Empyema of the pleura in adults. Empyema of the pleura Clinical rec.POC When surgical intervention is necessary

13.05.2020

Purulent pleurisy

RCHD (Republican Center for Health Development of the Ministry of Health of the Republic of Kazakhstan)
Version: Clinical protocols MH RK - 2015

Pyothorax without fistula (J86.9), Pyothorax with fistula (J86.0)

Pulmonology, Thoracic surgery, Surgery

general information

Short description

Expert Council
RSE on REM "Republican Center
health development "
Ministry of Health
and social development
Republic of Kazakhstan
dated December 10, 2015
Protocol No. 19

Protocol name:Empyema of the pleura in adults

Empyema of the pleura (purulent pleurisy) - limited or diffuse inflammation of the visceral or parietal pleural layers, occurring with the accumulation of purulent exudate in the pleural (physiological, anatomical) cavity and accompanied by signs of purulent intoxication, severe hyperthermia and, often, respiratory failure.

Chronic pleural empyema - a purulent-destructive process in the residual pleural cavity with coarse and persistent morphological changes, characterized by a long course with periodic exacerbations.

Protocol code:

ICD 10 code:
J86.0 - Pyothorax with fistula
J86.9 - Pyothorax without fistula

Abbreviations used in the protocol:
ALT - alanine aminotransferase
AST - aspartate aminotransferase
APTT - activated partial thromboplastin time
HIV - aIDS virus
K - potassium
Na - sodium
Ca - calcium
DN - respiratory distress
ITSH - infectious toxic shock
ELISA - linked immunosorbent assay
CT scan - cT scan
INR - international normalized ratio
MRI - magnetic resonance imaging
UAC - general blood analysis
OAM - general urine analysis
OEP - acute pleural empyema
TT - thoracotomy
TS - thoracoscopy
ESR erythrocyte sedimentation rate
Ultrasound - ultrasound procedure
FBS - fibrobronchoscopy
FEGDS - fibroesophagogastroduodenoscopy
HEP - chronic pleural empyema
ECG - electrocardiography
EP - pleural empyema
EFFGS - endoscopic esophagogastroscopy
EchoCG - Echocardiography

Protocol development date: 2015 year.

Protocol users:thoracic surgeons, general surgeons, internists, infectious disease specialists, pulmonologists, anesthesiologists-resuscitators, doctors and paramedics of the emergency medical care, general practitioners.

Level I	Evidence obtained from at least one properly designed randomized controlled trial or meta-analysis
Level II	Evidence from at least one well-designed clinical trial without appropriate randomization, from an analytical cohort or case-control study (preferably from a single center), or from dramatic results from uncontrolled trials
Level III	Evidence obtained from the opinions of reputable researchers based on clinical experience
Class A	Recommendations that have been approved by agreement of at least 75% of the multisectoral expert group
Class B	Recommendations that were somewhat controversial and did not meet with agreement
Class C	Recommendations that caused real controversy among group members

Classification

1. Clinical classification:

There are several classifications of pleural empyema.

By etiological basis	On a pathogenetic basis	By the nature of the damage to the lung tissue	By the nature of the communication of the empyema cavity with the external environment and the bronchial tree	According to the localization of the cavity,	By prevalence
non-specific	para- and metapneumonic	empyema without destruction of lung tissue (uncomplicated)	closed empyema	apical	total
specific	postoperative	empyema with destruction of lung tissue (complicated)	empyema with bronchopleural, bronchopleurothoracic and pleurothoracic fistula	interlobar	common (diffuse)
mixed	traumatic			paramediastinal;	limited
	metastatic			parietal
	contact * (transitional)			basal and their combinations
	sympathetic ** (sympathetic, collateral) pleural empyema

* Contact includes:
- empyema due to the breakthrough of mediastinal abscesses;
** To sympathetic:
- empyema with subphrenic abscesses
With limited empyema, one wall of the pleural cavity is involved in the process, with widespread (diffuse) empyema, two or more walls of the pleural cavity are involved in the process, with total empyema, the entire pleural cavity is covered by a pathological process - from the diaphragm to the dome of the pleura.

According to the degree of lung compression, there are three degrees of lung collapse:

By clinical type, there are :

sharp

subacute

septic

chronic empyema

The differentiation of these forms is advisable, but very difficult due to the lack of clear signs of the transition of acute empyema to the chronic stage.
Types of pleural empyema:
Acute (duration of the disease up to 8 weeks);
· Chronic (the duration of the disease is more than 8 weeks).
Acute and chronic pleural empyema are divided into groups:
By the nature of the exudate:
- purulent;
- putrid;
- anaerobic.
By the nature of microflora:
- specific (tuberculous, actinomycotic, syphilitic, etc.);
- nonspecific (staphylococcal, streptococcal, pneumococcal, anaerobic, etc.);
- caused by mixed flora.
By origin:
- primary;
- secondary.
By the nature of communication with the external environment:
- not communicating with the external environment (empyema proper);
- communicating with the external environment (pyopneumothorax).
By the prevalence of the process:
- free empyema (total, subtotal, small);
- limited (encapsulated) empyema:
- parietal (paracostal)
- basal (between the diaphragm and the surface of the lung)
- interlobar or interlobar (in the interlobar sulcus)
- apical or apical (above the apex of the lung)
- mediastinal (adjacent to the mediastinum)
By the number of cavities:
- single-chamber;
- multi-chamber (purulent accumulations in the pleural cavity are separated by adhesions).
By the presence of complications:
- not complicated;
- complicated;
- phlegmon of the chest wall;
- aspiration pneumonia of the opposite lung;
- purulent pericarditis;
- myocarditis;
- sepsis;
- acute osteomyelitis of the ribs;
- erosive bleeding from the intercostal artery and other vessels of the chest wall;
- hypoxic stomach ulcers with bleeding;
- thromboembolism of the branches of the pulmonary artery;
- hypoproteinemia with anasarca;
- contralateral spontaneous pneumothorax;
- hemoptysis or pulmonary bleeding.
According to the clinical course:
- proceeding with severe intoxication due to violent purulent inflammation of the empyema cavity or / and exacerbation of the inflammatory process in the lungs;
- proceeding with moderate intoxication;
- "erased" clinical picture and compensated condition of the patient.

Clinical picture

Symptoms, course

Diagnostic criteria:

Complaints and anamnesis:as a rule, EP is layered on the clinical manifestations of primary disease (pneumonia, lung abscess, pleurisy), a complication of which she was.

Complaints:
Severe, stabbing pain in the side (the localization of pain depends on the anatomical features of the location of the pathological (purulent) exudate and the formation of the adhesive (fibrous cords) process (supraphrenic, interlobar, rib-mediastinal, etc.), aggravated by breathing and coughing;
Emaciation;
· loss of appetite;
Weakness;
· Frequent dry, obsessive, painful cough, in some cases (in the presence of a bronchopleural fistula) there is a release of sputum or pus;
· Recurrent fever;
· Symptoms of severe intoxication: dry cough, body temperature 39-40 0, tachycardia;
· Frequent, incomplete (shallow) breathing;
Shortness of breath;
Purulent discharge from the chest wall fistula (if any);
· Vomiting with prolonged and increasing intoxication.

Anamnesis:
In the history of patients there is an indication of the transferred acute exudative pleurisy. In some cases, pleurisy was "cured" in a conservative way, in others one of the accepted operations was performed, after which a non-healing fistula of the chest wall remained, secreting a small amount of pus.
If EP is suspected, the disease begins with severe stabbing pains in one or another half of the chest, aggravated by breathing and coughing (Evidence level III, strength of recommendation A).

Physical examination:
· Retraction of the chest, narrowing of the intercostal space, kyphoscoliosis, restriction of respiratory excursion of the corresponding half of the chest;
Dullness is determined percussion, respiratory sounds are sharply weakened or not carried out;
Thickening of the nail phalanges of the fingers (with a long, sluggish process);
· Enlargement of the liver and spleen;
· The skin and subcutaneous layers of soft tissues may be hyperemic, edema and local soreness are noted;
· Forced position due to pain and shortness of breath;
With a prolonged and neglected process, symptoms of brain intoxication can be observed: mental disorders, headaches, irritability;
With prolonged and growing intoxication, cyanosis, DN, shock occurs;
Spirography - helps to assess respiratory capacity, the degree of respiratory failure, blood supply, liver and kidney failure.

Diagnostics

The list of basic and additional diagnostic measures:

Basic (mandatory) diagnostic examinations carried out at the outpatient level:
· UAC;
OAM;
· Biochemical blood test (total protein, urea, creatinine, total bilirubin, ALT, AST, glucose);

· ECG to exclude cardiac pathology;
· Plain chest x-ray (UD-V);
· Contrast radiography (fluoroscopy) of the esophagus and stomach with barium (in the standing position);
EFFGS (UD-V).

Additional diagnostic examinations carried out at the outpatient level:
· CT scan of the chest;
· Ultrasound of the abdominal cavity.

The minimum list of examinations that must be carried out when referring to a planned hospitalization: in accordance with the internal regulations of the hospital, taking into account the current order of the authorized body in the field of health.

Basic (mandatory) diagnostic examinations conducted at the inpatient level(for emergency hospitalization, diagnostic examinations are carried out that are not carried out at the outpatient level):
· UAC;
OAM;
· Biochemical blood test (total protein, albumin, urea, creatinine, bilirubin, ALT, AST, glucose, K, Na, Ca);
· Coagulology (APTT, PT, PTI, INR, fibrinogen A, fibrinogen B, blood clotting time);
· Puncture of the pleural cavity in order to evacuate the contents;
· Clinical and cytological analysis of punctate;
· Sowing punctate to determine flora;
Microbiological examination of sputum (or throat swab);
· Determination of sensitivity to antibiotics;
· Determination of the blood group according to the AB0 system;
· Determination of the Rh factor of blood;
· Blood test for HIV;
· Blood test for syphilis;
· Determination of HBsAg in blood serum;
· Determination of total antibodies to hepatitis C virus (HCV) in blood serum;
ECG;
· Bronchoscopy;
Fistulography;
· TS;
· Survey radiography of the chest organs in two projections (UD-V);
· Spirography to assess respiratory capacity.

Additional diagnostic examinations carried out at the inpatient level(in case of emergency hospitalization, diagnostic examinations are not carried out at an outpatient level):
· CT scan of the chest organs in order to clarify the prevalence of the process, communication with surrounding organs and the external environment, limited (degree of recommendation - A);
· Diagnostic TS in cases of collapse or atelectasis of the lung with an increase in respiratory failure, as well as for drainage of the pleural cavity, administration of antibacterial drugs, closure of the fistula;
· Ultrasound of the abdominal cavity and small pelvis (in cases of free fluid in the small pelvis, effusion, changes in the picture with polyserositis);
· Ultrasound of the pleural cavities (UD-V);
EFGDS in the presence of a tracheoesophageal or pleuro-gastric fistula (UD-V);
· Survey radiography of the abdominal organs (to exclude free gas and pathological effusion in the abdominal cavity and small pelvis);
ECG;
Echocardiography (taking into account the localization of the lesion and exclusion of pathological effusion into the mediastinal space and the detection of a pericardial-pleural fistula);
· MRI of the abdominal organs (in cases of the presence of a fistula between the pleural and abdominal cavity or hollow organ of the abdominal cavity, as well as if peritonitis is suspected).

Diagnostic measures carried out at the ambulance stage emergency care: are not carried out.

Instrumental research:
· Plain X-ray of the chest organs: when translucent, the squeezed lung on the sore side with a thickened surface, a cavity filled with air, with a horizontal level of fluid at the bottom. In chronic encased pleural empyema without fistula, there is a homogeneous intense parietal darkening with clear dense edges;
During fistulography, the boundaries, position of the cavity, the presence of a fistula are determined, the localization of the cavity is analyzed and further tactics are decided;
CT scan of the chest : the presence of a compressed lung, fluid (of different density) and air in the pleural cavity, displacement of the mediastinal organs to the healthy side, as well as the presence of strands, mooring lines and bridges with a cellular structure allows you to accurately determine the localization, the level of damage and the degree of respiratory failure in the patient, as well as makes it possible to determine the level and volume of the planned surgical intervention;
During bronchography, the localization of the pathological process, the connection with the surrounding tissues and cavities is determined, the state of the bronchial tree is assessed;
· Pleural puncture in the 7-8 intercostal space along the middle scapular line along the apical edge of the underlying rib allows you to assess the nature of the contents of the lesion cavity;
· Bronchoscopy allows you to determine the exact localization of the accumulation of pus, to sanitize the cavity and biopsy the affected area;
· TS helps to assess the empyema cavity, the nature of pleural adhesions, to identify the mouth of the pleurobronchial fistula and to target drainage.

Indications for specialist consultation:
· Consultation of a pulmonologist: in order to determine the degree of DN, lung functionality, as well as preoperative antibiotic therapy.
· Consultation with an anesthesiologist-resuscitator: to resolve the issue of surgical treatment, preoperative preparation, the choice of anesthesia method.
· Consultation with a cardiologist: to exclude the lesion of mediastinum, to exclude the presence of a fistula and contraindications to the operation or to prescribe cardiotrophic and stimulating drugs when choosing a conservative method of treatment.
· Consultation with an abdominal surgeon: in the presence of a fistulous passage into the cavity of the abdominal organs or the cavity itself, for parallel conservative therapy or sanitation of the abdominal cavity.
· Consultation with a clinical pharmacologist: in order to select an adequate therapy with antibacterial and supportive, accompanying drugs before, during and after the operation and throughout the treatment.
· Consultation of a therapist: in the presence of an appropriate concomitant pathology.

Laboratory diagnostics

Laboratory research:
UAC: leukocytosis with a shift of the leukocyte formula to the left, ESR up to 40-70 mm / h;
· Biochemical blood test: hypoproteinemia due to a decrease in the level of albumin, hypocholesterolemia, a decrease in the level of prothrombin, transaminases and fibrinogen;
General urine analysis: microhematuria, cylindruria, leukocyturia, bacteriuria, hypo-isostenuria are observed.

Differential diagnosis

Differential diagnosis:

Table 1 Differential diagnosis of EP

Nosology	Typical syndromes / symptoms	Differential test
Empyema of the pleura	Stitching pain, heaviness on the side of the lesion, forced position of the body, dry cough, fibril fever, discharge of pus from a fistula on the chest wall.	CT - the presence of a compressed lung, fluid (of different density) and air in the pleural cavity, displacement of the mediastinal organs to the healthy side, as well as the presence of cords, mooring lines and bridges with a cellular structure.
Serous pleurisy	Low-fibril temperature, difficulty breathing, dull pain in the chest, acrocyanosis.	Plain radiography of the lungs - unexpressed pleural lesions, tightness of the lung in the healthy direction, transparency and intensity of exudate, absence of gross deforming changes from the side of the pleural cavity.
Caseous pneumonia	Intoxication syndrome and bronchopulmonary manifestations of the disease are expressed. body temperature up to 39-40 ° C, constant. Loss of appetite up to anorexia, dyspeptic symptoms, and weight loss are also noted. Patients complain of chest pain, shortness of breath, cough with phlegm, sometimes stained with a rusty color or purulent character. Profuse sweat, cyanotic skin.	X-ray picture: affects the whole lobe or the whole lung and the process is bilateral, with the presence of a large number of cavities, destruction of the lung, high standing of the dome of the diaphragm
Lung gangrene	high fever, chest pain, shortness of breath, pallor and cyanosis of the skin, sweating, progressive weight loss, profuse foul-smelling phlegm	Radiography of the lungs - extensive darkening (decay cavity of heterogeneous density) within the lobe with a tendency to spread to adjacent lobes or the entire lung. CT - in large cavities, tissue sequesters of various sizes are determined. Microscopic examination of sputum: Dietrich plugs, necrotic elements of the lung tissue, the absence of elastic fibers.
Rib fracture or intercostal neuralgia	Acute pains, aggravated by breathing, physically normal state of health, the absence of a pronounced clinic.	Radiography of the OGK - the presence of a change in the structure of the rib (ribs); When prescribing analgesics, there are no other symptoms.
Esophageal pathology, CVS	Violation of the heartbeat, rhythm, pulse, cold sweat, tachycardia, vascular spasm, blood pressure surges. With pathology of the esophagus - dysphagia, regurgitation or vomiting, pain of a spasmodic nature, localized more in the mesogastrium or mediastinum.	ECG, myography, examination of the esophagus with a radiopaque probe or barium suspension, EFGDS. EchoCG.
Subphrenic abscess	Pain is more often in the right hypochondrium, self-relieved, fever may be absent, leukocytosis is moderate, without changing the formula.	Plain X-ray of the chest organs with the capture of the abdominal cavity. CT - indicates the exact localization of the pathological process in relation to the diaphragm and the connection between the two cavities.
Tumors of the mediastinum, chest cavity (Ewing's sarcoma, PNET, mesothelioma, MTS in the pleura)	The pains may be infrequent, volatile, and are relieved by analgesics. DN is periodically observed with a large tumor volume with tightness of organs. Tumor intoxication. Uncontrolled fever.	Biopsy - detection of tumor cells during thoracoscopy. The presence of pathological cells in the UAC, B / xAC - changes in the level of ferritin, LDH, ALP.

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Treatment

Treatment goals:
· Elimination of the source of inflammation (exudate, pleural sheets, fistula);
· Normalization of blood counts.

Treatment tactics:
· The main method of treatment for EN is local treatment (debridement of the pleural cavity) (level of evidence II, strength of recommendation - A);
When the diagnosis of EP is confirmed, emergency treatment is indicated in a hospital setting with the beginning of complex treatment;
· Pleural puncture with sampling of material for bacteriological examination and evacuation of the cavity contents;
· Preoperative preparation in all cases, taking into account the risk of generalization of the process, in order to exclude complications and minimize damage to surrounding organs and tissues, as well as to facilitate anesthesia.

Surgical intervention:

Surgery provided on an outpatient basis - pleural puncture.

inpatient surgery:
· Pleurectomy with lung decortication;
· Sanitation of the pleural cavity;
· Preliminary intubation of the opposite main bronchus with total or subtotal unilateral lesion.
Indications for surgery:
Early TS from the moment of diagnosis, which reduces the risk of developing infectious complications, generalization of the process, involvement of surrounding structures in the purulent process (level of evidence - III, strength of recommendation - B);
TT for a deeper examination of the cavity, decortication and radical elimination of the focus, followed by sanitation of the pleural cavity in the presence of:
- a neglected process or adhesions and gross deforming changes in the chest;
- sinus tracts.
Contraindications to surgery:
· Complications in the form of dissemination and generalization of the process;
Sepsis;
· ITSh;
· Bilateral defeat;
· DN above III degree.
Surgical treatment options:
· Thoracoscopy;
· Thoracotomy.
Open method (TT) performed by a wide incision along the intercostal spaces in the 6-8 intercostal space (sometimes with resection of 2-3 ribs) on the affected side. This type of operation is preferable for subtotal or total lesions, for ease of access, maximum activity of surgeons, speed of performance and complete resanction of half of the chest.
Closed method (TS) It is used for more limited processes, encapsulated and started, by puncturing 10 mm from 2 to 5 trocars. In comparison with the open approach, the TS provides better cosmetic results, reduces the duration of hospital stay, reduces postoperative pain and accelerates recovery, while also reducing the risk of postoperative complications. (strength of recommendation - B);
The use of a stapler gives a more reliable closure of the stump of the lobe of the lung or the stump of the hilum of the lung than using the traditional method. (recommendation strength - C);
Completion of the operation with primary suturing is indicated in all cases, if necrectomy is performed, there is no risk of fistula formation, and also taking into account the pressure of the chest cavity. (level of evidence - II, strength of recommendation - B).
Drainage of the pleural cavity in order to restore pressure in the cavity, evacuation of excess discharge (hemorrhagic serous, purulent), for the possibility of access and administration of drugs, evacuation of air is recommended in all cases.
Rethoracotomy with repeated revision and debridement is recommended in case of deterioration in the postoperative period, emergence of urgent complications.

Non-drug treatment:
Mode:mode 1 (bed);
Diet:diet 7 (rich in calories).

Drug treatment
Antibacterial therapy. For inflammation of the postoperative wound and for the prevention of postoperative inflammatory processes, antibacterial drugs are used. For this purpose, cefazolin or gentamicin are used in case of allergy to b-lactams or vancomycin in case of detection / high risk of methicillin-resistant Staphylococcus aureus. According to the recommendations of the Scottish Intercollegiate Guidelines and others, antibiotic prophylaxis for this type of surgery is strongly recommended. In cases of endoscopic removal of ITT for the purpose of antibiotic prophylaxis, it is prescribed one of the following drugs ... In the event of pyoinflammatory complications, preference should be given to combinations (2-3) of antibiotics of different groups. Changes in the list of antibiotics for perioperative prophylaxis should be carried out taking into account microbiological monitoring in the hospital.

Analgesic therapy. Non-narcotic and narcotic analgesics (tramadol or ketoprofen or ketorolac; paracetamol). NSAIDs are administered orally for pain relief. NSAIDs for postoperative analgesia should be started 30-60 minutes before the expected end of the operation intravenously. Intramuscular administration of NSAIDs for postoperative pain relief is not indicated due to the variability of drug concentrations in serum and pain caused by injection, with the exception of ketorolac (possibly intramuscular administration). NSAIDs are contraindicated in patients with a history of ulcerative lesions and bleeding from the gastrointestinal tract. In this situation, the drug of choice will be paracetamol, which does not affect the mucous membrane of the gastrointestinal tract. NSAIDs should not be combined with each other. The combination of tramadol and paracetamol is effective.

Medication treatment provided on an outpatient basis: not carried out.

Inpatient drug treatment:

N / a	iNN name	dose	multiplicity	route of administration	duration of treatment	note	UD
1	Morphine hydrochloride	1% -1 ml	every 6 hours	in / m	1-2 days		IN
2	Trimeperidine	2% - 1 ml	every 4-6 hours	in / m	1-2 days	Narcotic analgesic for pain relief in the postoperative period	IN
3	Ketoprofen	300 mg, maintenance - 150-200 mg / day 100 mg 100-200 mg in 100-150 ml of 0.9% sodium chloride solution	2-3 times	inside in / m	2-3 days	Non-narcotic analgesic	AND
4	Ketorolac	10-30 mg,	4 times / day (every 6-8 hours)	i / m, i / v, inside	no more than 5 days, 2 days for children, inside no more than 5-7 days.	Non-narcotic analgesic for the treatment of acute and severe pain	AND
5	Tramadol	100 mg - 2 ml	2-3 times	in / m	within 2-3 days	Analgesic of mixed type of action in the postoperative period	AND
6	Ampicillin	0.25-0.5 g (adults), 0.25-0.5 g	4-6 times a day every 6-8 hours	inside, in / m	from 5-10 days up to 2-3 weeks or more	Antibiotic of the semi-synthetic penicillin group wide range	AND
7	Ceftazidime	0.5-2 g	2-3 times a day	i / m, i / v	7-14 days	3rd generation cephalosporins	AND
8	Ceftriaxone	1-2 g or 0.5-1 g	1 time / day 2 times / day	i / m, i / v	7-14 days	3rd generation cephalosporins	AND
9	Cefotaxime	1 g 1g in severe cases	2 times a day 3-4 times	i / m, i / v	7-14 days	3rd generation cephalosporins	AND
10	Cefepim	0.5-1 g up to 2 g (for severe infections	2-3 times	i / m, i / v	7-10 days or more	4th generation cephalosporins	AND
11	Cefoperazone	2-4 g (adult), with severe infections: 8g (adult); 50-200 mg / kg (children)	2 times / day	i / m, i / v	7-10 days	3rd generation cephalosporins	AND
12	Amikacin	10-15 mg / kg.	2-3 times	i / v, i / m	with intravenous administration - 3-7 days, with intramuscular injection - 7-10 days.	Antibiotic - aminoglycosides	AND
13	Gentamicin	0.4 mg / kg, 0.8-1 mg / kg for severe infections	2-3 times	i / v, i / m	7-8 days	Antibiotic - aminoglycosides	IN
14	Ciprofloxacin	250mg-500mg	2 times	inside	7-10 days		IN
15	Levofloxacin	250-750 mg 250-750 mg	Once a day	inside, intravenously, slowly, every 24 hours (a dose of 250-500 mg is administered over 60 minutes, 750 mg - over 90 minutes).	7-10 days	In case of impaired renal function, an adjustment is required	AND
16	Meropenem	500 mg, at nosocomial infections - 1 g	Every 8 hours	i / v	7-10 days	Antibiotics - carbapenems	AND
17	Azithromycin	500 mg / day	Once a day	inside	3 days	Antibiotics - azalides	AND
18	Clarithromycin	250-500 mg each	2 times a day	inside	10 days	Macrolide antibiotics	AND
19	Metronidazole	500 mg,	Every 8 hours	inside in / continuous (inkjet) or drip injection - 5 ml / min.	7-10 days	Antibacterial agent, derivative of nitroimidazole	IN
20	Fluconazole	150 mg	Once a day	inside	once	Antifungal agent for the prevention and treatment of mycoses	AND
21	Nadroparin	0.3 ml	Once a day	i / v, s / c	7 days	Direct-acting anticoagulant (for the prevention of thrombosis). Should be reinforced with a combination or a second antibiotic after surgery	AND
22	Povidone - iodine	10% solution	daily	Outwardly	As needed	Antiseptic, for the treatment of the skin undiluted solution, drainage systems diluted 10 or 100 times	IN
23	Chlorhexidine	0.05% aqueous solution		outwardly	once		AND
24	Ethanol	solution 70%;		Outwardly	once	Antiseptic for the treatment of the operating field, the hands of the surgeon	AND
25	Hydrogen peroxide	3% solution		outwardly	As needed	Antiseptic for treatment	IN
26	Sodium chloride	0.9% - 400ml	1-2 times	IV drip	depending on the indication	Solutions for infusion, regulators of water-electrolyte balance and acid-base balance	AND
27	Dextrose	5%, 10% - 400 ml, 500 ml; solution 40% in ampoule 5ml, 10 ml	1 time	IV drip	depending on the indication	Solution for infusion, with hypoglycemia, hypovolemia, intoxication, dehydration	AND
28	Aminoplasmal	10% (5%) solution - up to 20 (40) ml / kg / day	1 time	IV drip	depending on the patient's condition	Means for parenteral nutrition	B
29	Infezol	solution for infusion, 10-25ml / kg body weight	1 time	IV drip	According to indications	Parenteral nutrition products, proteins and amino acids	IN

Medical treatment provided at the stage of emergency emergency care: not carried out.

Other types of treatment provided at the inpatient level:
· UHF;
· Magnetotherapy;
· Electrophoresis;
· Bioptron.

Treatment effectiveness indicators:
Lack of EP clinic (if conservative treatment);
· Healing of the surgical wound by primary intention, no signs of inflammation of the postoperative wound in the early postoperative period and fistula in the late period;
· The absence of fever, pain and other symptoms indicating a complicated course of the postoperative period.

Preparations ( active ingredients) used in the treatment

Azithromycin (Azithromycin)
Amikacin (Amikacin)
Aminoacids for parenteral nutrition + Other medicines (Multimineral)
Ampicillin (Ampicillin)
Hydrogen peroxide (Hydrogen peroxide)
Gentamicin
Dextrose
Ketoprofen (Ketoprofen)
Ketorolac (Ketorolac)
Clarithromycin (Clarithromycin)
Levofloxacin (Levofloxacin)
Meropenem
Metronidazole (Metronidazole)
Morphine
Nadroparin calcium
Sodium chloride
Povidone - iodine (Povidone - iodine)
Tramadol (Tramadol)
Trimeperidine
Fluconazole (Fluconazole)
Chlorhexidine (Chlorhexidine)
Cefepime
Cefoperazone (Cefoperazone)
Cefotaxime (Cefotaxime)
Ceftazidime
Ceftriaxone (Ceftriaxone)
Ciprofloxacin (Ciprofloxacin)
Ethanol

Hospitalization

Indications for hospitalization, indicating the type of hospitalization.

Indications for emergency hospitalization:
· Established diagnosis: acute pleural empyema;
· A reasonable assumption about the presence of ES.

Indications for planned hospitalization:
· Condition after unsuccessful conservative therapy of pleurisy, croupous pneumonia, hydro-, pneumothorax (2 weeks after the "recovery" of the X-ray picture of the lungs).

Prevention

Preventive actions

Secondary prevention: early diagnosis, timely hospitalization and surgical treatment.

Further management:
· Early activation on the day of surgery or on the first day.
· Enteral nutrition - drinking from the first day, liquid food - with the appearance of intestinal peristalsis and the passage of gases. Improving respiratory activity, de-intubation.
· Removal of the nasogastric tube (if installed) - on the day of surgery.
· Carrying out infusion therapy, antibiotic therapy, treatment of concomitant diseases according to indications.
· Prevention of thromboembolic complications and microcirculation disorders with low molecular weight heparins.
· Removal of control drainage - for 2-4 days in the absence of discharge or a decrease in the amount and serous content.
· Removal of stitches from a postoperative wound after TS - on the 5th day, after TT - on 10-12 days.
· Discharge in the case of an uncomplicated postoperative period is made within 1-2 weeks after discharge from the hospital, for this period it is released from work and visits to educational institutions.
· Pay attention to the appearance of symptoms - fever, shortness of breath, weakness, cough, pain, sputum production.
· Examination of the wound for discharge and inflammation.

Information

Sources and Literature

Minutes of meetings of the Expert Council of the RCHD MHSD RK, 2015
1. List of used literature: 1) Yu.F. Isakov, E. L. Stepanov, V. I. Geraskin - Guide to thoracic surgery in children, С 164 - 167, Moscow 1978. 2) Reference Guide for Physicians "Clinical Surgery" edited by Yu. M. Pantsyreva, C 125-128, Moscow 1988. 3) P. N. Napalkov, A. V. Smirnov, M. G. Schreiber - surgical diseases, 142-147, Moscow 1976 4) Operative surgery and topographic anatomy, edited by V.V. Kovanov, S 312-318. Moscow 1978 5) Bisenkov L.N. - Thoracic surgery, 2004. 6) Pods V.I., Pugachev A.G. - Pediatric thoracic surgery, 1975. 7) Kolesnikov I.S. - Gangrene of the lung and pyopneumothorax, 1983. 8) Bakulev A.N., R.S. Kolesnikov - Surgical treatment of purulent lung diseases, 1961. 9) VK Gostishchev - Operative purulent surgery, 1996. 10) Spasokukotsky S.I. 1938; Kolesov V.I. 1955; Pods V.I., 1967, Lukomsky G.I. 1976; Kabanov A.N., Sitko L.A. 1985.11) www.http: //free-medbook.ru 12) www.med.ru/patient/diseases/353 13) www.http: //diseases.academic.ru/1168

Information

List of protocol developers with qualification data:
1) Eshmuratov Temur Sherkhanovich - Candidate of Medical Sciences, JSC "National Scientific Center for Surgery named after A.N. Syzganov "Deputy Chairman of the Board.
2) Zharylkapov Nurlan Serikovich - Candidate of Medical Sciences, JSC "National Scientific Center of Surgery named after A.N. Syzganova ”, doctor of the department of thoracic surgery.
3) Kolos Anatoly Ivanovich - Doctor of Medical Sciences, Professor, JSC "National Scientific Medical Center", Chief Researcher.
4) Medeubekov Ulugbek Shalkharovich - Doctor of Medical Sciences, Professor, JSC "National Scientific Center of Surgery named after A.N. Syzganov ", deputy chairman of the board for scientific and clinical work.
5) Satbayeva Elmira Maratovna - Candidate of Medical Sciences, Republican State Enterprise at REM “Kazakh National Medical University named after S.D. Asfendiyarov "Head of the Department of Clinical Pharmacology.

Conflict of interests: missing.

Reviewers:
1) Pishchik Vadim Grigorievich - Doctor of Medical Sciences, Professor, Chief Thoracic Surgeon in St. Petersburg, Head of the Thoracic Surgery Service KB122 named after L.G. Sokolov.
2) Tuganbekov Turlybek Umitzhanovich - Doctor of Medical Sciences, Professor, JSC "Med. Astana University "Head of the Department of Surgical Disease No. 2.

Terms of revision of the protocol: revision of the protocol 3 years after its publication and from the date of its entry into force and / or in the presence of new methods with a high level of evidence.

Attached files

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NATIONAL CLINICAL RECOMMENDATIONS

"EMPIEMA OF THE PLEURA"

Working group for 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. Codes ICD-10

4. Prevention

5. Screening

6. Classification

7. Diagnostics

8. Differential diagnosis

9. Treatment:

10. What cannot be done?

11. Forecast

12. Further management, education and rehabilitation of patients

13. Bibliographic index

1. METHODOLOGY
Empyema of the pleura is not an independent disease, but a complication of other pathological conditions. However, it is allocated 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 the foreign and domestic approaches.

Tuberculous pleural empyema (as a complication of fibro-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
Empyema of the pleura (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. CODES ICD-10
J86.0 Pyothorax with fistula

J86.9 Pyothorax without fistula

4. PREVENTION
The 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 injury (including the operating room);

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

c) lack of conditions for the 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:

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 phthisiatric 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 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 causing its accumulation, with mandatory microbiological examination;

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

Timely indication 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 the data of computed tomography (in the presence of delimiting adhesions from the free pleural cavity);

- rational perioperative antibiotic prophylaxis in thoracic surgery;

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

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

Rational drainage of the pleural cavity during surgery;

Careful care of the 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 x-ray followed by ultrasound and / or computed tomography (if indicated) for timely detection of pleural effusion 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 (in the presence of clinical and radiological indications).

6. CLASSIFICATION
6.1. The internationally accepted classification of the American Thoracic Society (1962) identifies 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, the pH value, remains normal.

Fibrinous-purulent stage manifested by the loss of fibrin (due to 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.

Stage of organization characterized by the 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 pleural layers. Clinically and radiologically, this stage consists in the relative relief of the inflammatory process, the progressive development of delimiting adhesions (moorings), which are already of a connective tissue nature, scarring of the pleural cavity, which can lead to the embedding of the lung, and the presence of isolated cavities against this background, supported mainly by preservation of bronchopleural fistula.

R.U. 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\u003e 10 mm, glucose\u003e 0.4 g / l, pH\u003e 7.2.

Class 3. Uncomplicated borderline effusion:

negative results of Gram smear staining,

LDH\u003e 1000 U / L, glucose\u003e 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 staining results,

glucose
Class 6. Simple empyema:

Explicit pus, solitary purulent pocket or loose

the spread of pus in the pleural cavity.

Organization stage:

Class 7. Complex empyema:

Explicit pus, multiple purulent encumbrances,

fibrous moorings.
The practical significance of these classifications is that they allow objectifying the course of the disease and determining the stages of tactics (Strange C., Sahn S.A., 1999).
6.2. In the domestic literature, the division of empyema by the nature of the course (and to some extent by temporal criteria) is still accepted: 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, the period of transition of acute empyema to chronic is considered to be 2-3 months. However, this division is conditional. In some patients with pronounced reparative abilities, there is a rapid fibrotization of fibrinous layers on the pleura, while in others these processes are so suppressed that adequate fibrinolytic therapy makes it possible to "clear" 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 data) 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 pulmonary parenchyma (pleurogenic cirrhosis of the lung) and tissues of the chest wall.

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

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

6.3. According to communication 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 pleurodermal, bronchopleural, bronchopleurodermal, pleuroorganic, bronchopleuroorganic fistula).
6.4. By the volume of the lesion of the pleural cavity:

- total (on the plain radiograph lung tissue not defined);

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

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

6.5. Etiological factors 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 bone structure 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, unobvious without instrumental diagnostic methods.

Verification of the diagnosis of pleural empyema, as well as its assignment to one of the types, is impossible without the use of X-ray (including computed tomography) research methods.

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

Pyopneumothorax - type of acute pleural empyema (open, with bronchopleural communication), resulting from a breakthrough into the pleural cavity of a pulmonary abscess. The main pathological syndromes when it occurs are: pleuropulmonary shock (due to irritation of the vast receptor field of the pleura with pus and air); septic shock (due to the resorption of a large amount of microbial toxins by the pleura); valvular tension pneumothorax with a collapse of the lung, a sharp displacement of the mediastinum with impaired blood outflow in the vena cava system. IN clinical picture manifestations of cardiovascular failure (falling blood pressure, tachycardia) and respiratory failure (shortness of breath, dyspnea, cyanosis) prevail. 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 respiratory disorders, lung injury, predisposing to the occurrence of bronchopleural communication, blood loss, the presence of blood and exudate in the pleural cavity. At the same time, the early manifestations of these types of pleural empyema (increased body temperature, respiratory disturbances, intoxication) are masked by such frequent complications of chest injuries as pneumonia, atelectasis, hemothorax, coagulated hemothorax, which often leads to 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 thick 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 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 with anaerobic destructive processes, leukocytosis may 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 grows, especially pronounced with an 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, but with advanced purulent depletion, it can 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. A sharp 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 seriously ill patients it reaches 4 liters. Hyperammonemia and hypercreatininemia indicate a severe, advanced chronic purulent process, the formation of chronic renal failure due to renal amyloidosis.

professor P.K. Yablonsky (St. Petersburg, Professor E.G. Sokolovich (St. Petersburg), Associate Professor V.V. Lishenko (St. Petersburg, Professor I.Ya. Motus (Yekaterinburg), Candidate of Medical Sciences S.A. Skryabin (Murmansk) ...

Empyema of the pleura is not an independent disease, but a complication of other pathological conditions. However, it is allocated 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 the foreign and domestic approaches.

These clinical guidelines do not consider the tactics of treating acute failure of the bronchial stump after lobectomy and pneumonectomy as the cause of the pleural empyema that subsequently developed, as well as methods of preventing failure. This is the reason for a separate document. Tuberculous pleural empyema (as a complication of fibro-cavernous tuberculosis and as a complication of surgery) is not included in these recommendations due to the peculiarities of the course and treatment.

Empyema of the pleura (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. ICD-10 CODES: J86.0 Pyothorax with fistula J86.9 Pyothorax without fistula.

The conditions for the occurrence of pleural empyema are:

the presence of fluid in the pleural cavity as a result of the development of a primary pathological process (non-bacterial pleurisy, hydrothorax) or injury (including the operating room);
infection of the pleural cavity and the development of purulent inflammation, the features of the course of which are determined by the state of resistance of the organism, virulence of microflora;
lack of conditions for the expansion of the collapsed lung and the 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:

organizational measures:
1. introduction 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;
2. organization of timely hospitalization of patients with pneumonia, lung abscesses, bronchiectasis, tuberculosis in specialized pulmonological, thoracic surgical and phthisiatric departments;
3. organization of timely emergency surgical and specialized thoracic surgical care for pneumothorax, injuries of the esophagus and injuries of the chest;
therapeutic measures:
1. rational empirical antibacterial 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;
2. rapid restoration of the drainage function of the bronchi in patients with suppurative lung diseases;
3. timely puncture removal of effusion from the pleural cavity in patients with pneumonia (if indicated) with mandatory microbiological examination;
4. timely puncture removal of transudate from the pleural cavity (if indicated) in conditions that cause its accumulation, with mandatory microbiological examination;
5. restriction of indications for drainage of the pleural cavity without good reason in patients with transudate and small (clinically insignificant) exudate in the pleural cavity;
6. timely indication of indications for surgical treatment for "blocked" lung abscesses, lung gangrene, bronchiectasis;
7. performing external drainage of a "blocked" abscess (if indicated) only taking into account the data of computed tomography (in the presence of delimiting adhesions from the free pleural cavity);
8. rational perioperative antibiotic prophylaxis in thoracic surgery;
9. quick decision about surgery in patients with spontaneous pneumothorax with persistent collapse of the lung and / or air discharge through the drainage from the pleural cavity;
10. the use of additional methods of aerostasis of the lung tissue and strengthening the bronchus stump during surgical interventions;
11. rational drainage of the pleural cavity during surgery;
12. careful care of the drainage in the pleural cavity;
13. timely removal of drains from the pleural cavity after surgical interventions on the chest organs;
14. timely and adequate treatment of pathological processes in the subphrenic space (abscesses, acute pancreatitis), chest wall.

Identification of pleural empyema

Regular plain chest x-ray followed by ultrasound and / or computed tomography (if indicated) for timely detection of pleural effusion in the following groups of patients:
1. in patients in medical and pulmonary departments with a diagnosis of pneumonia - every 7-10 days; in the absence of positive dynamics from treatment, computed tomography of the chest organs is performed, and subsequent radiographs of the lungs are performed every 5 days;
2. in patients in thoracic surgical departments with diagnoses of "lung abscess without sequestration", "lung abscess with sequestration", "lung gangrene" - every 7-10 days; in the absence of positive dynamics from treatment, computed tomography of the chest organs is repeated;
3. in patients with prolonged bed rest with non-pulmonary diseases (in intensive care, toxicological, neurological and neurosurgical departments with respiratory failure, respiratory failure, with impaired swallowing) - every 7-10 days; with unclear radiological focal or infiltrative changes, computed tomography of the chest organs is performed;
4. in patients on artificial ventilation without pneumonia - every 10 days; in the presence of infiltration of lung tissue and fluid in the pleural cavity - every 5 days;
5. in patients with sepsis (extrapulmonary, without pneumonia) - every 7-10 days; in the presence of infiltration of lung tissue and fluid in the pleural cavity - every 5 days; with unclear radiological focal or infiltrative changes, computed tomography of the chest organs is performed;
6. in patients with prolonged fever of unknown origin for more than 1 week, an X-ray examination is performed; with unclear radiological focal or infiltrative changes, computed tomography of the chest organs is performed;
7. in patients after aspiration into the tracheobronchial tree of various origins - radiography after 1 day, after 5 and 10 days; in the presence of pulmonary infiltration, radiography is carried out until the infiltrate is completely resorbed or up to 1-1.5 months.
Puncture of the pleural cavity in identifying a clinically significant and accessible for puncture accumulation of effusion in patients of the above groups with visual assessment, general clinical analysis and microbiological control.
Puncture of the pleural cavity in conditions accompanied by the accumulation of transudate (if clinically indicated), with macroscopic control, general clinical analysis and microbiological examination.
Puncture of the pleural cavity in patients in the early period after pneumonectomy (in the presence of clinical and radiological indications).

Empyema classification:

Internationally accepted classification of the American Thoracic Society (1962) identifies 3 clinical morphological stages of the disease: exudative, fibrinous, organization. The exudative stage is 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, the pH value, remains normal. The fibrinous-purulent stage is manifested by the loss of fibrin (due to 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.

The stage of organization is characterized by the 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 pleural sheets. Clinically and radiologically, this stage consists in the relative relief of the inflammatory process, the progressive development of delimiting adhesions (moorings), which are already of a connective tissue nature, scarring of the pleural cavity, which can lead to the embedding of the lung, and the presence of isolated cavities against this background, supported mainly by preservation of bronchopleural fistula.

R.U. 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 fluid (<10 мм).
- Class 2. Typical parapneumonic effusion: fluid quantity\u003e 10 mm, glucose\u003e 0.4 g / l, pH\u003e 7.2.
- Class 3. Uncomplicated borderline effusion: negative results of Gram smear staining, LDH\u003e 1000 U / L, glucose\u003e 0.4 g / L, pH 7.0-7.2.
Purulent fibrinous stage:
- Class 4. Complicated pleural effusion (simple): positive Gram smear, glucose< 0,4 г/л, рН < 7,0. Отсутствие нагноения.
- Class 5. Complicated pleural effusion (complex): positive Gram stains, glucose< 0,4 г/л, рН < 7,0. Нагноение.
- Class 6. Simple empyema: Explicit pus, a solitary purulent pocket or free spread of pus in the pleural cavity.
Organization stage:
- Class 7. Complex empyema: Explicit pus, multiple purulent encumbrances, fibrous moorings.

The practical significance of these classifications is that they allow objectifying the course of the disease and determining the stages of tactics (Strange C., Sahn S.A., 1999). In the domestic literature, the division of empyema by the nature of the course (and to some extent by time criteria) is still accepted: 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, the period of transition of acute empyema to chronic is considered to be 2-3 months. However, this division is conditional. In some patients with pronounced reparative abilities, there is a rapid fibrotization of fibrinous layers on the pleura, while in others these processes are so suppressed that adequate fibrinolytic therapy makes it possible to "clear" the pleural sheets even in the long term (6-8 weeks) from the onset of the disease.

The most reliable criteria for the formed chronic empyema (according to computed tomography data) are:

rigid (anatomically irreversible) thick-walled residual cavity, to one degree or another collapsing the lung, with or without bronchial fistulas;
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), which make 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 to be justified, since it allows one to outline the range of studies necessary to verify the diagnosis and determine an adequate treatment program. Roughly chronic empyema corresponds to the stage of organization in the international classification.

According to communication 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 pleurodermal, bronchopleural, bronchopleurocutaneous, pleuroorganic, bronchopleuroorganic fistula).

By the volume of the lesion of the pleural cavity:

total (lung tissue is not determined on the plain radiograph);
subtotal (only the apex of the lung is determined on the plain radiograph);
delimited (during encapsulation and mooring of exudate): apical, parietal paracostal, basal, interlobar, paramediastinal.

Etiological factors are distinguished:

parapneumonic 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 the soft tissues and bone frame of the chest).

Empyema diagnosis

General clinical physical examination methods... The absence of specific anamnestic and physical signs makes the diagnosis of pleural empyema, especially parapneumonic, unobvious without instrumental diagnostic methods. Verification of the diagnosis of pleural empyema and its assignment to one of the types is impossible without the use of X-ray (including computed tomography) research methods. Nevertheless, some forms (the most severe and dangerous) of this disease can be suspected even clinically.

Pyopneumothorax - type of acute pleural empyema (open, with bronchopleural communication), resulting from a breakthrough into the pleural cavity of a pulmonary abscess. The main pathological syndromes when it occurs are: pleuropulmonary shock (due to irritation of the vast receptor field of the pleura with pus and air); septic shock (due to the resorption of a large amount of microbial toxins by the pleura); valvular tension pneumothorax with a 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, choking, 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 respiratory disorders, lung injury, predisposing to the occurrence of bronchopleural communication, blood loss, the presence of blood and exudate in the pleural cavity. At the same time, early manifestations of these types of pleural empyema (increased body temperature, respiratory disturbances, intoxication) are masked by such frequent complications of chest injuries as pneumonia, atelectasis, hemothorax, coagulated hemothorax, which often leads to 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 thick 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.

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

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 with anaerobic destructive processes, leukocytosis may 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 grows, especially pronounced with an unfavorable course of the disease.
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, but with advanced purulent depletion, it can 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. A sharp hypoproteinemia (3040 g / l) leads to the appearance of edema. Fluid retention in the interstitial sector averages 1.5 liters, and in the most seriously ill patients it reaches 4 liters. Hyperammonemia and hypercreatininemia indicate a severe, advanced chronic purulent process, the formation of chronic renal failure due to renal amyloidosis.
Moderate albuminuria is noted in the urine, hyaline and granular casts are sometimes found. It is necessary to control the specific gravity of urine, bearing in mind the possibility of developing amyloid-lipoid nephrosis.
Bacteriological blood test (blood culture for sterility) in the presence of clinical and laboratory signs of sepsis and / or prolonged fever.

Laboratory examination of sputum.

The daily amount of sputum collected in a screw-top spittoon should be read. Both an increase and a decrease in the amount of sputum can indicate both positive and negative dynamics of the disease.
Bacterioscopic examination of sputum makes it possible to roughly judge the etiology of destruction, since hard-to-cultivate microorganisms, in particular non-spore anaerobes, are clearly visible in smears, while aerobic microbes-commensals of the oral cavity and nasopharynx, contaminating the material and growing well on standard media, are almost invisible.
Due to the contamination of the microflora of the upper respiratory tract and the oral cavity, sputum culture on nutrient media, including with appropriate precautions (thorough rinsing of the mouth and pharynx with weak antiseptics before coughing up, etc.), is not always informative. The informative value of sputum cultures slightly increases with the quantitative method of research: the isolated microorganism is considered etiologically significant when its concentration in sputum is 106 microbial bodies in 1 ml. Bacteriological recognition anaerobic infection associated with significant methodological difficulties and is still available to a small number of medical institutions.

Plain X-ray of the chest organs.Should be undertaken immediately for all patients with suspected pleural empyema and, especially, pyopneumothorax. It allows you to establish the localization of the pathological process, determine the degree of exudate delimitation (free or encapsulated), and also relatively accurately determine its volume. When analyzing the radiograph (if it is not done by a radiologist), it is necessary to pay attention, in addition to the darkening of the lung tissue or the entire hemithorax, the presence of a cavity in the lung with a fluid level, to the displacement of the mediastinum to the healthy side (especially with total pyothorax or tension pyopneumothorax), the presence of air in the pleural cavity and / or mediastinal emphysema, the adequacy of the drainage standing (if it was placed at the previous stage). To accurately determine the size of the cavity of chronic empyema, its configuration, the condition of the walls (thickness, presence of fibrinous layers), as well as to verify and clarify the localization of bronchopleural communication, polypositional pleurography can be performed, including in lateroposition. For its implementation, 20-40 ml of a water-soluble contrast agent is injected into the pleural cavity through the drainage.

Computed tomography of the chest... Allows you to convincingly establish the nature of the lung lesion, which caused the pleural empyema, to determine the localization of encumbrances (for the subsequent selection of the drainage method), to determine the presence of a bronchial stump fistula. Multispiral computed tomography is the most reliable method for verifying chronic pleural empyema. In the presence of pleurodermal fistula in patients with chronic empyema, in some cases, during computed tomography, it is advisable to perform fistulography.

Ultrasound examination of the pleural cavities... It is necessary to determine the point for safe and adequate drainage of the pleural cavity in the presence of enclosures.

Diagnostic puncture of the pleural cavity... It is the final method for verifying the diagnosis. Obtaining purulent contents of the pleural cavity allows us to consider the presumptive diagnosis of pleural empyema absolutely reliable. Performed in the presence of clinical and radiological signs of pyothorax and pyopneumothorax. The exudate is sent for cytological, bacterioscopic and bacteriological examination (with the determination of the sensitivity of the flora to antibiotics). Signs of suppuration of parapneumonic exudate are: positive smears-prints of effusion on bacteria, glucose of pleural effusion less than 3.33 mmol / l (less than 0.4 g / l), inoculation of effusion on a bacterial culture is positive, pH of effusion less than 7.20 , LDH of effusion is more than 3 times the upper limit of normal. In some cases, in the exudative stage, a differential diagnosis is required between transudate and exudate. For this, it is necessary to measure the protein content in the pleural fluid. This is enough if the patient's blood protein level is normal, and the protein content in the pleural fluid is less than 25 g / l (transudate) or more than 35 g / l (exudate). In other situations, Light's criteria are used.

Pleural fluid is exudate if one or more of the following criteria are present:

the ratio of pleural fluid protein to serum protein is more than 0.5;
the ratio of lactate dehydrogenase of the pleural fluid and lactate dehydrogenase of blood serum is more than 0.6;
lactate dehydrogenase of the pleural fluid exceeds 2/3 of the upper limit of normal serum lactate dehydrogenase.

Fibrobronchoscopy... It has several goals: to identify the draining bronchus if the cause of empyema is a lung abscess; exclude central lung cancer, often causing pleural carcinomatosis (cancerous pleurisy), transforming into pleural empyema when exudate is infected; investigate bronchial washings to establish a microbiological agent and select rational antibacterial therapy; to sanitize the tracheobronchial tree in the presence of a destructive process in the lungs. It should be borne in mind that the washings from the bronchial tree obtained during bronchoscopy are almost always contaminated. The information content of the inoculation of the material obtained by bronchoscopy slightly increases with the quantitative method of research: the isolated microorganism is considered etiologically significant when its concentration in the bronchial lavage is 104 microbial bodies in 1 ml.

Valuable information can be obtained by combining bronchoscopy with the introduction of a vital dye solution into the pleural cavity via drainage in combination with a 3% hydrogen peroxide solution (retrograde chromobronchoscopy). From where the foaming dye enters the lumen of the subsegmental and segmental bronchi, it is possible to accurately determine the localization of the bronchopleural message. In some cases, information on the localization of the bronchopleural fistula can be obtained with selective bronchography by introducing a water-soluble contrast agent through the channel of the fibrobronchoscope installed in the zonal bronchus, with simultaneous fluoroscopic examination. If a bronchoesophageal fistula is suspected, contrast fluoroscopy of the esophagus and fibroesophagoscopy should be performed.

Examination of the function of external respiration... Has limited independent practical value. It can be useful in establishing the indications for surgery and its volume in the chronic stage of the disease to determine the functional reserves of the lungs and the tolerance of the operation.

Videothoracoscopy... It is a method of diagnosis and treatment of pleural empyema, but not the first stage. It allows you to assess the nature and prevalence of a purulent-destructive process in the lungs and pleura, the stage of the inflammatory process, to determine the localization and size of bronchopleural fistulas, and also, which is very important, to adequately drain the pleural cavity under visual control, especially in the presence of bronchopleural fistulas. It is used in the exudative and fibrinous-purulent stage with the ineffectiveness of simple drainage of the pleural cavity (in the presence of sedimentation and irrational working drainages). Videothoracoscopy can be supplemented with elements of the operation (debridement).

Treatment of pleural empyema

When a diagnosis of pleural empyema is established, the patient must be admitted to a specialized thoracic surgical department (except for patients with established tuberculous etiology). In this case, patients with pyopneumothorax, sepsis, hypovolemia, cardiovascular and respiratory failure are immediately hospitalized in the intensive care unit. In the treatment of pleural empyema, both conservative and surgical methods are used, which are applied in parallel to each other, starting from the earliest stage of treatment.

Surgical treatment can be palliative in nature (drainage of the pleural cavity, videothoracoscopic sanitation and drainage of the pleural cavity), and radical in nature (pleurectomy, decortication, lung resection). The choice of one or another surgical intervention is determined by the stage of pleural empyema (exudative, fibrinous-purulent, organizing), the severity of the patient's condition, the main pathological process in the lung, leading to empyema, and previous lung interventions.

The goal of treating pleural empyema is to permanently eliminate the empyema cavity as a result of the formation of limited pleurodesis (fibrothorax), which does not impair the function of external respiration. This requires the simultaneous solution of a number of tactical tasks:

removal of pus and sanitation of the empyema cavity;
expansion of the lung (elimination of the empyema cavity);
suppression of pathogens of the infectious process;
correction of homeostasis disorders caused by the development of purulent inflammation;
treatment of pathological processes in the lung, ribs, sternum, and other organs that cause infection of the pleural cavity.

Depending on the stage of the disease (exudative, fibrinogenic, organization), the solution to each problem will be different (Klopp M. Et al., 2008). At the same time, there are no recommendations in the foreign literature regarding the treatment of stages II and III from the position of evidence-based medical practice. Results from prospective and randomized trials are pending.

Treatment of pleural empyema in the exudative stage.

This event can be both the only and final method of treatment in a number of cases (“closed” pleural empyema, pleural empyema with an insignificant volume of bronchopleural communication), or a preparatory stage for the inevitable surgical intervention. Removal of pus and sanitation of the pleural cavity can be achieved in two ways - by puncture of the pleural cavity and "closed" drainage (thoracocentesis). With the help of punctures, the treatment of closed pleural empyema, a small volume (less than 300 ml) or exudative pleurisy that begins to transform into purulent, without a significant number of fibrinous layers on the pleural sheets and the formation of pleural adhesions is justified. Sometimes the puncture method is the most justified in the treatment of empyema localized in the "hard-to-reach" parts of the hemithorax - apical, paramediastinal, supraphrenic, interlobar.

With the puncture method of cavity sanitation, it is necessary:

completely aspirate the contents of the cavity at each puncture;
rinse the cavity with an antiseptic solution to a clean wash solution. In this case, the volume of a once injected solution should not exceed the volume of evacuated pus (prevention of stratification of adhesions and infection of other parts of the pleural cavity);
after washing the cavity, create maximum vacuum in it;
inject into the cavity before removing the needle a daily dose of an effective antibiotic (bactericidal, broad spectrum of activity until the results of bacteriological research are obtained) in a small volume of an antiseptic solution (10 times less than the volume of the cavity).
in the presence of flakes or bundles of fibrin in the exudate, which prevents aspiration, the composition of the solution "left" in the cavity is supplemented with a fibrinolytic preparation.

Puncture sanitation can last no more than 7-10 days; punctures are performed daily. The criterion for the effectiveness of puncture sanitation of the cavity is the rapid elimination of manifestations of intoxication, a decrease in the volume of the cavity (expansion of the lung), a decrease in the rate of accumulation of exudate and its transformation into serous-fibrous, and then serous. At the same time, there is a decrease in the content of leukocytes in it (no more than in peripheral blood, an increase in the content of lymphocytes up to 5-15%), and bacteriological examination does not reveal the growth of microflora.

A contraindication to the puncture method is empyema of the pleura of a significant volume (1-1.5 liters), as well as the presence of bronchopleural communication, including due to the fistula of the bronchial stump (it is impossible to completely aspirate the contents of the pleural cavity, create a vacuum in it to expand the lung).

In most cases, with pleural empyema, the so-called closed drainage (thoracocentesis) is used as a way to remove pus and sanitize the pleural cavity. This manipulation can be in the nature of emergency care (tense pyopneumothorax, total pleural empyema with displacement of the mediastinal organs). With “closed” pleural empyema, drainage debridement is often the definitive treatment.

Since unreasonable drainage of parapneumonic pleural effusion can itself be a cause of empyema, the indications for drainage of the pleural cavity proposed by the American College of Physicians - American Society of Internal Medicine and Infectious Diseases Society of America (Manuel Porcel J. et al., 2006):

symptoms of bacterial pneumonia and pleural effusion;
temperature over 380 С;
leukocytosis more than 11x109 / l;
purulent sputum;
pleurisy chest pain;
x-ray infiltration;
encapsulated pleural effusion;
pleural effusion pH less than 7.2;
pus in the pleural cavity;
positive culture of effusion.

With closed pleural empyema, the principles of cavity sanitation do not differ from those described for puncture management. It is more expedient to use double-lumen tubes, and in their absence, make them from the available materials (introduction of a thin long catheter into the lumen of the "main" tube). This will allow you to constantly flush the drainage tube and avoid obturation with detritus, fibrin bundles. To create a vacuum in the pleural cavity, various aspiration devices (pleuroaspirators) are used with a constant vacuum in the pleural cavity of 40-60 cm of water. Art. One cannot hope for a quick and complete expansion of the lung with a passive outflow of pus from the pleural cavity.

Rinsing of the pleural cavity should be carried out in a fractional way 2 times a day: through a thin lumen of the drainage with a closed wide one, an antiseptic solution (corresponding to the volume of the residual cavity) is injected, then a wide lumen of the drainage opens, the rinsing solution is evacuated. Usually used up to 500-1000 ml of antiseptic solution. Every day, in the dressing room, the cavity is washed with the help of Janet's syringe, while the permeability of the drainage, the stability of the vacuum in the pleural cavity, the state of soft tissues in the circumference of the drainage are determined. At the end of the cavity washing, a solution of antibiotics is injected into it, the drainage is closed for 1-1.5 hours.

Rehabilitation of the pleural cavity with open (with bronchopleural communication) empyema of the pleura has a number of features. It is extremely responsible to determine the place of drainage (polypositional fluoroscopy or ultrasound) and the depth of the drainage introduction. The drainage tube should be inserted into the lowest part of the cavity, since residual fluid always accumulates below the drainage tube (when empyema is closed, the fluid from the cavity is "squeezed" into the drain).

The lavage of the cavity should be carried out so as not to cause aspiration pneumonia when the solution enters the lung tissue (on the side of the lesion and the opposite). For this, the volume of the rinsing solution should be selected individually (not to cause coughing), and rinsing should be carried out when the patient is tilted towards the lesion. The level of vacuum in the pleural cavity in the initial period of treatment should be minimal (5-10 cm of water column), ensuring the evacuation of fluid from the cavity, and with sufficient sanitation, it is advisable to switch to passive drainage according to Bulau (“glove” siphon drainage) ... This helps to seal the defects of the lung tissue, which are present after the breakthrough into the pleural cavity of small subcortical abscesses or after damage to the lung during puncture, drainage (iatrogenic pyopneumothorax).

The efficiency of drainage is evidenced by the rapid expansion of the lung, observed during X-ray examination (immediately after drainage, on the next day, and then 1-2 times a week). The drainage of a large amount of fibrin flakes is the basis for the use of intrapleural fibrinolytic therapy (Sahin A. et al., 2012). Despite the fact that from a formal point of view, the site of application of fibrinolytic therapy is the fibrinous-purulent stage, it is advisable to prescribe it earlier before the appearance of pus, i.e. the exudative stage, when there is already a fibrin film on the pleura. Fibrinolytic therapy can reduce the duration of pleural drainage, normalize body temperature faster, achieve treatment success within the first 3 days in 86.5% of patients and, accordingly, reduce the frequency of surgical interventions (VATS) to 13.5%. Intrapleurally, 250,000 IU of streptokinase or 100,000 IU of urokinase is injected per 100 ml of saline. A comparative evaluation of the two drugs revealed the same efficacy (92%) with a lower complication rate when using urokinase and lower economic costs when using streptokinase (Bouros D. et al., 1997). There is a report on the use of deoxyribonuclease (Simpson G. et al., 2003).

With a decrease in the amount of exudate (up to 30-50 ml per day), the volume of the washing solution introduced into the cavity also decreases. The drainage is removed after the complete cessation of exudation, which is confirmed by pleurography (the injected contrast agent does not spread through the pleural cavity), and in some cases, when the drainage is depressurized (the lung does not collapse). This usually occurs after 1-1.5 weeks of treatment. Mandatory X-ray and ultrasound control after removal of the drainage (often accumulates in its bed exudate, which is the cause of recurrence and the formation of "encapsulated" empyema or suppuration of the drainage channel). If fluid is present, pleural puncture should be performed.

The lack of effect from closed drainage of the pleural cavity (preservation of clinical and laboratory signs of intoxication, fever, non-decreasing purulent discharge from the pleural cavity) within 2-3 days should be the reason for the use of videthoracoscopic sanitation of the pleural cavity (Pothula V., Krellenstein DJ, 1994; Hecker E., Hamouri S., 2008).

The expansion of the lung is achieved simultaneously with the performance of the first task by removing the liquid with a syringe "all the way" or by constant vacuum aspiration along the drain. With the localization of bronchopleural communication within one lobe, it is very effective method its elimination is a temporary obstruction of the lobar or segmental bronchi (temporary valve bronchial blocking). Special foam-rubber bronchial obturators and valve bronchoblockers are delivered to the installation area using a fiberoptic bronchoscope or with rigid subanesthetic bronchoscopy. Despite the decrease in the airiness of the lung in the zone of occlusion, the sealing of the bronchopleural communication allows to achieve expansion of the lung due to the ventilated sections, lifting the diaphragm. In some cases, it is advisable to impose a pneumoperitoneum.

If the tightness of the empyema cavity is restored after 2-4 days, the valve bronchoblocker can be left for 2-4 weeks (the time required for the development of the mooring lines that fix the lung to the chest wall). During this time, purulent endobronchitis also develops in the occluded part of the lung (the so-called post-occlusive syndrome). However, it quickly stops after removing the bronchoblocker. After restoring the airiness of the "disabled" pulmonary parenchyma, the drains can be removed. In cases where temporary endobronchial occlusion is ineffective within a week (with localization of bronchopleural fistulas in adjacent lobes), it is inappropriate to continue it.

Occlusion of the main bronchus is possible, but it has a risk of developing severe respiratory disorders and a risk of migration of the foam obturator with the development of asphyxia. An alternative way to "turn off the entire lung" can be the setting of 2-3 occluders in the lobar bronchi. Installation of a valve bronchoblocker with a fistula of the stump of the main bronchus after pneumonectomy is almost always impossible due to the small size of the stump itself. Adequate drainage of the pleural cavity and its sanitation in case of "open" empyema of the pleura should limit the treatment of patients in general surgical hospitals, since special surgical methods of eliminating the cavity with these types of empyema can be carried out only in specialized institutions (thoracoscopic sanitation of the cavity with "filling" of bronchial fistulas, temporary endobronchial occlusion or valvular bronchial blockage, therapeutic pneumoperitoneum).

Choice antibacterial drug for empirical therapy is determined by the etiological structure of empyema, which depends on the characteristics of the onset of the disease. Empyema associated with pneumonia (with or without lung abscess); empyema associated with abscesses of aspiration genesis. The main microorganisms are anaerobes (Bacteroides spp., F. nucleatum, Peptostreptococcus spp., P. niger), often in combination with enterobacteria (Enterobacteriaceae) due to aspiration of the contents of the oropharynx, as well as Staph. aureus. In this case, the drugs of choice are: inhibitor-protected penicillins (amoxicillin / clavulanate, ampicillin / sulbactam) in combination with III generation aminoglycosides (amikacin) and / or with metronidazole; III generation cephalosporins in combination with III generation aminoglycosides. Alternative drugs include: protected third-generation cephalosporins (cefoperazone / sulbactam) in combination with metronidazole; IV generation cephalosporins (cefepime) in combination with metronidazole; respiratory fluoroquinolones (levofloxacin, moxifloxacin) in combination with metronidazole; carbapenems; vancomyin, linezolid (only for reasonably high risk of MRSA).

Empyema associated with lung gangrene... The main microorganisms are anaerobes (Bacteroides spp., F. nucleatum, Peptostreptococcus spp., P. niger), Ps.aeruginosa, Klebsiella pneumonia, Staph. aureus. In this case, the drugs of choice are: 3rd generation cephalosporins in combination with 3rd generation aminoglycosides and metronidazole; respiratory fluoroquinolones in combination with III generation aminoglycosides and metronidazole. Alternative drugs include: IV generation cephalosporins in combination with vancomycin (or linezolid); carbapenems.

Empyema associated with septic abscesses... The main pathogens are Staphylococcus, including MRSA (for intravenous sepsis), Enterobacteriaceae, Str. pneumonia, Enterococcus spp., Pseudomonas spp. In this case, the drugs of choice are: III-IV generation cephalosporins in combination with metronidazole; respiratory fluoroquinolones in combination with metronidazole. Alternative drugs include: vancomycin plus carbapenems; linezolid in combination with cefoperazone / sulbactam.

Empyema post-traumatic and postoperative... The main pathogens are Staph. aureus, Str. Pneumonia, H. influenza. In this case, the drugs of choice are: inhibitor-protected penicillins; cephalosporins of the III-IV generation. Alternative drugs include vancomycin (monotherapy).

Putrefactive empyema, as well as the absence of bacterioscopic results and microflora growth during sowing... In these situations, the etiological role of anaerobes and / or gram-negative enterobacteria should be suspected. The drugs of choice are: inhibitor-protected penicillins (ampicillin / sulbactam, amoxicillin / clavulanate); inhibitor-protected cephalosporins of the third generation (cefoperazone / sulbactam). Alternative drugs are: III-IV generation cephalosporins in combination with metronidazole; lincosamides (clindamycin) in combination with third generation aminoglycosides.

In the future, the choice of the drug is carried out individually in accordance with the type of pathogen isolated and its sensitivity. The duration of therapy is determined individually (it can be up to 3-4 weeks). Routes of administration of antibiotics: intramuscular, intravenous. Currently, no convincing data have been obtained on the advantage of the regional route of administration (in pulmonary artery by performing angiopulmonography or in the bronchial arteries by performing aortography and selective bronchial arteriography).

Correction of disorders of homeostasis caused by the development of purulent inflammation.

Careful patient care; when foul-smelling sputum is released, it is advisable to isolate the patient.
Food should be varied, high-calorie, contain a sufficient amount of complete animal proteins and vitamins. In case of insufficient nutritional status, it is necessary to prescribe supplementary food (balanced nutritional mixtures).
Restoration of basic hemodynamic parameters (reduction of the BCC to the capacity of the vascular bed), stabilization of hemodynamics. For this purpose, a subclavian catheter must be inserted for long-term and massive infusion therapy in the most severe patients (it is preferable to introduce it on the side of the affected lung to prevent pneumothorax on the “healthy” side). In order to prevent thrombophlebitis and angiogenic sepsis, careful catheter care is required.
Maintaining energy balance: the introduction of concentrated glucose solutions (25-40%) with the obligatory addition of insulin (1 unit per 4 g of glucose).
Correction of electrolyte balance: polyionic solutions containing potassium, magnesium, calcium, etc. These solutions are administered at 1-3 liters per day, depending on the patient's condition.
Restoring protein balance (in the amount of at least 40-50% of the daily requirement) using amino acid solutions (polyamine, panamine, aminosteril, aminosol, vamyn, etc.). In severe hypoalbuminemia, it is recommended to inject 200 ml of albumin 2 times a week. Supplementary parenteral nutrition should provide the body with at least 7-10 g of nitrogen and 1500-2000 kcal / day. The assimilation of the introduced nitrogen is increased with the simultaneous introduction of anabolic hormones and vitamins. Criteria for prescribing nutritional support: body weight deficit more than 10%, body mass index less than 20 kg / m, hypoproteinemia (content total protein less than 60 g / l) or hypoalbuminemia (plasma albumin less than 30 g / l).
Decrease in the high proteolytic activity of blood serum (especially with gangrene and unfavorable abscesses): protease inhibitors (contrikal up to 100,000 units / day).
Anti-inflammatory therapy: 1% calcium chloride solution intravenously, 200-300 ml 2 times a week.
Restoration of the patient's immunological reactivity in the acute period: substitutional (passive) immunotherapy in the form of repeated transfusions of antistaphylococcal plasma, antistaphylococcal gamma globulin, immunoglobulin G preparation, enriched immunoglobulin containing all the most important classes of immunoglobulins (IgG, IgM, IgA).
Improvement of microcirculation in the area of \u200b\u200bthe inflammatory focus: trental, heparins (unfractionated, low molecular weight), cryoplasma antienzyme complex according to E. ATseimakh and Ya.N. Shoikhetu (2006): fresh frozen plasma 800-1000 ml, contrikal 80,000 - 100,000 IU 3 times a day, heparin 5000 IU 4 times a day or low molecular weight heparins in therapeutic doses.
Correction of hypoxemia: oxygen therapy.
Correction of anemia (according to indications): transfusion of erythrocyte mass, washed thawed erythrocytes.
Extracorporeal detoxification: plasmapheresis, low-flow hemodiafiltration (only with adequate drainage of the pleural cavity and all enclosures to avoid bacterial-toxic shock).
Increase of nonspecific resistance of the organism: extracorporeal ultraviolet blood irradiation, ozone therapy.
Treatment of heart failure: cardiac glycosides, aminophylline, cordiamine.
Respiratory support: dosed, controlled oxygen therapy; CPAP therapy (continuous positive airway pressure with spontaneous breathing); non-invasive mask ventilation; invasive ventilation: forced, controlled, controlled (controlled by Volume Control and Pressure Control); modes of assisted invasive ventilation (VIVL); spontaneous breathing: T-tube, oxygen therapy, breathing with atmospheric air.

Treatment of pathological processes in the lung, ribs, sternum, and other organs that caused infection of the pleural cavity. Taking into account the greatest etiological significance of pneumonia and lung abscess, measures aimed at ensuring optimal drainage of destruction foci in the lung through the bronchial tree should come to the fore. A list of measures and treatments is given in the relevant National Clinical Guidelines.

Treatment of pleural empyema in the fibrinous-purulent stage.

Removal of pus and debridement of the empyema... The likelihood of a final empyema cure by "closed" drainage is much less than in the previous stage, even with "closed" empyema. It will be effective only at the very beginning of the fibrinous-purulent stage (Ferguson M.K., 1999). Drainage of the pleural cavity is considered more often as an emergency measure for decompression of hemithorax with the aim of subsequent videothoracoscopic rehabilitation of empyema. Prolonged attempts at sanitation through a blind drainage system are unjustified, especially in the presence of a bronchopleural fistula. It is necessary to set indications for videothoracoscopic sanitation as early as possible with a targeted installation of drains for flowing flushing (Pothula V., Krellenstein D.J., 1994). Videothoracoscopic sanitation will be effective only if it is applied as early as possible at this stage (Wait M.A. et al., 1997; Klopp M. et al., 2008).

The fibrinous-purulent stage with multiple encumbrances requires the use of video-assisted thoracic surgery (VATS). Taken in the early stages of the fibrinogenic stage, it allows for the so-called "debridement" (surgical removal of nonviable, damaged and infected tissues and tissue detritus from the wound surface to improve healing of potentially healthy tissues), as well as, in some cases, partial decortication (Cham CW et al ., 1993; Landreneau RJ et al., 1996; Hecker E., Hamouri S., 2008; Klopp M. et al., 2008).

In a number of patients, the established drains cannot cope with their function due to the peculiarities of the course of the underlying disease. These include: gangrene of the lung and a breakthrough of a lung abscess with sequestration (the presence of large sequesters and still unbroken foci of lung necrosis, putrefactive empyema), extensive defects of the soft tissues of the chest wall, the development of severe anaerobic phlegmon of the chest wall, the presence of significant bronchopleural communication with the progression of purulent intoxication post-traumatic pleural empyema after gunshot wounds... In such situations, preference should be given to the so-called "open" drainage of the empyema. Minithoracotomy is performed with resection of 1-2 ribs with suturing of the edges of the skin to the parietal pleura (chest wall fenestration, thoracostomy, thoracoabscessostomy).

An important condition for performing this operation is the presence of delimiting adhesions (moorings) between the visceral and parietal pleura in the destruction zone. Usually, such moorings are formed in 1-2 weeks from the onset of the disease (i.e., just in time for the onset of the fibrinous-purulent stage) and are clearly detected by computed tomography. Otherwise, when performing thoracotomy, a total collapse of the lung with severe respiratory disorders may occur, and the need to seal the cavity for their elimination negates the sanitizing effect of open drainage of the pleural cavity.

Radical surgical interventions through thoracotomy (pleurectomy, decortication, including lobectomy, pneumonectomy) in this stage of the disease should be used according to very strict indications: sepsis with increasing intoxication and multiple organ failure with blocked abscess or gangrene of the lung, despite draining the pleural cavity and intensive treatment, including methods of extracorporeal detoxification. The danger of such operations is associated with bacterial-toxic shock, technical complications due to infiltration of the lung root, the risk of failure of the bronchial stump in a purulent process. Therefore, in the case of a torpid course of empyema due to bronchopleural fistula, reduced local and general immunity, sanitation video-thoracoscopic interventions, including video-assisted minithoracotomy, should be preferred (Mackinlay T.A. et al., 1996).

Expansion of the lung (elimination of the empyema cavity)... Straightening of the lung, as in the treatment in the exudative stage, is achieved simultaneously with the performance of the first task by continuous vacuum aspiration along the drainage. When the bronchopleural message is localized within one lobe, indications for valve bronchoblocking become very persistent. Despite the decrease in the airiness of the lung in the zone of occlusion, the sealing of the bronchopleural communication allows to achieve expansion of the lung due to the ventilated sections, lifting the diaphragm. The elimination of bronchopleural communication allows more vigorous sanitization of the pleural cavity (there is no danger of aspiration of the wash solution).

Suppression of pathogens of the infectious process... In the fibrinous-purulent stage, antibacterial therapy continues, which will already have an etiotropic nature (aimed at a specific pathogen) after receiving the results of a microbiological study. It may be necessary to change the antibacterial drug due to microbial resistance or dose adjustment.

Conducted in accordance with the above principles. It is possible to correct the volume and composition of infusion therapy, both upward (with increasing intoxication) and downward (with the predominance of anabolism over catabolism).

Treatment of pathological processes in the lung, ribs, sternum, and other organs that caused infection of the pleural cavity. Continues in accordance with the main pathological process.

Treatment of pleural empyema at the stage of organization.

Removal of pus and debridement of the empyema... By the time of the transition of empyema to the stage of organization against the background of treatment, the purulent cavity tends to be purified, the drainage discharge decreases, regardless of the presence or absence of a bronchopleural fistula. With a successful course of the process, the onset of obliteration of the empyema cavity is possible. In this case, the measures for sanitation of the cavity consist in the continuation of rinsing with an aqueous solution of an antiseptic through the drainage until the cavity is completely cleansed and the drainage is removed. The drainage is removed after the complete cessation of exudation, which is confirmed by pleurography (the injected contrast agent does not spread through the pleural cavity). This usually occurs after 2-3 weeks of treatment. Mandatory X-ray and ultrasound control after the removal of the drainage, as often accumulates in its bed exudate, which is the cause of relapse and the formation of "encapsulated" empyema or suppuration of the drainage canal. If fluid is present, pleural puncture should be performed.

With a prolonged, torpid course associated with the presence of a bronchopleural fistula, reduced local and general immunity, obliteration of the cavity does not occur, there is a constant discharge of air, and the drainage cannot be removed. In terms of time, this corresponds approximately to 1-1.5 months. In fact, we are talking about the formation of chronic empyema (in the traditional sense of the word for domestic medicine). Such patients often have to be discharged home with drainage for a while, having previously trained them to self-rinse, in order to perform a radical operation through thoracotomy in 2-3 months.

A separate group is represented by patients who were re-admitted with already formed chronic pleural empyema for planned radical surgery. If they have a cavity of chronic empyema with a closed or functioning (including drainage) pleurodermal fistula in combination with signs of systemic inflammatory reaction syndrome, the first stage is to stop the purulent process. This is achieved by flushing the cavity through a previously installed drainage or a newly installed drainage, focusing on the data of computed tomography or ultrasound examination. The resulting discharge is sent for bacteriological examination, the results of which will be important when choosing an antibacterial drug after surgery. After a short preparation, a decision is made to perform a radical surgical intervention through thoracotomy.

Expansion of the lung (elimination of the empyema cavity)... The expansion of the lung is impossible to achieve due to dense moorings and sclerotic process in the compromised part of the lung (pneumofibrosis, pneumocirrhosis, fibroatelectasis). Thoracotomy is indicated for patients.

Suppression of pathogens of the infectious process... In the organizing stage, the infectious process in the empyema cavity is either arrested, or the concentration of microbial bodies does not determine the clinical picture due to the delimitation of the cavity by a fibrous capsule. Therefore, systemic antibiotic therapy can be discontinued. When a patient with chronic empyema is admitted for a planned radical surgery, empiric antibiotic therapy before surgery is advisable only in the presence of a systemic inflammatory reaction syndrome in a short course during preoperative preparation.

Correction of disorders of homeostasis caused by the development of purulent inflammation... With a favorable course of the disease, its transition to the organizing stage indicates a decrease in the pathological effect on homeostasis. Therefore, it is possible to postpone only the correction of impaired functions and life support systems. For patients admitted for elective radical surgery, correction of homeostasis in the preoperative period should be aimed at eliminating hypoproteinemia, anemia, hypokalemia, hyperammonemia, hypercreatininemia, cardiovascular and respiratory failure, thrombophilia.

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Treatment of pleural empyema

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J86.9 Pyothorax without fistula

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general information

Short description

Classification

Clinical picture

Symptoms, course

Diagnostics

Laboratory diagnostics

Differential diagnosis

Undergo treatment in Korea, Israel, Germany, USA

Treatment

Preparations ( active ingredients) used in the treatment

Hospitalization

Prevention

Information

Sources and Literature

Information

Attached files

Attention!

Identification of pleural empyema

Empyema classification:

Empyema diagnosis

Treatment of pleural empyema

Treatment of pleural empyema in the exudative stage.

Treatment of pleural empyema in the fibrinous-purulent stage.

Treatment of pleural empyema at the stage of organization.

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Treatment of pleural empyema

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