National clinical guidelines for pleural empyema Working group on 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, otherwise a mass of complications may develop.

Brief information about the disease

Pleural empyema (ICD-10 assigned the code J86 to this pathology) is a serious disease that is accompanied by inflammation of the pleura. At the same time, purulent masses begin to accumulate in the anatomical cavities (the pleural cavity in this case).

According to statistics, men are faced with a similar 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 empyema of the pleura can be different. If we are talking about the primary form of the disease, then the triggers in this case are the activity of pathogenic microorganisms, the penetration of blood or air into the cavity, as well as a significant decrease in immunity. Primary empyema (in medicine, the disease also appears under the name "purulent pleurisy") develops when:

• violation of the integrity of the chest against the background of injury or injury;
• previous surgical interventions, if they led to the formation of bronchial fistulas;
• thoracoabdominal injuries of the chest.

Secondary purulent pleurisy develops against the background of other pathologies. The list is quite impressive:

• purulent processes in any organ system;
• inflammation of the tissues of the lungs;
• the formation of an abscess in the tissues of the lung;
• 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;
• the formation of ulcers in the liver;
• sepsis;
• osteomyelitis;
• rupture of the esophagus;
• 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 bacillus, 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

To date, there are many schemes that allow classifying such a pathology, because a variety of factors must be taken into account.

For example, depending on the characteristics and duration of the course, acute and chronic pleural empyema are distinguished. Symptoms of these forms can be different. For example, in an acute inflammatory-purulent process, signs of intoxication come to the fore, while the disease lasts less than a month. If we are talking about the chronic form of the disease, then the symptoms are more blurred, but they disturb 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 (purulent masses are contained in the pleural cavity and do not go outside) and an open form of the disease (the formation of fistulas between the pleura and the lungs, bronchi, skin through which exudate circulates is observed).

The volume of formed pus is also taken into account:

• small empyema - the volume of purulent masses does not exceed 250 ml;
• medium, at 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 focus, the pathological process can be either one- or two-sided. Of course, all these characteristics are important for the preparation of an effective treatment regimen.

Stages of development of the disease

To date, there are three stages in the 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 fibro-serous. The 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 sheets. 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 that fetter the lung is observed. 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 aches in the muscles, drowsiness, weakness, sweating.
• A characteristic symptom of empyema is coughing. At first it is dry, but gradually becomes productive. When coughing, sputum is greenish-yellow, gray or rye. Often, the discharge has an extremely unpleasant odor.
• Shortness of breath is also included in the list of symptoms - at first it appears only during physical activity, but then the patient is disturbed even at rest.
• As the pathology progresses, pain in the sternum appears, which intensifies on 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, 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 about 15% of cases, the process becomes chronic. However, the clinical picture is different. Symptoms of intoxication are absent, as well as fever. Cough disturbs the patient constantly. Patients also complain of recurrent headaches. In the absence of treatment, various deformities of the chest develop, as well as scoliosis, which is associated with some compensatory mechanisms.

Possible Complications

According to statistics, the right 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;
• the formation of blood clots, blockage of blood vessels;
• multiple organ failure;
• the formation of bronchopleural fistulas;
• development of amyloidosis;
• thromboembolism of the pulmonary artery associated with thrombosis (requires urgent surgical intervention, as otherwise the probability of death is high).

As you can see, the consequences of the disease are very dangerous. That is why in no case should you 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 degree of its spread, and the causes of occurrence.

• To begin with, an anamnesis is collected, the study of the patient's medical data. With an external examination of the chest, one or another degree of deformation, bulging or smoothing of the intercostal spaces may be noticed. If we are talking about chronic pleural empyema, then the patient has scoliosis. Very characteristic is the drooping of the shoulder and the protrusion of the scapula from the side of the lesion.
• Auscultation is required.
• In the future, the patient is sent for various studies. Mandatory are laboratory tests of blood and urine, during which it is possible to determine the presence of an inflammatory process. Microscopic examination of sputum and aspirated fluid is carried out.
• Exudate samples are used for bacterial culture. This procedure allows you to determine the type and type of pathogen, check the degree of its sensitivity to certain drugs.
• Informative are fluoroscopy and radiography of the lungs. In the pictures, the affected areas are darkened.
• Pleurofistulography is a procedure that helps to detect fistulas (if any).
• A pleural puncture and ultrasonography of the pleural cavity will also be provided.
• 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 assess its volume, and diagnose the presence of certain complications.

Based on the data obtained, the doctor selects the appropriate drugs and draws up an effective treatment regimen.

Therapeutic treatment

Treatment of pleural empyema primarily involves the removal of purulent masses - this can be done both during a puncture and through a full opening of the chest (this method is resorted to only as a last resort).

Since the formation of purulent exudate is to some extent associated with the activity of pathogenic microorganisms, antibiotics with a wide spectrum of effects in the form of tablets must be introduced into the treatment regimen. Drugs from the group of aminoglycosides, cephalosporins, fluoroquinolones are considered effective. In addition, sometimes antibacterial agents are injected directly into the pleural cavity to achieve maximum results.

Sometimes patients are prescribed a transfusion of protein preparations, for example, special hydrolysates, albumin, purified blood plasma. Additionally, solutions of glucose and electrolytes are introduced, which help restore the body's functioning.

Mandatory is immunomodulating therapy, as well as taking vitamin complexes - this helps to strengthen the immune system, which, in turn, contributes to the rapid recovery of the body. For example, with severe fever, antipyretic and non-steroidal anti-inflammatory drugs are used.

After the symptoms of empyema become less pronounced, physical therapy is recommended for patients. Special breathing exercises help strengthen the intercostal muscles, normalize lung function, and saturate the body with oxygen. A therapeutic massage will also be useful, which also helps to clear the lungs of sputum, improve the well-being of the body. Additionally, sessions of therapeutic gymnastics are held. Ultrasound therapy also gives good results. During rehabilitation, doctors recommend patients to undergo restorative spa 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 accumulation of a large amount of pus, requires surgical intervention. Such methods of therapy allow you to remove the 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 parts of the pleura with further decortication of the affected lung. If there are fistulas between the tissues of the pleura, bronchi, lungs and skin, then the surgeon closes them. In the event that the pathological process has not spread to the lungs, the doctor may decide on a 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.

• An ordinary bow is considered effective. Preparing the medicine is easy. Peel a medium-sized onion from the husk, rinse and chop. Next, you need to squeeze the juice and mix it with natural honey (in equal amounts). The medicine is recommended to be taken twice a day for a tablespoon. It is believed that the tool perfectly copes with cough, facilitates sputum discharge.
• At home, you can prepare an effective mucolytic collection. You need to mix equal amounts of elecampane rhizomes, coltsfoot herbs, mint, linden flowers and licorice root. 20 g of the plant mixture should be poured with a glass of boiling water, then let it brew. The remedy after cooling by filtering and divided into three equal portions - they need to be drunk during the day. Every day you need to prepare fresh medicine.
• Horsetail is also considered effective. 20 g of dry grass of the plant (crushed) should be poured with 0.5 liters of boiling water. The container must be covered and left for four hours in a warm place, after which the infusion is filtered. It is recommended to take 100 ml four times a day for 10-12 days.
• There is a medicinal collection that facilitates the process of breathing and helps to cope with shortness of breath. It is necessary to displace equal amounts of immortelle grass, dried calendula flowers with currant leaves, tansy and bird cherry. A tablespoon of the mixture is poured with a glass of boiling water and insisted. 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 equal amounts of natural honey and fresh radish juice. Herbalists recommend taking medicine in a spoon (table) 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 to adhere 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, stab the body, take vitamins, spend time in the fresh air);
• preventive examinations should not be avoided - the earlier the disease is detected, the less likely it is to develop certain complications.

It should be noted that in most cases, such a disease responds well to therapy. Pleural empyema is not in vain considered a dangerous pathology - it should not be ignored. According to statistics, about 20% of patients develop certain complications. Mortality in this disease ranges from 5 to 22%.

Compiled and edited by V. V. Lishenko, Associate Professor of the Department of Surgery and Innovative Technologies of the VCERM named after A.M. Nikiforova of the Ministry of Emergency Situations of Russia, head of the department of purulent pulmonary surgery of the clinic of hospital surgery 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, Moscow City Clinical Hospital No. 23 named after Medsantrud, Department of Health, Moscow; Senior Researcher, Scientific Research Institute "Surgical Infection", Research Center of the State Budgetary Educational Institution of Higher Professional Education First Moscow State Medical University named after M.I. I.M. Sechenov of the Ministry of Health of Russia, an 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 I.I. P.G. Balandin.

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 VTSERM named after A.M. Nikiforova, an employee of the purulent pulmonary department of the clinic. P.A. Kupriyanov of the 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.

Deynega 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 with involvement of 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 into the pleura of abscesses from the lung, mediastinum, etc.) by a primary non-bacterial exudative reaction of the pleura (non-infectious exudative pleurisy). This is due to increased permeability of the blood and lymphatic capillaries of the cortical layers of the lungs involved in the perifocal inflammatory response in various pathological processes, primarily in the lung parenchyma, as well as injuries to the lung and chest wall. The accumulation of exudate in the pleural cavity is facilitated by swelling of the mesothelial layer, blockade of the suction surfaces of the pleura with 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 collagenoses (systemic lupus erythematosus, periarteritis nodosa), with postembolic lung infarction, carcinomatosis and mesothelioma of the pleura. Fluid in the pleural cavity can accumulate with circulatory failure, chylothorax. A pronounced exudative reaction is observed when blood flows into the pleural cavity (the so-called hempleuritis) with closed injuries of the chest.

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

Some researchers identify a hematogenous route of infection penetration into the pleural cavity (sepsis, septic embolism of the vessels of the pulmonary circulation), however, 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 enter the pleural cavity from the environment with air, foreign bodies, injuring projectiles, is typical for open chest injuries, including surgical interventions on the organs of the chest cavity. In this case, the exudative reaction is due to both trauma to the pleura, and irritation of its outflowing 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 said to occur when subcortically located abscesses of the lung parenchyma break into it. The entry into the pleural cavity of a large amount of the contents of the abscess 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 an infectious-toxic shock. The same mechanism of development of the infectious process in the pleural cavity is observed in lung gangrene, when large areas of the lung parenchyma, together with the visceral pleura, undergo putrefaction. The constant microbial invasion and the prevalence of the process (involvement of all parts of the pleura, including the parietal) determines the particular severity of the course of pleural empyema with such a 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 state of the local

and general immunity, type of pathogen.

AT The etiological structure of pleural empyema, according to recent studies, is dominated by staphylococci, streptococci, Pseudomonas aeruginosa, Proteus. In more than a third of cases, these microorganisms are in association with numerous types of non-clostridial anaerobic microflora (bacteroids, fusobacteria, peptostreptococci). In the initial stages of the development of the disease, as a rule, an increase in the exudative reaction of the pleura is observed, 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 accumulation of fluid in the pleural cavity. The high content of fibrinogen in the pleural exudate leads to the formation of significant fibrinous layers on the walls of the pleural cavity, the formation of thick detritus, mainly in its lower sections. With a 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 a purulent one. Over time, the exudative phase of inflammation turns into a proliferative one: granulations are formed on the pleural sheets, which subsequently form adhesions (moorings). The presence of a large number

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 reactivity of the body, inhibition of reparative processes, a purulent or putrefactive process spreads, empyema becomes total, which, in the absence of timely assistance, leads to a 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 a torpidity of the course of the process: there is a significant amount of fibrinous deposits on the pleural sheets, the adhesions between them are loose, the granulations are sluggish, the formation of mature connective tissue is slowed down. Such features of the inflammatory reaction determine the tendency to the chronic course of the process, when new foci of purulent inflammation appear in the thickness of the organized fibrinous masses.

However, the most common reason for the transition of an acute purulent process into a chronic one is the constant infection of the pleural cavity in the presence of communication with a 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 of fistulas - bronchopleural, pleuropulmonary.

It should be emphasized that purulent exudate from the pleural cavity is not resorbed. The purulent process presented to the natural course inevitably ends with a breakthrough of the abscess into the bronchial tree or outward when the tissues of the chest wall (empyema necessitatis) are melted. Rarely, with a small amount of purulent exudate, it is possible to delimit it with powerful adhesions and long-term (years) existence. 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, a violation of the function of external respiration, associated with the exclusion from breathing of the lung parenchyma squeezed by exudate on the affected side, and when the mediastinum is displaced, it is the opposite. Often the cause of life-threatening respiratory disorders is the 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 late period from the onset of the disease, the severity of respiratory disorders is determined by two factors: the degree of collapse of the lung (the volume of the empyemic cavity) and the state of the lung parenchyma, since the prolonged presence of the lung in a collapsed state against the background of a purulent lesion of the visceral pleura leads to deep 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, leading at a high level 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 resistance of the organism, the virulence of the microflora.

1. Communication with the external environment

Pleural empyema

	closed			open
				reported (reported by an external
	not reportedreportedexternal			external environment))
	external environment)

With pleurocutaneous fistula - with bronchopleural fistula

With bronchopleurocutaneous fistula - with pleuroorgan fistula - with bronchopleuroorgan fistula

Latticed lung (debatable issue)

2. By volume

Pleural empyema

Total		Subtotal		Delimited
When Rg study		Only defined		When mooring
lung tissue is
		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 course of the pathological process acute, subacute and chronic pleural empyema. However, such a 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 deposits on the pleura occurs, while in others these processes are so inhibited that adequate fibrinolytic therapy allows "clearing" the pleural sheets 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), it should apparently be used morphological changes not in the pleura, but in the lung parenchyma (pleurogenic cirrhosis of the lung), which serve as a criterion for assessing the results of treatment, determine an adequate scope of surgery. sign of developing 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 surgery is required; in acute pleural empyema, cure can be achieved without radical operations (pleurectomy with decortication, combined with resection of the lung, ribs, sternum, etc.).

At the same time, the use of 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 you 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 the "lattice lung", can also be attributed to chronic empyema of the pleura. This term refers to a condition that develops after injuries (operations) of the chest and lung, when lung tissue with many small bronchial fistulas is “soldered” to an extensive chest defect.

Clinical manifestations and diagnosis

The clinical manifestations of pleural empyema are very diverse, which is due to various mechanisms for the 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 localization. However, in the vast majority of cases, symptoms are clearly manifested

- general purulent intoxication

- breathing disorders

- varying degrees of severity "local" manifestations.

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 into the pleural cavity of the pulmonary abscess. This term was introduced into use by S. I. Spasokukotsky (1935) to denote a severe, “... acute condition that occurs during, as well as in the immediate aftermath of the outpouring of pus and the release of air into the pleural cavity from a lung abscess ...” when "... there is now more, then less clearly expressed state of shock

or, in any case, a significant deterioration in the patient's condition. These changes in pyopneumothorax are associated at the time of its

the occurrence with the development of pleuropulmonary shock caused by irritation with pus and air of the extensive pleural receptor field, septic shock due to the resorption of a large amount of microbial toxins by the pleura. However, the greatest danger to the life of the patient is the occurrence of a valvular mechanism, leading to the development of a tension pneumothorax, characterized by a significant increase in pressure in the pleural cavity, lung collapse, a sharp displacement of the mediastinum with a violation of the outflow of blood in the vena cava system. The clinical picture is dominated by manifestations of cardiovascular insufficiency (falling blood pressure, tachycardia) and respiratory failure (shortness of breath, suffocation, cyanosis). Delay in the provision of emergency care ("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 (operation): violation of the integrity of the chest and associated 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, early manifestations of these types of pleural empyema (fever, respiratory disorders, intoxication) are masked by such frequent complications of chest injuries as pneumonia, atelectasis, hemothorax, clotted hemothorax, which often causes unjustified delays in 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, 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 sections of the lung 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 present level of diagnostics, verification of the diagnosis of "empyema of the pleura", as well as assigning it to one of the types, is impossible without

application of radiation research methods. The most informative method of X-ray examination in EP is CT scan, the modern capabilities of which to obtain a 3D image, allows you to obtain data right during the study 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 exudate delimitation (free or encapsulated), and also accurately determine its volume.

To accurately determine the size of the empyema cavity, its configuration, the state of the walls (thickness, the presence of fibrinous layers), as well as verification and clarification of the localization of the bronchopleural message, polypositional pleurography, including in lateroposition. To carry it out, 20-40 ml of a water-soluble contrast agent is injected into the pleural cavity through drainage (less often - puncture).

A very informative study is an 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 layers, the thickness of the fluid layer immediately before the start of the puncture, etc.).

In the presence of a pleurocutaneous fistula, valuable information can be obtained from fistulographyperformed with an x-ray or CT scan.

Endoscopic methods ( bronchoscopy, thoracoscopy), as well as ultrasound scan allow you to get a more detailed idea of ​​the nature of morphological changes in the pleural sheets, in the pleural cavity and in the lung tissue.

Bronchoscopy performed in patients with pleural empyema aims to exclude central lung cancer, often causing 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 washings of the bronchi (sowing, etc.) in order to establish a microbiological agent and select a rational antibiotic therapy. Valuable information can be obtained by combining bronchoscopy with the introduction of a dye solution of a vital dye into the pleural cavity (retrograde chromobronchoscopy). By the way the dye enters the lumen of the subsegmental and segmental bronchi, one can accurately determine not only the localization, but also the prevalence of the bronchopleural message. In some cases, information about the localization of the bronchopleural fistula can be obtained with 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 such diseases as: pneumonia, damage to the pleura and lungs, abscess, gangrene, the transition of inflammation from neighboring and distant inflammatory foci.

Very often, the formation of serous exudate in the pleural cavity leads to the disorder, 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, consider them:

1. Primary
   • Post-traumatic - chest wounds, injuries, thoracoabdominal injuries.
   • Postoperative - pathology with / without bronchial fistula.
2. Secondary
   • Diseases of the sternum organs - 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 empyema with unspecified etiology.

The disease is associated with the spread of suppuration from neighboring tissues and organs (lungs, chest wall, pericardium). This happens with diseases such as:

• Pericarditis.
• Transfer of infection with lymph and blood from other foci of inflammation (tonsillitis, 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 respiratory infections.

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 the microbial flora (pyogenic cocci, tubercle bacilli, bacilli). The acute form may occur due to microbial infection and suppuration of the effusion during inflammatory processes in the lungs.

Pathogenesis

Any disease has a mechanism of development, which is accompanied by certain symptoms. The pathogenesis of pyothorax is associated with a primary inflammatory disease. In the primary form of the disease, 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 sheets and the introduction of harmful microflora. As a rule, this happens with open chest injuries or after surgery on the lungs. Primary surgical care plays an important role in the development of pathology. If it is provided in the first hours of malaise, 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 the lymphatic vessels or through the hematogenous route.

At the same time, the pathogenesis of an acute handicap of a purulent lesion of the pleura is rather complicated and is determined by a decrease in the immunobiological reactivity of the organism during the 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 work of the whole organism.

Symptoms of pleural empyema

The symptoms of the disorder gradually increase, and the exudate accumulates, mechanically squeezing the lungs and heart. This causes a displacement of organs in the opposite direction and causes disturbances in respiratory and cardiac activity. 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. Consider the symptoms of pleural empyema using the example of acute and chronic forms.

Acute inflammation:

• Cough with foul-smelling sputum.
• Pain in the chest, which is relieved by calm breathing and worse 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 aggravation of the general condition.

Chronic empyema:

• Subfebrile body temperature.
• Pain in the chest of an unexpressed character.
• Chest deformity.

First signs

At an early stage, all forms of a purulent process in the pleura have similar symptoms. The first signs are manifested in the form of a 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 fissures are clogged with fibrin and squeezed by the swelling that has appeared. In this case, the absorption of exudate from the pleural cavity stops.

That is, the first and main symptom of the disease is the accumulation of exudate, swelling and squeezing of organs. This leads to a displacement of the mediastinal organs and a sharp violation of the functions of the cardiovascular and respiratory systems. In the acute form of pyothorax, the inflammation progresses pathologically, increasing the 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 an acute empyema. The disease is in close relationship with other lesions of the bronchopulmonary system (gangrene and lung abscess, pneumonia, bronchiectasis). Pyothorax has a wide microbial spectrum, damage to the pleura can be both primary and secondary.

Symptoms of acute pleural empyema:

• Pain in the chest, aggravated by inhalation, coughing and changing position of the body.
• Dyspnea at rest.
• Blueness of lips, earlobes and hands.
• Increased body temperature.
• Tachycardia over 90 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 fistulas. If the empyema is widespread, then the contents are removed using thoracocentesis, 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

Prolonged accumulation of pus in the chest cavity indicates a congestive inflammatory process that requires medical intervention. Chronic pleural empyema lasts longer than two months, is characterized by the penetration of an infectious agent into the pleural cavity and is a complication of the acute form. The main causes of the disease are the mistakes made in the treatment of acute pyothorax and other features of the disease.

Symptoms:

• Subfebrile temperature.
• Cough with purulent sputum.
• Deformation of the chest on the side of the lesion due to narrowing of the intercostal spaces.

Chronic inflammation leads to the formation of thick cicatricial adhesions, which retain a purulent cavity, and keep the lung in a dormant state. The gradual resorption of the exudate is accompanied by the deposition of fibrin threads on the pleura sheets, which leads to their gluing and obliteration.

Forms

Pyothorax can be both bilateral and 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 by 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 struck 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 the severity of the flow:

• Lungs.
• Medium severity.
• Heavy.

Diseases can be classified depending on the cause and nature of the inflammatory process and a number of other symptoms characteristic of the disease.

According to the international classification of diseases of the 10th revision, pleural empyema is included in the J00-J99 category of respiratory diseases.

Let's consider in more detail the code for microbial code 10:

J85-J86 Purulent and necrotic conditions of the lower respiratory tract

• J86 Pyothorax
  • Pleural empyema
  • Lung destruction (bacterial)
• J86.0 Pyothorax with fistula
• J86.9 Pyothorax without fistula
  • Pyopneumothorax

Since pyothorax is a secondary disease, the auxiliary code of the primary lesion is used in the diagnosis to make the final diagnosis.

Types of chronic pyothorax:

1. Limited
   • Apical - in the region of the apex of the lung
   • Basal - on the diaphragmatic surface
   • Mediastinal - facing the mediastinum
   • Parietal - affect the lateral surface of the organ
2. Unlimited
   • Small
   • Total
   • Subtotal

Depending on the type of disease, the age of the patient and other individual characteristics of his body, treatment is selected. Therapy is aimed at restoring the normal functioning of the respiratory system.

Encapsulated pleural empyema

A limited form of a purulent-inflammatory process is characterized by localization in a certain part of the pleural cavity surrounded by pleural adhesions. Encapsulated empyema of the pleura can be multi-chamber and single-chamber (apical, interlobar, basal, parietal).

As a rule, this species has a tuberculous etymology, therefore, it breaks up in the lateral part of the pleura or supradiaphragmatically. Encapsulated pyothorax is exudative, with the effusion limited to adhesions between the pleural sheets. 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.
• Violent cough with expectoration.
• Pain in the chest.

For diagnosis, ultrasound is performed to detect accumulated fluid and x-rays. To determine the cause of the disease, a pleural puncture is done. Treatment takes place in a hospital and involves strict bed rest. For therapy, corticosteroid hormones, various physiotherapy procedures and a special diet are prescribed.

Complications and consequences

The uncontrolled course of any disease leads to serious complications. The consequences of a purulent process in the pleura pathologically affect the state of the whole organism. The lethal outcome is 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 that connects the pleural cavity to 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 are manifested by all organs and systems. But most often it is bronchopleural fistulas, multiple organ failure, bronchiectasis, 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, it is possible for pus to break through the lungs into the bronchi or through the chest and skin. If purulent inflammation opens outward, it takes the form of an 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

To recognize purulent pleurisy, many methods are used. Diagnosis of empyema of the pleura is based on the symptoms of the disease and, as a rule, is not difficult.

Consider the main methods for detecting a 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 the pleural fluid - allows you to identify the pathogen and determine the nature of the exudate. Material for research is obtained using pleural puncture - thoracocentesis.
3. X-ray - used to identify changes characteristic of the disease. The picture shows a darkening, which corresponds to the spread of purulent contents and the displacement of the mediastinal organs to the healthy side.
4. Ultrasound and CT - determine the amount of purulent fluid and allow you to specify the place for pleural puncture.
5. Pleurofistulografiya - X-ray, which is carried out in the presence of purulent fistulas. A radiopaque preparation is injected into the hole formed and pictures are taken.

Analyzes

In addition to instrumental diagnostic methods, laboratory methods are also used to detect the disease. Analyzes are necessary to determine the pathogen, the stage of empyema and other features of the inflammatory process.

Analyzes to detect purulent pleurisy:

• General analysis of blood and urine.
• Analysis of the pleural fluid.
• Examination of aspirated fluid.
• bacteriological research.
• Bacterioscopy of smear with Gram stain.
• Determination of pH (with pyothorax below 7.2)

Laboratory diagnostics is carried out at all stages of treatment and allows you to track the effectiveness of the chosen therapy.

Instrumental diagnostics

For effective treatment of purulent-inflammatory disease, it is necessary to conduct a lot of research. Instrumental diagnostics is necessary to determine the nature of inflammation, its localization, stage of spread and other features of the course.

Main instrumental methods:

• Polypositional fluoroscopy - localizes the lesion, determines the degree of lung collapse, the nature of 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 state of the basal parts of the organ filled with exudate.

Tomography - performed after drainage of the pleural cavity from pus. If the organ is callabed by more than ¼ of its volume, then the interpretation of the results obtained is difficult. In this case, drainage and an aspirator are connected to the tomography apparatus.

• Pleurography - a picture of the lungs in three projections. Allows you to assess the size of the cavity, the presence of fibrinous layers, sequesters and the condition of the walls of the pleura.
• Bronchoscopy - reveals tumor lesions of the lungs and bronchial tree, which can be complicated by cancer.
• Fibrobronchoscopy - gives an idea of ​​the nature of the inflammatory process in the bronchi and trachea, which occur 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 x-ray looks like a shadow, which is most often located in the lower lung. This sign indicates the presence of fluid in the organ. If massive infiltration of the lower lobe of the lung is observed, then the radiograph is performed in the supine position on the affected side. Thus, the exudate is distributed along the chest wall and is clearly visible in the picture.

If the disease is complicated by a bronchopleural fistula, then air accumulation is observed in the pleural cavity. On the picture, you can see the upper border of the effusion and assess the degree of collapse of the lung. Significantly changes radiography - adhesive process. During the diagnosis, it is not always possible to identify a purulent cavity, since it can be both in the lung and in the pleura. If purulent pleurisy is accompanied by destruction of the respiratory organs, then the deformed parenchyma is visible on the radiograph.

Differential Diagnosis

Since the purulent process in the pleura is a secondary disease, differential diagnosis is extremely important for its detection.

Acute empyema is often a complication of pneumonia. If during the study a mediastinal shift is detected, then this indicates a pyothorax. In addition, there is a partial expansion and bulging of the intercostal spaces, pain on palpation, 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 pushing of the bronchial branches and their deformation is determined.

• Lung atelectasis

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 lung field and the transition to the chest wall. To detect purulent pleurisy, a transthoracic biopsy of the lung tissue is performed.

• Specific damage to 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 carried out.

In addition to the diseases described above, do not forget about differentiation with 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 organs and the body. The main task of therapy is the emptying of the pleural cavity from purulent contents. Treatment is carried out in a hospital with strict adherence to bed rest.

Algorithm for the relief of the disease:

• Purification of the pleura from pus by drainage or puncture. The earlier the procedure was performed, the lower the risk of complications.
• The use of antibiotic drugs. In addition to the general course of taking the medication, antibiotics are used to wash the pleural cavity.
• Without fail, the patient is prescribed vitamin therapy, immunostimulating and detoxification treatment. It is possible to use protein preparations, UVI blood, hemosorption.
• In the process of recovery, a diet, therapeutic exercises, physiotherapy, massages and ultrasound therapy are indicated for the normal recovery of the body.
• If the disease proceeds in a neglected chronic form, then the treatment is carried out surgically.

Drug treatment of pleural empyema

Treatment of a 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.

For treatment, the following drugs are prescribed:

• 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 performed using aminoglycosides, carbapenems and monobactams. Antibiotics are selected as rationally as possible, taking into account probable pathogens and based on the results of bacteriological diagnostics.

• Mix onion juice with honey in a 1:1 ratio. Take the remedy 1-2 tablespoons 2 times a day after meals. The medicine has anti-infective properties.
• Remove pits from fresh cherries and chop the pulp. The medicine should be taken ¼ cup 2-3 times a day after meals.
• Heat the olive oil and rub it on the affected side. You can make an oil compress and leave it overnight.
• Mix equal proportions of honey and black radish juice. Means to take 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 it brew 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 tablespoons 2-3 times a day before meals.

NATIONAL GUIDELINES

"EMPIEMA OF THE PLEURA"

Working group on the preparation of the text of clinical guidelines:

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 (Yekaterinburg).

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 can not be done?

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 therapeutic 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 describing the treatment of the disease, it was possible to avoid the contradiction between foreign and domestic approaches.

These clinical guidelines do not consider the tactics of treating acute incompetence of the bronchus stump after lobectomy and pneumonectomy as the cause of subsequently developed pleural empyema, as well as methods for preventing insolvency. This is the reason for a separate document.

Tuberculous empyema of the pleura (as a complication of fibrous-cavernous tuberculosis and as a complication of surgery) 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
The conditions for the occurrence of empyema of the pleura 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 the operating room);

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

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

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

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

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

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

b) therapeutic measures:

Rational empirical antibiotic therapy of suppurative lung diseases based on the principles of de-escalation, taking into account the data of 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 that cause its accumulation, with mandatory microbiological examination;

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

Timely presentation 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 (if there are delimiting adhesions from the free pleural cavity);

- rational perioperative antibiotic prophylaxis in thoracic surgery;

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

Application of additional methods of aerostasis of the lung tissue and strengthening of the bronchus stump during surgical interventions;

Rational drainage of the pleural cavity during surgical interventions;

Careful care of drainage in the pleural cavity;

Timely removal of drains 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), chest wall.
5. SCREENING
1. Regular plain chest radiography 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. Punctures of the pleural cavity in conditions accompanied by accumulation of transudate (in the presence of clinical indications), with macroscopic control, general clinical analysis and microbiological examination.

4. Punctures of the pleural cavity in patients in the early period after pneumonectomy (in the presence of 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, organizations.

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.

Stage fibrinous-purulent manifested by the loss of fibrin (due to the suppression of fibrinolytic activity), which forms loose delimiting adhesions with pus encapsulation and the formation of purulent pockets. The development of bacteria is accompanied by an increase in the concentration of lactic acid and a decrease in the 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 radiographically, this stage consists in the relative relief of the inflammatory process, the progressive development of delimiting adhesions (mooring), which are already of a connective tissue nature, scarring of the pleural cavity, which can lead to blockage of the lung, and the presence of isolated cavities against this background, supported mainly by preservation of the 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:

a 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 gram stain results,

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

Purulent-fibrinous stage:

Class 4. Complicated pleural effusion (simple):

positive gram stain results,

glucose
Class 5. Complicated pleural effusion (complex):

positive Gram stain results,

glucose
Class 6. Simple empyema:

Explicit pus, solitary purulent pocket or free

spread of pus in the pleural cavity.

Organization stage:

Class 7. Complex empyema:

Explicit pus, multiple purulent encystation,

fibrous stitches.
The practical significance of these classifications is that they allow 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, the division of empyema according to the nature of the course (and, to some extent, according to temporal criteria) is still accepted: acute and chronic(exacerbation phase, remission phase).

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

The most common cause of the transition of an acute purulent process into a chronic one is the constant infection of the pleural cavity in the presence of communication with a 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 to be the period of transition of acute empyema to chronic - 2-3 months. However, this division is conditional. In some patients with pronounced reparative abilities, rapid fibrotization of fibrinous deposits on the pleura occurs, while in others these processes are so inhibited that adequate fibrinolytic therapy allows "clearing" the pleural sheets even in the long term (6-8 weeks) from the onset of the disease.

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

A sign of the development of chronic empyema of the pleura 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 the 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 the message with the external environment, there are:

- "closed" , without fistula (does not communicate with the external environment);

- "open" , with a fistula (there is a communication with the external environment in the form of a pleurocutaneous, bronchopleural, bronchopleurocutaneous, pleuroorgan, bronchopleuroorgan fistula).
6.4. According to the volume of the lesion of the pleural cavity:

- total (lung tissue is not detected on the survey radiograph);

- subtotal (on the survey radiograph, only the apex of the lung is determined);

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

6.5. According to the etiological factors, there are:

- 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, subdiaphragmatic abscess, liver abscess, inflammation of the soft tissues and bone skeleton of the chest).

7. DIAGNOSIS
7.1. General clinical physical methods of examination.

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 assigning it to one of the types, is impossible without the use of x-ray (including computed tomography) research methods.

However, some 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 into the pleural cavity of the pulmonary abscess. The main pathological syndromes in its occurrence are: pleuropulmonary shock (due to irritation with pus and air of the extensive pleural receptor field); 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 shift of the mediastinum with a violation of the outflow of blood in the system of vena cava. The clinical picture is dominated by manifestations of cardiovascular insufficiency (falling 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 (operation): violation of the integrity of the chest and associated disorders of external respiration, 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 disorders, intoxication) are masked by such frequent complications of chest injuries as pneumonia, atelectasis, hemothorax, clotted hemothorax, which often causes unjustified delays in 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 sections of the lung 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 the study of blood and urine.

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

a) In the acute period of the disease, leukocytosis is noted with a pronounced shift of the leukocyte formula to the left, a significant increase in ESR. In severe cases, especially after a previous viral infection, as well as in anaerobic destructive processes, leukocytosis can be insignificant, and sometimes the number of leukocytes even decreases, especially due to lymphocytes, but 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 with sputum and purulent exudate, and with a violation of protein synthesis in the liver due to intoxication. The level of C-reactive protein, lactate dehydrogenase, creatine kinase, transaminases increases. Due to the predominance of catabolic processes, the content of glucose in the blood can be increased. In the acute period, the content of plasma fibrinogen increases significantly, however, with advanced purulent exhaustion, it may decrease due to a violation of the synthesis of this protein in the liver. Changes in hemostasis are manifested in the form of inhibition of fibrinolysis. The volume of circulating blood decreases in more than half of the patients, and mainly due to the globular volume. Sharp hypoproteinemia (30-40 g/l) leads to edema. Fluid retention in the interstitial sector averages 1.5 liters, and in the most seriously ill patients reaches 4 liters. Hyperammonemia and hypercreatininemia indicate a severe, advanced chronic purulent process, the formation of chronic renal failure due to amyloidosis of the kidneys.

Pleural empyema- accumulation of purulent exudate in the pleural cavity with secondary compression of the lung tissue in 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, occurring simultaneously with pneumonia Postoperative, occurring as a complication of surgery on the organs of the chest or upper abdomen. the amount of effusion is distinguished by small pyothorax - accumulation of exudate in the pleural sinuses (amount of 200-500 ml); average pyothorax - accumulation of exudate to the angle of the scapula in the VII intercostal space (amount of 500-1000 ml); large pyothorax - accumulation of exudate above the angle of the scapula (amount of more than 1 liters).

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

The reasons

Etiology. Pathogens: .. staphylococci.. pneumococci.. facultative and obligate anaerobes. Direct route of infection.. Lung injury.. Chest wounds.. Rupture of the esophagus.. Rupture of abscess, lung gangrene, cavities.. Pneumonia.. Tuberculosis.. Progression of bacterial lesions of the lungs (abscess or bacterial destruction).. Bronchiectasis.. Resection lung and other operations on the organs of the chest.. 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 pleural effusion. Fibrinous - purulent phase (7-21 days). The fluid occupies the lower parts of the pleural cavity. In the absence of adequate drainage, a multilocular empyema is formed. Chronic phase (after 21 days). As a result of the deposition of fibrin, the pleura thickens along the border of the pleural effusion. Abscesses appear in neighboring areas.

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

Symptoms (signs)

Clinical picture

Acute pleural empyema. Cough with expectoration. Prolonged and frequent bouts of coughing with a large amount of sputum indicate the presence of a bronchopleural fistula.. Chest pain is minimally pronounced with quiet breathing, sharply increases during a full deep breath.. Shortness of breath.. Violation of voice tremor or distinct egophony.. Dull or dull percussion sound on the side of the lesion, the upper limit of dullness corresponds to the Ellis-Damuazo-Sokolov line .. Weakening or absence of breathing during auscultation over the effusion area .. Bronchial breathing over the compressed lung adjacent to the effusion .. Skin redness occurs only when pus breaks from the empyema cavity skin .. The general condition progressively worsens: weakness, loss of appetite, weight loss, hectic body temperature, frequent pulse.

Chronic empyema of the pleura .. Body temperature can be subfebrile or normal, if the outflow of pus is disturbed, it becomes hectic .. Cough with purulent sputum discharge .. Deformation of the chest on the side of the lesion 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 noises over the cavity are not heard.

Diagnostics

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

Special Studies. Thoracocentesis - pleural fluid is cloudy, thick, gradually turning into true pus, has a specific unpleasant odor. Laboratory examination of the aspirated fluid.. Bacterioscopy of a Gram-stained smear.. Bacteriological examination (often the results of these methods differ).. pH determination - when pH is less than 7.2 empyema.. Glucose concentration is lower than the concentration of glucose in the blood. X-ray examination.. The mediastinum is displaced in the direction opposite to the side of effusion accumulation.. Basal blackout with a horizontal level in case of 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. Costal chondritis. Gangrene of the lung. Caseous pneumonia. Mesothelioma of the pleura. 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 by puncture or drainage. Straightening of the lung using constant aspiration, exercise therapy. Rational antibiotic therapy.

Conservative therapy. Early acute empyema - repeated pleural punctures are necessary with aspiration of purulent exudate and adequate antibiotic therapy (clindamycin, ceftriaxone in combination with metronidazole; aminoglycosides, monobactams, carbapenems can be prescribed). blood. Infusion therapy and partial parenteral nutrition. Formed empyema with thick purulent exudate is 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 aspirated through both tubes and the lung is completely expanded. 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 + bronchus tamponade.. In case of ineffectiveness, surgical treatment: repneumolysis, decortication of the lung, curettage of the pyogenic layer to the fibrous capsule, suturing of the bronchial fistula or resection of the affected area lung .. In tuberculous empyema, the volume of the operation is increased - a total parietal pleurectomy is performed.

Complications. Perforation.. Into the lung 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, with chronic empyema it can be unfavorable.

Synonyms. Purulent pleurisy. Pyothorax.

ICD-10. J86 Pyothorax