when formulating a preliminary diagnosis seems justified, since it allows us to outline the range of studies necessary to verify the diagnosis and determine an adequate treatment program.

Taking into account the above circumstances, a pathological process called “ethmoid lung” can also be attributed to chronic pleural empyema. This term refers to a condition that develops after wounds (surgeries) of the chest and lung, when lung tissue with many small bronchial fistulas is “soldered” to an extensive chest defect.

Clinical manifestations and diagnosis

Clinical manifestations of pleural empyema are very diverse, which is due to different mechanisms of development of pathological changes in the pleural cavity, the characteristics of the course of the infectious process in each individual patient and the amount of previous treatment. They depend mainly on the prevalence and location. However, in the vast majority of cases, symptoms appear clearly

- general purulent intoxication

- breathing disorders

- “local” manifestations of varying degrees of severity.

Despite the commonality of the main clinical manifestations of pleural empyema, it is necessary to know the features that some individual types of this disease have.

Pyopneumothorax is a type of acute pleural empyema (open, with bronchopleural communication, occurring against the background of an acute purulent-destructive process in the lung), resulting from a breakthrough of a pulmonary abscess into the pleural cavity. This term was introduced into use by S.I. Spasokukotsky (1935) to designate a severe, “...acute condition that occurs during, as well as shortly after, the outpouring of pus and the release of air into the pleural cavity from a lung abscess...” when “...a more or less clearly expressed state of shock is observed

or, in any case, a significant deterioration in the patient’s condition.” The indicated changes in pyopneumothorax are associated at the time of its

occurrence with the development of pleuropulmonary shock caused by irritation by pus and air of the extensive receptor field of the pleura, septic shock due to the resorption of a large number of microbial toxins by the pleura. However, the greatest danger to the patient’s life is the occurrence of a valve mechanism, leading to the development of tension pneumothorax, characterized by a significant increase in pressure in the pleural cavity, lung collapse, and a sharp displacement of the mediastinum with impaired blood outflow in the vena cava system. The clinical picture is dominated by manifestations of cardiovascular failure (drop in blood pressure, tachycardia) and respiratory failure (shortness of breath, suffocation, cyanosis). Delay in providing emergency assistance (“unloading” puncture and drainage of the pleural cavity) can be fatal for the patient. Therefore, the use of the term “pyopneumothorax” as a preliminary diagnosis is legitimate, since it obliges the doctor to intensively monitor the patient, quickly verify the diagnosis, and all medical personnel to immediately provide the necessary assistance.

A feature of the clinical manifestations of post-traumatic, including postoperative pleural empyema, is the development of an infectious process against the background of severe changes caused by trauma (surgery): violation of the integrity of the chest and associated external respiratory disorders, lung injury predisposing to the occurrence of bronchopleural communication, blood loss, the presence of blood clots and exudate in the pleural cavity. At the same time, the early manifestations of these types of pleural empyema (fever, respiratory problems, intoxication) are masked by such frequent complications of chest injuries as pneumonia, atelectasis, hemothorax, coagulated hemothorax, which often causes unjustified delays in the full sanitation of the pleural cavity.

In the clinical picture of chronic pleural empyema, signs of chronic purulent intoxication prevail, periodic exacerbations of the purulent process in the pleural cavity are noted, occurring against the background of pathological changes that support chronic purulent inflammation: bronchial fistulas, osteomyelitis of the ribs, sternum, suppurative chondritis. An indispensable attribute of chronic pleural empyema is a persistent residual pleural cavity with thick walls consisting of powerful layers of dense connective tissue. In the adjacent parts of the pulmonary parenchyma, sclerotic processes develop, causing the development of a chronic process in the lung - chronic pneumonia, chronic bronchitis, bronchiectasis, which have their own characteristic clinical picture.

At the modern level of diagnostics, verification of the diagnosis of “pleural empyema”, as well as its attribution to one of the types, is impossible without

application of radiation research methods. The most informative method of X-ray examination for EP is CT scan, whose modern capabilities to obtain a 3D image allow you to obtain data directly during the examination to formulate a diagnosis for all classification categories. A simpler method of x-ray examination is

polypositional fluoroscopy. It allows you to accurately establish the localization of the pathological process, determine the degree of delimitation of the exudate (free or encysted), and also accurately determine its volume.

To accurately determine the size of the empyema cavity, its configuration, the condition of the walls (thickness, presence of fibrinous layers), as well as to verify and clarify the localization of bronchopleural communication, a polypositional pleurography, including in later position. To carry it out, 20-40 ml of water-soluble contrast agent is injected into the pleural cavity through drainage (less commonly, puncture).

A very informative study is ultrasound of the pleural cavity.

This method allows a more detailed assessment of the nature of the contents of the pleural cavity (the number and nature of fibrinous deposits, the thickness of the liquid layer immediately before the puncture, etc.).

In the presence of a pleurocutaneous fistula, valuable information can be obtained by fistulography, performed during an X-ray or CT examination.

Endoscopic methods ( bronchoscopy, thoracoscopy), and ultrasound scanning allow us to obtain a more detailed understanding of the nature of morphological changes in the pleural layers, in the pleural cavity and in the lung tissue.

Bronchoscopy, performed in patients with pleural empyema, aims to exclude central lung cancer, which often causes pleural carcinomatosis (cancerous pleurisy), which transforms into pleural empyema when the exudate becomes infected; carry out sanitation of the tracheobronchial tree in the presence of a destructive process in the lungs, examine the bronchial lavage water (culture, etc.) in order to identify the microbiological agent and select rational antibacterial therapy. Valuable information can be obtained by combining bronchoscopy with the introduction of a vital dye solution into the pleural cavity through drainage (retrograde chromobronchoscopy). By how the dye enters the lumen of the subsegmental and segmental bronchi, not only the location, but also the extent of the bronchopleural communication can be accurately determined. In some cases, information about the localization of a bronchopleural fistula can be obtained through selective bronchography by introducing a water-soluble contrast agent through the channel of a fiberoptic bronchoscope installed in the zonal bronchus, with

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.

• 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.

NATIONAL CLINICAL GUIDELINES

"EMPYEMA OF PLEURA"

Working group for the preparation of the text of clinical recommendations:

Doctor of Medical Sciences, Professor E.A. Korymasov (Samara) – executive editor.

Doctor of Medical Sciences, Professor P.K. Yablonsky (St. Petersburg).

Doctor of Medical Sciences, Professor E.G. Sokolovich (St. Petersburg).

Candidate of Medical Sciences, Associate Professor V.V. Lishenko (St. Petersburg).

Doctor of Medical Sciences, Professor I.Ya. Motus (Ekaterinburg).

Candidate of Medical Sciences S.A. Scriabin (Murmansk).

2. Definition

3. ICD-10 codes

4. Prevention

5. Screening

6. Classification

7. Diagnostics

8. Differential diagnosis

9. Treatment:

10. What should you not do?

11. Forecast

12. Further management, education and rehabilitation of patients

13. Bibliographic index

1. METHODOLOGY
Pleural empyema is not an independent disease, but a complication of other pathological conditions. However, it is singled out as a separate nosological unit due to the uniformity of the clinical picture and treatment measures.

In these clinical guidelines, pleural empyema is presented as a three-stage disease in accordance with the classification of the American Thoracic Society (1962). This approach differs from the traditional gradation of empyema into acute and chronic, adopted in domestic medical practice. When presenting the treatment of the disease, it was possible to avoid a contradiction between the foreign and domestic approaches.

These clinical recommendations do not consider treatment tactics for acute bronchial stump incompetence after lobectomy and pneumonectomy as the cause of subsequent pleural empyema, as well as methods for preventing incompetence. This is the reason for a separate document.

Tuberculous pleural empyema (as a complication of fibrous-cavernous tuberculosis and as a complication of surgical intervention) is not included in these recommendations due to the peculiarities of the course and treatment.

2. DEFINITION
Pleural empyema (purulent pleurisy, pyothorax) is an 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.

3. ICD-10 CODES
J86.0 Pyothorax with fistula

J86.9 Pyothorax without fistula

4. PREVENTION
Conditions for the occurrence of pleural empyema are:

a) the presence of fluid in the pleural cavity as a result of the development of a primary pathological process (non-bacterial pleurisy, hydrothorax) or trauma (including operating room);

b) infection of the pleural cavity and the development of purulent inflammation, the course of which is determined by the state of the body’s resistance and the virulence of the microflora;

c) lack of conditions for expansion of the collapsed lung and elimination of the pleural cavity (fistulas, sclerotic processes in the pulmonary parenchyma).

Therefore, specific preventive measures to avoid the occurrence of purulent inflammation in the pleural cavity are to prevent these factors:

Introduction and strict adherence to protocols for the treatment and prevention of community-acquired and nosocomial pneumonia, for perioperative empirical antibacterial therapy in thoracic surgical departments;

Organization of timely hospitalization of patients with pneumonia, lung abscesses, bronchiectasis, tuberculosis in specialized pulmonology, thoracic surgical and phthisiology departments;

Organization of timely emergency surgical and specialized thoracic surgical care for pneumothorax, esophageal injuries and chest injuries;

b) therapeutic measures:

Rational empirical antibacterial therapy for suppurative lung diseases, based on the principles of de-escalation, taking into account data from local microbiological monitoring of a particular hospital;

Rapid restoration of the drainage function of the bronchi in patients with suppurative lung diseases;

Timely puncture removal of effusion from the pleural cavity in patients with pneumonia (if indicated) with mandatory microbiological examination;

Timely puncture removal of transudate from the pleural cavity (if indicated) in conditions causing its accumulation, with mandatory microbiological examination;

Limitation of indications for drainage of the pleural cavity without compelling reasons in patients with transudate and small (clinically insignificant) exudate in the pleural cavity;

Timely identification of indications for surgical treatment for “blocked” lung abscesses, lung gangrene, bronchiectasis;

Performing external drainage of a “blocked” abscess (if indicated) only taking into account computed tomography data (in the presence of delimiting adhesions from the free pleural cavity);

- rational perioperative antibiotic prophylaxis in thoracic surgery;

Quick decision-making about surgery in patients with spontaneous pneumothorax with persistent lung collapse and/or air discharge through drainage from the pleural cavity;

The use of additional methods of aerostasis of lung tissue and strengthening of the bronchial stump during surgical interventions;

Rational drainage of the pleural cavity during surgical interventions;

Careful care of drainage in the pleural cavity;

Timely removal of drainage from the pleural cavity after surgical interventions on the chest organs;

Timely and adequate treatment of pathological processes in the subphrenic space (abscesses, acute pancreatitis), the chest wall.
5. SCREENING
1. Regular plain radiography of the chest followed by ultrasound and/or computed tomography (if indicated) for the timely detection of effusion in the pleural cavities in the following groups of patients:

3. Puncture of the pleural cavity in conditions accompanied by the accumulation of transudate (if there are clinical indications), with macroscopic control, general clinical analysis and microbiological examination.

4. Puncture of the pleural cavity in patients in the early period after pneumonectomy (if there are clinical and radiological indications).

6. CLASSIFICATION
6.1. The classification of the American Thoracic Society (1962), generally accepted in the international community, distinguishes 3 clinical and morphological stages of the disease: exudative, fibrinous-purulent, organization.

Stage exudative characterized by the accumulation of infected exudate in the pleural cavity as a result of a local increase in the permeability of the pleural capillaries. In the accumulated pleural fluid, the glucose content and pH value remain normal.

Fibrinous-purulent stage manifested by loss of fibrin (due to suppression of fibrinolytic activity), which forms loose delimiting adhesions with encystation of pus and the formation of purulent pockets. The development of bacteria is accompanied by an increase in lactic acid concentration and a decrease in pH value.

Organization stage characterized by activation of fibroblast proliferation, which leads to the appearance of pleural adhesions, fibrous bridges that form pockets, and a decrease in the elasticity of the pleura. Clinically and radiologically, this stage consists of relative relief of the inflammatory process, the progressive development of demarcating adhesions (shvart), which are already of a connective tissue nature, scarring of the pleural cavity, which can lead to walling up of the lung, and the presence of isolated cavities against this background, supported mainly by preservation of bronchopleural fistula.

R.W. Light proposed classes of parapneumonic effusion and pleural empyema, specifying each stage of the above classification:

Exudative stage:

Class 1. Minor effusion:

small amount of liquid (

Class 2. Typical parapneumonic effusion:

amount of liquid > 10 mm, glucose > 0.4 g/l, pH > 7.2.

Class 3. Uncomplicated borderline effusion:

negative results of Gram staining of the smear,

LDH > 1000 U/L, glucose > 0.4 g/L, pH 7.0–7.2.

Purulent-fibrinous stage:

Class 4. Complicated pleural effusion (simple):

positive results of Gram smear staining,

glucose
Class 5. Complicated pleural effusion (complex):

positive Gram stain results,

glucose
Class 6. Simple empyema:

Obvious pus, single pocket of pus, or loose

spread of pus throughout the pleural cavity.

Organization stage:

Class 7. Complex empyema:

Obvious pus, multiple purulent encystations,

fibrous moorings.
The practical significance of these classifications is that they allow us to objectify the course of the disease and determine the stages of tactics (Strange C., Sahn S.A., 1999).
6.2. In the domestic literature, empyema is still divided according to the nature of its course (and to some extent according to time criteria): acute and chronic(exacerbation phase, remission phase).

Chronic pleural empyema is always untreated acute pleural empyema (Kupriyanov P.A., 1955).

The most common reason for the transition of an acute purulent process to a chronic one is the constant infection of the pleural cavity in the presence of its communication with the focus of purulent destruction in the lung (abscess, gangrene), in the presence of a purulent process in the tissues of the chest and ribs (osteomyelitis, chondritis), with the formation of various types fistulas – bronchopleural, pleuropulmonary.

Traditionally, it is considered that the period of transition from acute empyema to chronic is 2-3 months. However, such a division is conditional. In some patients with pronounced reparative abilities, rapid fibrotization of fibrinous layers on the pleura occurs, while in others these processes are so suppressed that adequate fibrinolytic therapy makes it possible to “cleanse” the pleural layers even in the long term (6-8 weeks) from the onset of the disease.

Therefore, the most reliable criteria for the formation of chronic empyema (according to computed tomography) are: a) rigid (anatomically irreversible) thick-walled residual cavity, to one degree or another collapsing the lung, with or without bronchial fistulas; b) morphological changes in the pulmonary parenchyma (pleurogenic cirrhosis of the lung) and tissues of the chest wall.

A sign of the development of chronic pleural empyema after pneumonectomy should be considered the presence of pathological processes (bronchial fistulas, osteomyelitis of the ribs and sternum, purulent chondritis, foreign bodies), making it impossible to eliminate the purulent process in the residual cavity without additional surgery (pleurectomy, decortication, in combination with lung resection, ribs, sternum).

The use of a time factor (3 months) seems justified, since it allows us to outline the range of studies necessary to verify the diagnosis and determine an adequate treatment program.

Approximately chronic empyema corresponds to the stage of organization in the international classification.

6.3. 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 communication with the external environment in the form of pleurocutaneous, bronchopleural, bronchopleurocutaneous, pleuroorgan, bronchopleuroorgan fistula).
6.4. According to the volume of damage to the pleural cavity:

- total (lung tissue is not detected on a plain X-ray);

- subtotal (on a plain radiograph only the apex of the lung is identified);

- delimited (during encystation and mooring of exudate): apical, parietal paracostal, basal, interlobar, paramediastinal.

6.5. According to etiological factors, they are distinguished:

- para- and metapneumonic ;

- due to purulent-destructive lung diseases (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 the bone frame of the chest).

7. DIAGNOSTICS
7.1. General clinical physical examination methods.

The absence of specific anamnestic and physical signs makes the diagnosis of pleural empyema, especially parapneumonic, not obvious without instrumental diagnostic methods.

Verification of the diagnosis of pleural empyema, as well as classifying it as one of the types, is impossible without the use of radiological (including computed tomography) research methods.

However, certain forms (the most severe and dangerous) of this disease can be suspected even clinically.

Pyopneumothorax– a type of acute pleural empyema (open, with bronchopleural communication), resulting from a breakthrough of a pulmonary abscess into the pleural cavity. The main pathological syndromes when it occurs are: pleuropulmonary shock (due to irritation of the extensive receptor field of the pleura by pus and air); septic shock (due to resorption of a large number of microbial toxins by the pleura); valvular tension pneumothorax with collapse of the lung, a sharp displacement of the mediastinum with impaired blood outflow in the vena cava system. The clinical picture is dominated by manifestations of cardiovascular failure (drop in blood pressure, tachycardia) and respiratory failure (shortness of breath, suffocation, cyanosis). Therefore, the use of the term “pyopneumothorax” as a preliminary diagnosis is legitimate, since it obliges the doctor to intensively monitor the patient, quickly verify the diagnosis and immediately provide the necessary assistance (“unloading” puncture and drainage of the pleural cavity).

Post-traumatic and postoperative, pleural empyema develop against the background of severe changes caused by trauma (surgery): violation of the integrity of the chest and associated external respiratory disorders, lung injury predisposing to the occurrence of bronchopleural communication, blood loss, the presence of blood clots and exudate in the pleural cavity. At the same time, the early manifestations of these types of pleural empyema (fever, respiratory problems, intoxication) are masked by such frequent complications of chest injuries as pneumonia, atelectasis, hemothorax, coagulated hemothorax, which often causes unjustified delays in the full sanitation of the pleural cavity.

Chronic pleural empyema characterized by signs of chronic purulent intoxication, there are periodic exacerbations of the purulent process in the pleural cavity, occurring against the background of pathological changes that support chronic purulent inflammation: bronchial fistulas, osteomyelitis of the ribs, sternum, purulent chondritis. An indispensable attribute of chronic pleural empyema is a persistent residual pleural cavity with thick walls consisting of powerful layers of dense connective tissue. In the adjacent parts of the pulmonary parenchyma, sclerotic processes develop, causing the development of a chronic process in the lung - chronic pneumonia, chronic bronchitis, bronchiectasis, which have their own characteristic clinical picture.
7.2. Laboratory methods for examining blood and urine.

General clinical blood and urine tests, biochemical blood tests are aimed at identifying signs of intoxication and purulent inflammation, and organ failure.

a) In the acute period of the disease, leukocytosis is observed with a pronounced shift in the leukocyte formula to the left, and a significant increase in ESR. In severe cases, especially after a previous viral infection, as well as during anaerobic destructive processes, leukocytosis may be insignificant, and sometimes the number of leukocytes even decreases, especially due to lymphocytes, however, these cases are characterized by the most dramatic shift in the formula (to myelocytes). Already in the first days of the disease, as a rule, anemia increases, especially pronounced in the unfavorable course of the disease.

b) Hypoproteinemia is observed, associated both with the loss of protein in sputum and purulent exudate, and with impaired protein synthesis in the liver due to intoxication. The level of C-reactive protein, lactate dehydrogenase, creatine kinase, and transaminases increases. Due to the predominance of catabolic processes, the blood glucose level may be increased. In the acute period, the plasma fibrinogen content increases significantly, but with advanced purulent depletion it can decrease due to impaired synthesis of this protein in the liver. Changes in hemostasis manifest themselves in the form of inhibition of fibrinolysis. The volume of circulating blood decreases in more than half of the patients, mainly due to the globular volume. Severe hypoproteinemia (30-40 g/l) leads to the appearance of edema. Fluid retention in the interstitial sector averages 1.5 liters, and in the most severely ill patients reaches 4 liters. Hyperammonemia and hypercreatininemia indicate a severe, advanced chronic purulent process, the formation of chronic renal failure due to renal amyloidosis.

Empyema of the pleura- accumulation of purulent exudate in the pleural cavity with secondary compression of lung tissue during pleurisy.

Code according to the international classification of diseases ICD-10:

Classification. By localization.. Unilateral or bilateral.. Limited (localized in any part of the pleural cavity, surrounded by pleural adhesions); subtotal (empyema is limited to two or three anatomical walls of the pleural cavity, for example costal and diaphragmatic, or mediastinal, diaphragmatic and costal; total (purulent exudate fills the entire pleural cavity).. Basal or paramediastinal. Due to.. Metapneumonic, developed as a result of pneumonia. . Parapneumonic, which arose simultaneously with pneumonia.. Postoperative, which arose as a complication of surgery on the organs of the thoracic or upper abdominal cavity. Along the way.. Acute (duration of the disease - up to 8 weeks).. Chronic (duration - more than 8 weeks)... The amount of effusion is divided into small pyothorax - accumulation of exudate in the pleural sinuses (amount 200-500 ml); medium pyothorax - accumulation of exudate up to the angle of the scapula in the 7th intercostal space (amount 500-1000 ml); large pyothorax - accumulation of exudate above the angle of the scapula (amount more than 1 liter).

Frequency- about 320 per 100,000 population in industrial countries.

Causes

Etiology. Pathogens: .. staphylococci.. pneumococci.. facultative and obligate anaerobes. Direct route of infection.. Lung injury.. Chest wounds.. Rupture of the esophagus.. Breakthrough of an abscess, gangrene of the lung, cavity.. Pneumonia.. Tuberculosis.. Progression of bacterial damage to the lungs (abscess or bacterial destruction).. Bronchiectasis.. Resection lungs and other operations on the chest organs.. Pneumothorax.. Acute mediastinitis.. Osteomyelitis of the ribs and vertebrae. Indirect route of infection.. Subdiaphragmatic abscess.. Acute pancreatitis.. Liver abscesses.. Inflammation of the soft tissues and bone frame of the chest wall. Idiopathic empyema.

Pathogenesis. Acute (serous) phase (up to 7 days). Primary formation of pleural effusion. Fibrinous-purulent phase (7-21 days). Fluid occupies the lower parts of the pleural cavity. In the absence of adequate drainage, multilocular empyema forms. Chronic phase (after 21 days). As a result of fibrin deposition, the pleura thickens along the border of the pleural effusion. Abscesses occur in neighboring areas.

Pathomorphology. Hyperemia and leukocyte infiltration of the pleura. Fibrin deposition. Accumulation of fluid in the pleural cavity. Thickening of the pleura, formation of moorings. Organization of empyema, formation of connective tissue.

Symptoms (signs)

Clinical picture

Acute pleural empyema. Cough with sputum production. Prolonged and frequent coughing attacks with the release of a large amount of sputum indicate the presence of a bronchopleural fistula. Pain in the chest is minimally expressed during quiet breathing, sharply intensifies during a full deep breath. Shortness of breath. Violation of vocal tremors or distinct egophony. Dull or dull percussion sound on the affected side, the upper limit of dullness corresponds to the Ellis-Damoiso-Sokolov line.. Weakening or absence of breathing during auscultation over the area of ​​effusion.. Bronchial breathing over the compressed lung adjacent to the effusion.. Redness of the skin occurs only when pus breaks out of the empyema cavity under skin.. The general condition is progressively worsening: weakness, loss of appetite, weight loss, hectic body temperature, rapid pulse.

Chronic pleural empyema.. Body temperature can be subfebrile or normal, if the outflow of pus is disturbed, it becomes hectic.. Cough with the discharge of purulent sputum.. Deformation of the chest on the affected side due to narrowing of the intercostal spaces. Scoliosis develops in children. Percussion data depend on the degree of filling of the cavity with pus; respiratory sounds above the cavity are not heard.

Diagnostics

Laboratory research. Leukocytosis, shift of the leukocyte formula to the left, hypo- and dysproteinemia, increased ESR. Analysis of pleural fluid - exudate (relative density above 1.015, protein above 30 g/l, albumin/globulin ratio - 0.5-2.0, Rivalta test positive, leukocytes above 15).

Special studies. Thoracentesis - the pleural fluid is cloudy, thick, gradually turning into true pus, and has a specific unpleasant odor. Laboratory examination of aspirated fluid.. Bacterioscopy of a smear with Gram stain.. Bacteriological examination (the results of these methods often differ).. Determination of pH - in case of empyema, pH is less than 7.2.. Glucose concentration is lower than the concentration of glucose in the blood. X-ray examination.. The mediastinum is shifted to the side opposite to the side of the accumulation of effusion.. Basal darkening with a horizontal level with putrefactive infection or bronchopleural fistula. CT allows you to most accurately determine the presence of fluid in the pleural cavity and localize intrapleural encystation. Pleurofistulography is a contrast study of the pleural cavity through fistulas. Ultrasound allows you to determine the amount of effusion, localize the site of puncture and drainage of the pleural cavity.

Differential diagnosis. Rib fracture. Costochondritis. Gangrene of the lung. Caseous pneumonia. Pleural mesothelioma. Compression of the intercostal nerve. Shingles. Acute bronchitis. Pathology of the cardiovascular system and esophagus.

Treatment

TREATMENT

General principles. Treatment of the underlying disease. Early complete removal of exudate from the pleural cavity using puncture or drainage. Lung straightening using constant aspiration, exercise therapy. Rational antibiotic therapy.

Conservative therapy. Early acute empyema - repeated pleural punctures with aspiration of purulent exudate and adequate antibiotic therapy (clindamycin, ceftriaxone in combination with metronidazole; aminoglycosides, monobactams, carbapenems can be prescribed) are necessary.. Washing of the pleural cavity with the introduction of antibiotics, proteolytic enzymes.. Immunostimulating therapy.. UV irradiation blood. Infusion therapy and partial parenteral nutrition. Formed empyemas with thick purulent exudate are an indication for long-term closed drainage.

Surgery

Acute empyema.. Free pleural empyema - constant washing of the pleural cavity through two tubes, after 2-3 days the contents are sucked out through both tubes and complete expansion of the lung is achieved.. Wide thoracotomy with resection of the ribs, toilet of the pleural cavity and subsequent drainage is indicated in the presence of large sequesters and clots in the pleural cavity.. In the presence of a bronchial fistula - tamponade of the corresponding bronchus.. If the above measures are ineffective, early decortication of the lung is indicated.

Chronic empyema.. Sanitation of empyema through drainage with active aspiration.. In the presence of a bronchial fistula: the same + bronchial tamponade.. If ineffective - surgical treatment: repneumolysis, lung decortication, curettage of the pyogenic layer to the fibrous capsule, suturing of the bronchial fistula or resection of the affected area lung.. In case of tuberculous empyema, the volume of the operation is increased - a total parietal pleurectomy is performed.

Complications. Perforation.. Into the pulmonary parenchyma with the formation of bronchopleural fistulas.. Through the chest with accumulation of pus in the soft tissues of the chest wall. Septicopyemia. Secondary bronchiectasis. Amyloidosis.

The prognosis with timely treatment is favorable, but with chronic empyema it can be unfavorable.

Synonyms. Purulent pleurisy. Pyothorax.

ICD-10. J86 Pyothorax