Empyema of the pleura Clinical river ROC. Empyema of the pleura in adults Laboratory examination of sputum

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.

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.

2. DEFINITION
Pleural empyema (purulent pleurisy, pyothorax) is an accumulation of pus or fluid with biological signs of infection in the pleural cavity with involvement of the parietal and visceral pleura in the inflammatory process and secondary compression of the lung tissue.

3. 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) the absence 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:

Implementation and strict adherence to protocols for the treatment and prevention of community-acquired and nosocomial pneumonia, on 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 the transudate from the pleural cavity (if indicated) in conditions causing its accumulation, with mandatory microbiological examination;

Restricting 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 with data 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;

The use of additional methods of aerostasis of the lung tissue and strengthening the bronchus stump during surgery;

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 organs of the chest;

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 clinically indicated), with macroscopic control, general clinical analysis and microbiological examination.

4. Puncture of the pleural cavity in patients 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 capillaries of the pleura. 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 staining smear according to Gram,

LDH\u003e 1000 U / L, glucose\u003e 0.4 g / L, pH 7.0–7.2.

The stage is purulent-fibrinous:

Class 4. Complicated pleural effusion (simple):

positive results of Gram smear staining,

glucose
Class 5. Complicated pleural effusion (complex):

positive results of Gram staining,

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 into 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.

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.

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 (lung tissue is not detected on a plain radiograph);

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

- delimited (when encapsulating and mooring 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 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 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 causes unjustified delays in the full sanitation of the pleural cavity.

Chronic pleural empyema characterized by signs of chronic purulent intoxication, there are periodic exacerbations of the purulent process in the pleural cavity, occurring against the background of pathological changes that support chronic purulent inflammation: bronchial fistulas, osteomyelitis of the ribs, sternum, purulent chondritis. An indispensable attribute of chronic pleural empyema is a persistent residual pleural cavity with thick walls, consisting of 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 blood and urine tests.

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 increases, 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 significantly increases, however, 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.

The disease is a complication of diseases such as: pneumonia, damage to the pleura and lungs, abscess, gangrene, transition of inflammation from neighboring and distant inflammatory foci.

Very often, the formation of serous exudate in the pleural cavity, which gradually takes the form of pus, leads to the disorder. This leads to intoxication of the body and aggravates the course of the disease.

Various diseases of the respiratory system cause a number of pathological consequences, the diagnosis and treatment of which are significantly complicated. The causes of pleural empyema are divided into three groups, consider them:

1. Primary
   • Post-traumatic - chest injuries, trauma, thoracoabdominal injuries.
   • Postoperative - pathology with / without bronchial fistula.
2. Secondary
   • Diseases of the sternum - pneumonia, gangrene and lung abscess, cysts, spontaneous pneumothorax, lung cancer, secondary suppuration.
   • Diseases of the retroperitoneal space and abdominal cavity - peritonitis, cholecystitis, appendicitis, ulcerative lesions duodenum and stomach abscesses.
   • Metastatic pyothorax is a purulent process of any localization complicated by infection and sepsis (phlegmon, osteomyelitis).
3. Cryptogenic empyema with unrefined etiology.

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

• Pericarditis.
• Transfer of infection with lymph and blood from other foci of inflammation (tonsillitis, sepsis).
• Liver abscess.
• Osteomyelitis of the ribs and spine.
• Cholecystitis.
• Pancreatitis
• Pericarditis.
• Mediastinitis.
• Pneumothorax.
• Injuries, injuries, complications after surgery.
• Pneumonia, gangrene and lung abscess, tuberculosis and other respiratory infections.

The main factor for the development of the disease is a decrease in the protective properties of the immune system, the ingress of blood or air into the pleural cavity and microbial flora (pyogenic cocci, tubercle bacilli, bacilli). Acute form may occur due to microbial infection and suppuration of effusion during inflammatory processes in the lungs.

Pathogenesis

Any disease has a development mechanism that is accompanied by certain symptoms. The pathogenesis of pyothorax is associated with a primary inflammatory disease. In the primary form of the disease, inflammation is in the pleural cavity, and in the secondary form, it is a complication of another inflammatory-purulent process.

• Primary empyema appears due to a violation of the barrier function of the pleural sheets and the introduction of harmful microflora. As a rule, this happens with open chest injuries or after undergoing lung surgery. Primary surgical care plays an important role in the development of pathology. If it is provided in the first hours of illness, then pyothorax occurs in 25% of patients.
• The secondary form in 80% of cases is a consequence of chronic and acute purulent lesions of the lungs, pneumonia. Initially, pneumonia can occur simultaneously with purulent pleurisy. Another option for the development of the disease is the spread of the inflammatory process to the pleura from the tissues of neighboring organs and the chest wall. In rare cases, the disorder is provoked by purulent and inflammatory diseases of the abdominal organs. Harmful microorganisms penetrate from the abdominal cavity into the pleura through the lymphatic vessels or by hematogenous route.

At the same time, the pathogenesis of an acute form of purulent lesion of the pleura is rather complicated and is determined by a decrease in the immunobiological reactivity of the organism when harmful microorganisms penetrate. In this case, changes can increase gradually with the development of pleurisy (fibrinous, fibrinous-purulent, exudative) or acutely. A severe form of purulent intoxication causes dysfunctions of the endocrine organs, which pathologically affects the work of the whole organism.

Symptoms of pleural empyema

The symptoms of the disorder gradually increase, and the exudate accumulates, mechanically compressing the lungs and heart. This causes displacement of organs in the opposite direction and causes disturbances in respiratory and cardiac activity. Without timely and correct treatment, purulent contents break through the bronchi and skin, causing external and bronchial fistulas.

The clinical picture of the disease depends on its type and cause. Consider the symptoms of pleural empyema using the example of acute and chronic forms.

Acute inflammation:

• Cough with offensive sputum.
• Chest pains that are better with calm breathing and worse with deep inspiration.
• Cyanosis - a blue tint appears on the skin of the lips and hands, indicating a lack of oxygen.
• Shortness of breath and rapid aggravation of the general condition.

Chronic empyema:

• Subfebrile body temperature.
• Pain in the chest, not expressed.
• Deformation of the chest.

First signs

At an early stage, all forms of a purulent process in the pleura have similar symptoms. The first signs are manifested in the form of cough with sputum production, shortness of breath and pain in the chest, fever and intoxication.

At the initial stage, part of the exudate accumulated in the chest cavity is absorbed and only fibrin remains on the walls of the pleura. Later, the lymph gaps are clogged with fibrin and squeezed by the resulting swelling. In this case, the absorption of exudate from the pleural cavity stops.

That is, the first and main sign of the disease is the accumulation of exudate, swelling and compression of organs. This leads to a displacement of the mediastinal organs and a sharp disruption of the functions of the cardiovascular and respiratory systems. In the acute form of pyothorax, inflammation progresses pathologically, increasing the intoxication of the body. Against this background, dysfunction of vital organs and systems develops.

Acute pleural empyema

The inflammatory process in the pleura, which lasts no longer than one month, is accompanied by the accumulation of pus and symptoms of septic intoxication - this is acute empyema. The disease is closely related to other lesions of the bronchopulmonary system (gangrene and lung abscess, pneumonia, bronchiectasis). Pyothorax has a wide microbial spectrum; pleural damage can be both primary and secondary.

Symptoms of acute pleural empyema:

• Pain in the chest, worse with inspiration, coughing and changes in body position.
• Shortness of breath at rest.
• Blueness of lips, earlobes and hands.
• Elevated temperature body.
• Tachycardia over 90 beats per minute.

Treatment should be comprehensive. In the early stages of therapy, it is necessary to remove the contents of the pleura to expand the lung and obturate the fistula. If empyema is widespread, then the contents are removed by thoracocentesis and then drained. The most effective way of sanitation is considered to be regular washing of the pleural cavity with an antiseptic solution with antibiotics. wide range actions and proteolytic enzymes.

With progressive empyema, various pathological complications and ineffective drainage, surgical treatment is performed. Patients are shown a wide thoracotomy and open debridement, after which the chest cavity is drained and sutured.

Chronic pleural empyema

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

Symptoms:

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

Chronic inflammation leads to the formation of thick cicatricial adhesions that preserve the purulent cavity and keep the lung dormant. The gradual resorption of the exudate is accompanied by the deposition of fibrin filaments on the pleural sheets, which leads to their adhesion and obliteration.

Forms

Pyothorax can be both bilateral and unilateral, but the latter form is more common.

Since there are many forms and types of inflammatory changes in the pleura, a special classification has been developed. Empyema of the pleura is divided by etiology, nature of complications and prevalence.

By etiology:

• Infectious - pneumococcal, streptococcal, staphylococcal.
• Specific - actinomycotic, tuberculous, syphilitic.

By duration:

• Acute - up to two months.
• Chronic - more than two months.

By prevalence:

• Encapsulated (limited) - inflammation on only one wall of the pleural cavity.
  • Diaphragmatic.
  • Mediastinal.
  • Apical.
  • Costal.
  • Interlobar.
• Common - the pathological process struck two or more walls of the pleura.
• Total - the entire pleural cavity is affected.

By the nature of the exudate:

• Purulent.
• Serous.
• Serous fibrous.

According to the severity of the course:

• Lungs.
• Medium severity.
• Heavy.

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

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

Let's take a closer look at the code for MKB 10:

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

• J86 Pyothorax
  • Empyema of the pleura
  • Lung destruction (bacterial)
• J86.0 Pyothorax with fistula
• J86.9 Pyothorax without fistula
  • Pyopneumothorax

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

Types of chronic pyothorax:

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

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

Encapsulated pleural empyema

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

As a rule, this species has a tuberculous etymology, therefore it disintegrates in the lateral part of the pleura or supraphragmatically. Settled pyothorax is exudative, and the effusion is limited to adhesions between the pleural sheets. Pathology involves the transition of acute to chronic inflammation and is accompanied by symptoms such as:

• A sharp decrease in the protective properties of the immune system.
• Degenerative changes in the structure of connective tissues and massive adhesions.
• Violent cough with expectoration.
• Chest pain.

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

Complications and consequences

The uncontrolled course of any disease leads to serious complications. The consequences of a purulent process in the pleura pathologically affect the state of the whole organism. The lethal outcome is about 30% of all cases and depends on the form of the disease and its root cause.

Very often, purulent pleurisy takes on a chronic form, which is characterized by a long course and painful symptoms. A breakthrough of pus through the chest wall to the outside or into the lungs leads to the formation of a fistula that connects the pleural cavity to the lungs or the external environment. But the most dangerous consequence sepsis is considered, that is, the penetration of infection into the circulatory system and the formation of purulent-inflammatory foci in various organs.

Regardless of its shape, pyothorax has a number of serious consequences. Complications manifest themselves from all organs and systems. But most often these are bronchopleural fistulas, multiple organ failure, bronchiectasis, septicopyemia. The disease can lead to lung perforation and accumulation of pus in the soft tissues of the chest wall.

Since the purulent exudate does not dissolve on its own, it is possible for pus to break through the lungs into the bronchi or through the chest and skin. If the purulent inflammation breaks out, then it takes the form of an open pyopneumothorax. In this case, its course is complicated by a secondary infection, which can be brought in during a diagnostic puncture or during dressings. Prolonged suppuration leads to purulent peritonitis and pericarditis, sepsis, amyloid degeneration of organs and death.

Diagnostics of the pleural empyema

Many methods are used to recognize purulent pleurisy. The diagnosis of pleural empyema is based on the symptoms of the disease and, as a rule, is not difficult.

Consider the main methods for detecting a disease on early stages, determining its prevalence and nature:

1. Analysis of blood and urine - show pronounced leukocytosis with a significant shift in the leukocyte formula.
2. Analysis of pleural fluid - allows you to identify the pathogen and determine the nature of the exudate. Material for research is obtained using pleural puncture - thoracocentesis.
3. Radiography - used to identify changes characteristic of the disease. The picture shows darkening, which corresponds to the spread of purulent contents and displacement of the mediastinal organs to the healthy side.
4. Ultrasound and CT - determine the amount of purulent fluid and allow you to clarify the place for pleural puncture.
5. Pleurophistulography - radiography, which is carried out in the presence of purulent fistulas. A X-ray contrast agent is injected into the resulting hole and pictures are taken.

Analyzes

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

Analyzes to identify purulent pleurisy:

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

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

Instrumental diagnostics

For the effective treatment of pyoinflammatory disease, a lot of research is needed. Instrumental diagnostics is necessary to determine the nature of inflammation, its localization, stage of spread and other features of the course.

Basic instrumental methods:

• Polypositional fluoroscopy - localizes the lesion, determines the degree of lung collapse, the nature of the mediastinal displacement, the amount of exudate and other pathological changes.
• Lateroscopy - determines the vertical dimensions of the affected cavity and makes it possible to assess the state of the basal parts of the organ, filled with exudate.

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

• Pleurography is a snapshot of the lungs in three projections. Allows you to assess the size of the cavity, the presence of fibrinous layers, sequesters and the condition of the pleural walls.
• Bronchoscopy - reveals tumor lesions of the lungs and bronchial tree, which can be complicated by cancer.
• Fibrobronchoscopy - gives an idea of \u200b\u200bthe nature of the inflammatory process in the bronchi and trachea, which occur in the acute form of pleural empyema.

Empyema of the pleura on the radiograph

One of the most informative and available methods for diagnosing inflammation of the respiratory system is X-ray. The pleural empyema on the roentgenogram looks like a shadow, which is most often located in the lower parts of the lung. This sign indicates the presence of fluid in the organ. If there is massive infiltration of the lower lobe of the lung, then the x-ray is taken while lying on the affected side. Thus, the exudate is distributed along the chest wall and is clearly visible in the picture.

If the ailment is complicated by a bronchopleural fistula, then there is an accumulation of air in the pleural cavity. The image shows the upper boundary of the effusion and assess the extent of the collapse of the lung. Significantly changes the radiography - the adhesive process. During the diagnosis, it is not always possible to identify a purulent cavity, since it can be both in the lung and in the pleura. If purulent pleurisy is accompanied by the destruction of the respiratory system, then a deformed parenchyma is visible on the roentgenogram.

Differential diagnosis

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

Acute empyema is very often a complication of pneumonia. If during the study a displacement of the mediastinum is revealed, then this indicates pyothorax. In addition, there is a partial expansion and bulging of the intercostal spaces, painful sensations on palpation, and weakened breathing. Tomography, puncture and multi-axis fluoroscopy are critical.

A purulent process in the pleura is similar in its X-ray and clinical picture to an abscess. Bronchography is used for differentiation. During the study, the repression of the bronchial branches and their deformation are determined.

• Lung atelectasis

Diagnosis is complicated by the fact that the obstructive form of the disease may be accompanied by effusion into the pleural cavity and squeezing of part of the lung with pleural fluid. For differentiation, bronchoscopy and puncture of the pleural cavity are used.

Oncology is characterized by peripheral shading of the pulmonary field and the transition to the chest wall. To detect purulent pleurisy, a transthoracic biopsy of lung tissue is performed.

• Specific lesion of the pleura

We are talking about tuberculous and mycotic lesions, code pathology precedes empyema. To make the correct diagnosis, exudate studies, puncture biopsy, thoracoscopy and serological tests are performed.

In addition to the diseases described above, do not forget about differentiation from diaphragmatic hernias and cysts.

Treatment of pleural empyema

To eliminate the purulent process in the lungs, only modern and effective methods are used. Treatment of pleural empyema is aimed at restoring the normal functioning of the respiratory system and the body. The main task of therapy is to empty the pleural cavity from purulent contents. Treatment is carried out in a hospital with strict adherence to bed rest.

Disease relief algorithm:

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

Medicinal treatment of pleural empyema

Treatment of a purulent-inflammatory disease is a long and complex process. The effectiveness of therapy is largely determined by the drugs used. Medicines are selected based on the form of the disorder, the nature of the course, the root cause and the individual characteristics of the patient's body.

For treatment, the following drugs are prescribed:

• Aminoglycosides - Amikacin, Gentamicin
• Penicillins - Benzylpenicillin, Piperacillin
• Tetracyclines - Doxycycline
• Sulfonamides - Co-trimoxazole
• Cephalosporins - Cephalexin, Ceftazidime
• Lincosamides - Clindamycin, Lincomycin
• Quinolones / Fluoroquinolones - Ciprofloxacin
• Macrolides and Azalides - Oleandomycin

For aspiration of purulent contents, antibiotic therapy is performed using aminoglycosides, carbapenems and monobactams. Antibiotics are selected as rationally as possible, taking into account probable pathogens and based on the results of bacteriological diagnostics.

• Mix the juice of the onion with honey in a 1: 1 ratio. Take the product 1-2 tablespoons 2 times a day after meals. The medicine has anti-infective properties.
• Remove pits from fresh cherries and chop the flesh. The medicine should be taken ¼ glass 2-3 times a day after meals.
• Heat olive oil and rub it on the affected side. You can make an oil compress and leave it overnight.
• Mix equal proportions of honey and black radish juice. Take the agent 1-2 tablespoons 3 times a day.
• Take a glass of aloe juice, a glass of vegetable oil, linden flowers, birch buds, and a glass of linden honey. Pour boiling water over the dry ingredients and let it brew in a water bath for 20-30 minutes. Add honey and aloe to the finished infusion, mix thoroughly and add vegetable oil. The medicine is taken 1-2 tablespoons 2-3 times a day before meals.

Sheets with further accumulation of purulent masses in the pleural cavity. The disease requires immediate and comprehensive treatment, since otherwise a host of complications may develop.

Brief information about the disease

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

According to statistics, men are faced with this disease three times more often than the fair sex. In most cases, empyema is a complication of other pathologies.

The reasons for the development of the disease

The causes of pleural empyema can be different. If we are talking about the primary form of the disease, then the triggering mechanisms in this case are the activity of pathogenic microorganisms, the penetration of blood or air into the cavity, as well as a significant decrease in immunity. Primary empyema (in medicine, the disease also appears under the name "purulent pleurisy") develops when:

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

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

• purulent processes in any organ system;
• inflammation of the lung tissue;
• the formation of an abscess in the tissues of the lung;
• oncological diseases of the respiratory system;
• spontaneous pneumothorax (violation of the integrity of the pleural cavity);
• inflammation of the appendix;
• peptic ulcer of the stomach and intestinal tract;
• gangrene of the lungs;
• cholecystitis;
• peritonitis;
• the formation of abscesses in the liver;
• sepsis;
• osteomyelitis;
• rupture of the esophagus;
• inflammation of the pericardium;
• inflammatory processes in the pancreas;
• infectious diseases of the respiratory system;
• tuberculosis.

It is worth noting that the disease can be caused by the activation of some pathogenic microorganisms, in particular, pneumococci, streptococci, staphylococci, tubercle bacillus, pathogenic fungi and anaerobic bacteria. Pathogens can enter the tissues of the respiratory system along with the flow of blood and lymph from other organs.

Empyema of the pleura: classification

Today, there are many schemes that make it possible to classify such a pathology, because a variety of factors must be taken into account.

For example, depending on the characteristics and duration of the course, acute and chronic pleural empyema are distinguished. The symptoms of these forms can be different. For example, in an acute inflammatory-purulent process, signs of intoxication come to the fore, while the disease lasts less than a month. If we are talking about a chronic form of the disease, then the symptoms are more blurred, but they bother the patient for a long time (more than 3 months).

Depending on the nature of the exudate, empyema can be purulent, specific, putrid and mixed. There is a closed (purulent masses are contained in the pleural cavity and do not go out) and an open form of the disease (there is the formation of fistulas between the pleura and the lungs, bronchi, skin through which exudate circulates).

The volume of pus formed is also taken into account:

• small empyema - the volume of purulent masses does not exceed 250 ml;
• average, at which the volume of exudate is 500-1000 ml;
• large empyema - there is an accumulation of a large amount of pus (more than 1 liter).

Depending on the location of the focus, the pathological process can be either one- or two-sided. Of course, all of these characteristics are important for an effective treatment regimen.

Stages of development of the disease

Today, there are three stages in the development of this pathology.

• The first phase is serous. Serous effusion begins to accumulate in the pleural cavity. If at this stage the patient was not provided with appropriate assistance, then in the serous fluid, the active reproduction of the pyogenic flora begins.
• The second stage is fibro-serous. The exudate in the pleural cavity becomes cloudy, which is associated with the activity of pathogenic bacteria. Fibrinous plaque forms on the surface of the parietal and visceral sheets. Gradually, adhesions form between the sheets. Thick pus accumulates between the leaves.
• The third stage is fibrous. At this stage, the formation of dense adhesions that fetter the lung is observed. Since the lung tissue does not function normally, it also undergoes fibrotic processes.

Symptoms of pathology

The acute form of empyema of the lungs is accompanied by very characteristic symptoms.

• The patient's body temperature rises.
• There are other symptoms of intoxication, in particular, chills, pain and muscle aches, drowsiness, weakness, sweating.
• Cough is a common symptom of empyema. It is dry at first, but gradually becomes productive. When coughing, sputum is released that is greenish-yellow, gray or rye. Discharge often has an extremely unpleasant odor.
• Dyspnea is also included in the list of symptoms - at first it appears only during physical activity, but then bothers the patient at rest.
• As the pathology progresses, pains appear in the sternum, which intensify on exhalation and inhalation.
• Changes in the work of the respiratory system also affect the functioning of the heart, causing certain disturbances in its rhythm.
• Patients complain of constant weakness, rapid fatigue, decreased performance, feeling of weakness, lack of appetite.
• Disorders of the respiratory system are sometimes accompanied by some external symptoms. For example, the skin on the patient's lips and fingertips becomes bluish.

According to statistics, in about 15% of cases, the process becomes chronic. In this case, the clinical picture looks different. There are no symptoms of intoxication, as well as an increase in temperature. The cough bothers the patient constantly. Patients also complain of recurrent headaches. In the absence of treatment, various chest deformities develop, as well as scoliosis, which is associated with some compensatory mechanisms.

Possible complications

According to statistics, correctly selected treatment helps to cope with pleural empyema. Complications, however, are possible. Their list is as follows:

• dystrophic changes in the kidneys;
• serious damage to the myocardium, kidneys and some other organs;
• formation of blood clots, blockage of blood vessels;
• multiple organ failure;
• formation of bronchopleural fistulas;
• the development of amyloidosis;
• thromboembolism of the pulmonary artery associated with thrombosis (requires urgent surgical intervention, as otherwise there is a high probability of death).

As you can see, the consequences of the disease are very dangerous. That is why in no case should you ignore the symptoms of the disease and refuse the help of a qualified specialist.

Diagnostic measures

The diagnosis of pleural empyema is extremely important. The doctor is faced with the task of not only confirming the presence of pyothorax, but also determining the nature of the pathological process, the degree of its spread, the causes of its occurrence.

• To begin with, anamnesis is collected, the study of the patient's medical data. On external examination of the chest, one or another degree of deformation, bulging or smoothing of the intercostal space may be noticed. If we are talking about chronic pleural empyema, then the patient has scoliosis. The lowering of the shoulder and protrusion of the scapula from the side of the lesion are very characteristic.
• Auscultation is mandatory.
• In the future, the patient is sent to various studies. Laboratory tests of blood and urine are mandatory, during which it is possible to determine the presence of an inflammatory process. Microscopic examination of sputum and aspirated fluid is performed.
• Exudate samples are used for bacterial culture. This procedure allows you to determine the genus and type of pathogen, to check the degree of its sensitivity to certain drugs.
• Fluoroscopy and radiography of the lungs are informative. In the pictures, the affected areas are darkened.
• Pleurophistulography is a procedure that helps detect fistulas (if any).
• Pleural puncture and ultrasonography of the pleural cavity are also performed.
• Sometimes the patient is additionally sent for magnetic resonance imaging and / or computed tomography. Such studies help the doctor evaluate the structure and functioning of the lungs, detect the accumulation of exudate and assess its volume, diagnose the presence of certain complications.

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

Therapeutic treatment

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

Since the formation of purulent exudate is in one way or another associated with the activity of pathogenic microorganisms, antibiotics of a wide range of effects in the form of tablets are necessarily introduced into the therapy regimen. Drugs from the group of aminoglycosides, cephalosporins, fluoroquinolones are considered effective. In addition, sometimes antibacterial agents are injected directly into the pleural space for maximum results.

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

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

After the symptoms of empyema become less severe, physical therapy is recommended. Special breathing exercises help to strengthen the intercostal muscles, normalize lung function, and saturate the body with oxygen. A therapeutic massage will also be useful, which also helps to clear the lungs of phlegm, improve the well-being of the body. Additionally, sessions of therapeutic gymnastics are held. Ultrasound therapy also gives good results. During rehabilitation, doctors recommend that patients undergo restorative spa treatment.

When is surgery necessary?

Unfortunately, sometimes only surgery helps to cope with the disease. Empyema of the pleura, which is characterized by a chronic course and accumulation of large amounts of pus, requires surgical intervention. Such methods of therapy can relieve the symptoms of intoxication, eliminate fistulas and cavities, straighten the affected lung, remove purulent exudate and sanitize the pleural cavity.

Sometimes a thoracostomy followed by open drainage is performed. Sometimes the doctor decides to remove some areas of the pleura with further decortication of the affected lung. If there are fistulas between the tissues of the pleura, bronchi, lungs and skin, then the surgeon closes them. In the event that the pathological process has not spread to the lungs, then the doctor may decide on partial or complete resection of the affected organ.

Traditional medicine

Therapy for such a disease must necessarily be comprehensive. And sometimes the use of various herbal remedies is allowed.

• An ordinary bow is considered effective. It is easy to prepare the medicine. Peel a medium-sized onion, rinse and chop. Next, you need to squeeze out the juice and mix it with natural honey (in equal amounts). The medicine is recommended to be taken twice a day for a tablespoon. It is believed that the remedy is excellent for coughing, facilitates the discharge of sputum.
• At home, you can prepare an effective mucolytic collection. You need to mix equal amounts of elecampane rhizome, coltsfoot herb, mint, linden flowers and licorice root. Pour 20 g of the herbal mixture with a glass of boiling water, then let it brew. After cooling by filtering, we divide the product into three equal portions - they need to be drunk during the day. Fresh medicine needs to be prepared every day.
• Horsetail is also considered effective. 20 g of dry herb of a plant (crushed), you need to pour 0.5 liters of boiling water. Cover the container and leave for four hours in a warm place, then strain the infusion. It is recommended to take 100 ml four times a day for 10-12 days.
• There is a medicinal product that makes breathing easier and helps to cope with shortness of breath. It is necessary to displace in equal amounts the herb of immortelle, dried calendula flowers with currant leaves, tansy and bird cherry. Pour a tablespoon of the mixture with a glass of boiling water and insist. You need to take 2-3 tablespoons three times a day.
• If there are problems with the work of the respiratory system, then you need to mix equal amounts of natural honey and fresh radish juice. Herbalists recommend taking the medicine in a spoon (tablespoon) three times a day.

Of course, home remedies can only be used with the permission of a specialist.

Unfortunately, there are no specific preventive measures. Nevertheless, doctors advise to adhere to some rules:

• all inflammatory diseases (especially when they are accompanied by a purulent process) require timely therapy;
• important to strengthen immune system, as this reduces the risk of developing such diseases (you need to try correctly, stab the body, take vitamins, spend time in the fresh air);
• preventive examinations should not be avoided - the earlier the disease is detected, the less likely it is to develop certain complications.

It should be noted that in most cases, such a disease responds well to therapy. Pleural empyema is not for nothing considered a dangerous pathology - you should not ignore it. According to statistics, approximately 20% of patients develop certain complications. Mortality in this disease ranges from 5 to 22%.

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

Zolotarev DV, Candidate of Medical Sciences, Head of the Department of Purulent Thoracic Surgery, Moscow City Clinical Hospital No. 23 named after "Medsantrud", Moscow DZ; Senior Researcher, Research Center, Surgical Infection Research Center, First Moscow State Medical University. I.M.Sechenov of the Ministry of Health of Russia, employee of the department of purulent pulmonary surgery of the Military Medical Academy in the period 1996-1999.

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

Popov V.I., Doctor of Medical Sciences, Head of the Department of Purulent Pulmonary Surgery of the Military Medical Academy in the period 1998-2005.

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

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

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

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

ICD code 10

J86.0 Pyothorax with fistula

J86.9 Pyothorax without fistula

Definition

Empyema of the pleura is a purulent (putrid) inflammation that develops in the pleural cavity with the involvement of the parietal and visceral pleura in the pathological process.

Etiology and pathogenesis

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

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

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

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

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

The direct path of infection of the pleural cavity is said when subcortical abscesses of the pulmonary parenchyma break into it. The ingress of a large amount of the contents of the abscess into the pleural cavity causes a violent exudative reaction, and the resorption of microbial toxins by the intact pleura in the early stages of the development of the process leads to the development of an infectious-toxic shock. The same mechanism of development of the infectious process in the pleural cavity is observed with gangrene of the lung, when large areas of the pulmonary parenchyma together with the visceral pleura undergo putrefactive decay. Constant microbial invasion and the prevalence of the process (involvement of all parts of the pleura, including the parietal) determines the particular severity of the course of pleural empyema with such a mechanism of occurrence.

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

and general immunity, type of pathogen.

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

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

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

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

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

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

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

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

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

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

1. By communication with the external environment

Empyema of the pleura

	Closed melting			Open
				reported (reported by external
	not reported communicated external			external environment))
	external environment)

With pleurodermal fistula - with bronchopleural fistula

With bronchopleurodermal fistula - with pleuroorganic fistula - with bronchopleuroorganic fistula

Lattice lung (controversial issue)

2. By volume

Empyema of the pleura

Total		Subtotal		Delimited
With Rg research		Defined only		When mooring
lung tissue is not
		apex of the lung		exudate
determined

By localization

By pathogenesis

- parapneumonic;

Due to purulent-destructive lung diseases;

- post-traumatic;

- postoperative.

3. Most authors distinguish by the duration of the course of the pathological process acute, subacute and chronicempyema of the pleura. However, such a division of pleural empyema only by the duration of the disease, and in some cases, by the presence of morphological signs of chronic inflammation (the formation of mature connective tissue) is conditional. In some patients with pronounced reparative abilities, rapid fibrotization of fibrinous layers on the pleura occurs, while in others, these processes are so suppressed that adequate fibrinolytic therapy makes it possible to “clear” the pleural sheets even in the long term (6-8 weeks) from the onset of the disease. Thus, as a classification sign of acute or chronic pleural empyema (in the presence of a lung), morphological changes should apparently be used not in the pleura, but in the pulmonary parenchyma (pleurogenic cirrhosis of the lung), which serve as a criterion for evaluating the results of treatment, determine an adequate the amount of surgery. 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. Thus, to cure chronic pleural empyema requires radical surgery, in acute pleural empyema, cure can be achieved without radical operations (pleurectomy with decortication, in combination with resection of the lung, ribs, sternum, etc.).

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

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

Clinical manifestations and diagnosis

The clinical manifestations of pleural empyema are very diverse, which is due to different mechanisms of the development of pathological changes in the pleural cavity, the peculiarities of the course of the infectious process in each particular patient and the volume of previous treatment. They mainly depend on the prevalence and location. However, in the vast majority of cases, symptoms are clearly manifested.

- general purulent intoxication

- breathing disorders

- varying degrees of severity of "local" manifestations.

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

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

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

the occurrence with the development of pleuropulmonary shock caused by irritation of the extensive 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. However, the greatest danger to the patient's life is the occurrence of a valve mechanism leading to the development of a tense pneumothorax, characterized by a significant increase in pressure in the pleural cavity, 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). Delay in the provision of emergency assistance ("unloading" puncture and drainage of the pleural cavity) can be fatal for the patient. Therefore, the use of the term "pyopneumothorax" as a preliminary diagnosis is legitimate, since it obliges the doctor to intensively monitor the patient, to quickly verify the diagnosis, and all medical staff - to the immediate provision of the necessary assistance.

A feature of the clinical manifestations of post-traumatic, including postoperative pleural empyema, is the development of an infectious process against a 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 bundles 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 causes unjustified delays in the full sanitation of the pleural cavity.

In the clinical picture of chronic pleural empyema, signs of chronic purulent intoxication prevail, 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.

At the modern level of diagnostics, verification of the diagnosis of "empyema of the pleura", as well as its assignment to one of the types, is impossible without

application of radiation research methods. The most informative method of X-ray examination with EP is cT scan, the modern capabilities of which to obtain a 3D image, allows directly during the study to obtain data for formulating a diagnosis for all classification categories. A simpler method of X-ray examination is

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

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

Ultrasound of the pleural cavity is a very informative study.

This method allows you to evaluate in more detail the nature of the contents of the pleural cavity (the number and nature of fibrinous layers, the thickness of the fluid layer immediately before the start of the puncture, etc.).

In the presence of a pleurodermal fistula, valuable information can be obtained with fistulography performed with an x-ray or CT scan.

Endoscopic methods ( bronchoscopy, thoracoscopy), and ultrasound scanallow you to get a more detailed understanding of the nature of morphological changes in the pleural sheets, in the pleural cavity and in the lung tissue.

Bronchoscopy, performed in patients with pleural empyema, aims to exclude central lung cancer, often causing pleural carcinomatosis (cancerous pleurisy), transforming into pleural empyema when exudate is infected; to sanitize the tracheobronchial tree in the presence of a destructive process in the lungs, to examine the bronchial lavage water (sowing, etc.) in order to establish a microbiological agent and select a rational antibacterial therapy. Valuable information can be obtained by combining bronchoscopy with the introduction into the pleural cavity of the drainage of a staining solution of vital dye (retrograde chromobronchoscopy). By the way the dye enters the lumen of the subsegmental and segmental bronchi, it is possible to accurately determine not only the localization, but also the prevalence of bronchopleural communication. 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

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. Scriabin (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 bronchus 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:

1. the presence of fluid in the pleural cavity as a result of the development of a primary pathological process (non-bacterial pleurisy, hydrothorax) or injury (including the operating room);
2. 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;
3. 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:

1. 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;
2. 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 pleural effusion in patients with pneumonia (if indicated) with obligatory microbiological examination;
   4. timely puncture removal of the transudate from the pleural cavity (if indicated) in conditions causing 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

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:
   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 distress, respiratory failure, swallowing disorder) - 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.
2. 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.
3. 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.
4. 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.
• The stage is purulent-fibrinous:
  • 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, it is still accepted to divide empyema by the nature of the course (and to some extent by time criteria): acute and chronic (exacerbation phase, remission phase).

Chronic pleural empyema is always untreated acute pleural empyema (Kupriyanov P.A., 1955). The most common reason for the transition of an acute purulent process into 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:

1. rigid (anatomically irreversible) thick-walled residual cavity, to one degree or another collapsing the lung, with or without bronchial fistulas;
2. 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:

1. "Closed", without a fistula (does not communicate with the external environment);
2. "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, not obvious 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, 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.

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.

1. 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.
2. 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 significantly increases, however, 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.
3. 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.
4. Bacteriological blood test (blood culture for sterility) in the presence of clinical and laboratory signs of sepsis and / or prolonged fever.

Laboratory research sputum.

1. 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.
2. 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.
3. Due to the contamination of the microflora of the upper respiratory tract and 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 chest X-ray.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 the 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 choice 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 the 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; to 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 standpoint 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 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 action until the results of bacteriological research are obtained) in a small volume of 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 research 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 is opened, 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 a Janet 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 rinsing the cavity, 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 with x-ray examination (immediately after drainage, 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 makes it possible to reduce the duration of pleural drainage, to normalize body temperature faster, to achieve treatment success within the first 3 days in 86.5% of patients and, accordingly, to 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 effectiveness (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 videhoracoscopic 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. When the bronchopleural communication is localized within one lobe, a very effective method of eliminating it is a temporary obstruction of the lobar or segmental bronchi (temporary valve bronchoblocking). 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 has recovered after 2-4 days, the valve bronchoblocker can be left for 2-4 weeks (the time required for the development of the moorings 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 for a week (with localization of bronchopleural fistulas in adjacent lobes), it is impractical 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 blocking, 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 enterobacteriaceae (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 III 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 (into the pulmonary artery by performing angiopulmonography or into 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. Subsidiary parenteral nutrition must 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 of more than 10%, body mass index less than 20 kg / m, hypoproteinemia (total protein content less than 60 g / l) or hypoalbuminemia (plasma albumin less than 30 g / l).
• Decrease in 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 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 pressure in respiratory tract 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 have caused the 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-installed drain 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 washing (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 in the soft tissues of the chest wall, the development of severe anaerobic phlegmon of the chest wall, the presence of significant bronchopleural communication with 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 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 to eliminate them 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, preference should be given to sanitation video-thoracoscopic interventions, including video-assisted minithoracotomy (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 have caused the 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 the 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 removal of the drainage, as often accumulates in its bed exudate, which is the cause of recurrence 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 have been admitted repeatedly 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 a 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.

Treatment of pathological processes in the lung, ribs, sternum, and other organs that caused infection of the pleural cavity. The nature and extent of damage to the compromised organs (lungs, ribs, sternum) should be taken into account when choosing the amount of radical intervention (extended radical surgery).

Choosing a method of surgery for pleural empyema at the stage of organization in a planned manner... The main tasks of a planned radical operation in patients at the stage of organization are: termination of bronchopleural communication, elimination of the residual cavity. The volume of radical surgery will depend on the etiology of empyema, the nature of the previous intervention on the lung and chest, the volume of the empyema cavity, the state of the pulmonary parenchyma, the presence of a bronchopleural fistula, the presence of incompetence of the stump of the main or lobar bronchus, the severity of the patient's condition (decompensated concomitant diseases of the life support systems). Operational access to this stage is only thoracotomy.

Patients with parapneumonic empyema, as well as empyema due to abscess and gangrene of the lung, suppurative pleurisy and hemotrax. With limited empyema in non-operated patients (including those with bronchopleural fistula) and preserved pulmonary parenchyma, decortication of the lung is used (removal of moorings from the visceral pleura). The negative aspect of this operation is the preservation of the parietal moorings - a real source of pleural cavity reinfection. With subtotal and total empyema, significantly collapsed lung, but relatively intact pulmonary parenchyma, pleurectomy is indicated - removal of the visceral and parietal moorings in the form of a single empyema sac. In the presence of bronchopleural fistulas and a compromised lung (chronic abscess, fibroatelectasis, pneumocirrhosis), incapable of re-expansion, as well as in connection with extensive intraoperative lung damage, it is necessary to expand the scope of the operation to pleurobectomy or pleuropneumonectomy.

Patients with chronic postoperative empyema due to fistula of the stump of a large bronchus. The scope of the operation in such situations depends on the localization of the bronchial fistula. With a fistula of the stump of a lobar bronchus after a previous lobectomy, both tasks of a planned radical operation are solved simultaneously - a "residual" pneumonectomy with pleurectomy is performed. In the presence of a fistula of the stump of the main bronchus after pneumonectomy, the choice of the method of intervention is determined by the length of the remaining part of the stump, therefore, treatment options are possible. If the length of the stump according to computed tomography data is more than 1.5 cm, then preference should be given to transsternal transpericardial resection of the stump. If the length of the stump is less than 1.5 cm, then it is unlikely that it will be possible to place a stapler on such a stump. In this regard, it is possible to undertake transthoracic (through thoracotomy) myobronchoplasty using rotational flaps of the latissimus dorsi muscle or omentobronchoplasty using a greater omentum with preserved axial blood flow (Grigoriev E.G., 1989). The advantage of using a greater omentum is due to the fact that as a result of a previous pneumonectomy for gangrene of the lung during thoracotomy, the vessels and nerves of the latissimus dorsi were intersected, which led to their hypotrophy.

There are reports of the use of autologous mesenchymal stem cells by injecting the fistulous opening during fibrobronchoscopy (Gomez-de-Antonio D. et al., 2010; Petrella F. et al., 2015). In any case, the closure of the bronchopleural fistula should precede the final eradication of the empyema (Ferguson M.K., 1999). If, as a result of all successful measures to eliminate the fistula of the stump of the main bronchus, a residual cavity remains, then the second stage (delayed) is one of the types of thoracoplasty.

Types of thoracoplasty... Thoracoplasty is a surgical procedure in which part of the ribs are removed and thereby provide mobilization and retraction of the chest wall. The purpose of the operation is to eliminate the persistent residual empyema cavity, most often after pneumonectomy, or if the lung is incapable of re-expansion, or if decortication or pleurectomy cannot be performed. All methods of thoracoplasty are divided into 2 groups - interpleural and extrapleural. With interpleural thoracoplasty, the purulent cavity in the pleura is widely opened by complete excision of the ribs with intercostal spaces and parietal pleural scars (Shede thoracoplasty). The most commonly used thoracoplasty ladder according to Limberg. Above the purulent cavity, the ribs are excised under the bone and through their bed, longitudinal cuts are made parallel to each other. The strips of soft tissues formed after the dissection of the bed of the resected ribs are incised in front and behind (alternately) and are transformed into stems with a feeding posterior or anterior leg. These stems are placed on the bottom of the empyema cavity and held there with a tamponade. Thus, the cavity is eliminated.

In addition to thoracoplasty, omentoplasty can be used. In extrapleural thoracoplasty, subperiosteal resection of the ribs is performed, but the pleural cavity is not opened, and the falling chest wall provides compression and collapse of the lung tissue. Extensive thoracoplastic operations to eliminate a persistent residual cavity in chronic pleural empyema are rarely used today, since resection of 8-10 ribs is not inferior to pneumonectomy in terms of trauma, and long-term consequences (development of cirrhosis of the lung, formation of a pulmonary heart, progressive respiratory failure) are severe. Limited thoracomyoplastic operations (three-, five-ribbed) are widely used at the present time. The essence of the operation consists in resection of 3-5 ribs over the empyema cavity and tamponade of the sanitized cavity with a muscle flap on the pedicle (one of the large muscles of the chest wall).

Palliative surgery for chronic empyema... Sometimes patients with chronic empyema have to resort to palliative surgery - thoracostomy with an open pleural cavity. This intervention is performed in patients with chronic pleural empyema after lobectomy and pneumonectomy with the futility of traumatic radical surgery (elimination of a fistula, thoracoplasty, thoracomyoplasty) in case of tumor recurrence, extremely low lung, heart and kidney function, and as a palliative measure that facilitates cavity care.

When providing assistance to patients with pleural empyema, it is impossible:

• to establish a drainage in the pleural cavity in patients with transudate and small (clinically insignificant) exudate in the pleural cavity without good reason to avoid infection and the development of empyema;
• delay the terms of simple drainage (drainage, delivered "blindly") more than 3 days, if intoxication and purulent discharge along the drainage does not decrease;
• hope for a quick and complete expansion of the lung with a passive outflow of pus from the pleural cavity;
• to continue temporary endobronchial occlusion of the bronchopleural fistula for more than a week, if during this period it turns out to be ineffective;
• remove drainage from the pleural cavity (with a favorable course of the disease) without X-ray and ultrasound monitoring of the cavity condition and lung expansion;
• perform "open" drainage of empyema (chest wall fenestration, thoracostomy, thoracoabscessostomy) without making sure that there are delimiting adhesions (moorings) between the visceral and parietal pleura in the destruction zone according to computed tomography;
• to postpone the performance of a planned radical operation in the exudative stage and in the organizing stage due to the risk of bacterial-toxic shock, intraoperative technical complications due to infiltration of the lung root, the risk of early postoperative failure of the bronchial stump in a purulent process;
• to perform in general surgical hospitals special surgical methods of eliminating the cavity with "open" empyema (thoracoscopic sanitation of the cavity with "filling" of bronchial fistulas, temporary endobronchial occlusion or valve bronchoblocking, therapeutic pneumoperitoneum).
• strive in all cases of formed residual cavities to "chronize" the process (patients with residual cavities in the pleural cavity more than 5-8 cm, pleural drainages and active pulmonary-pleural fistulas).

Forecast

The possible outcomes of the pathological process should be clearly represented. Any prolonged existence of a purulent process in the pleura is always accompanied by the death of the mesothelial layer of the pleura and its cicatricial degeneration, therefore, "restitutio ad integrum" (complete recovery), as an outcome of pleural empyema, even under the most favorable conditions, is impossible. Thus, recovery with pleural empyema means stopping the purulent inflammatory process in the pleural cavity and eliminating it due to the formation of cicatricial adhesions between the chest wall and the pulmonary surface.

However, the elimination of the cavity in this way can not always be regarded as a completely favorable outcome of the disease. Despite the absence of conditions for the recurrence of purulent inflammation in the obliterated cavity, the formation of an excessively thick layer of dense fibrous tissue at the site of the parietal and visceral pleura is often observed, which leads to a significant decrease in the volume of hemithorax, narrowing of the intercostal spaces, and displacement of the mediastinum towards the lesion. This causes a significant decrease in the indicators of the function of external respiration, as a result of both disturbances in ventilation and due to a pronounced reduction in pulmonary blood flow. The same dysfunctions of external respiration are observed after extensive thoracoplastic operations in order to eliminate the residual cavity by "tamponade" of its soft tissues of the chest wall after resection of the ribs. At the same time, a gross cosmetic defect, even with uncomplicated postoperative period accompanied by a sharp deformation of the spine in the long term.

Thus, from the modern point of view, the most desirable end result of the treatment of pleural empyema is persistent elimination of the empyema cavity as a result of the formation of limited pleurodesis (fibrothorax), which does not impair the function of external respiration. An unfavorable outcome of the disease is the formation of chronic pleural empyema, since its elimination is impossible without a highly traumatic, sometimes multi-stage operation, the results of which are rarely good.

Patient management after discharge from the hospital is carried out in the following areas:

• correction of the work schedule and lifestyle;
• to give up smoking;
• good nutrition;
• prevention of respiratory disorders;
• remedial physical education, including breathing exercises;
• bronchodilators, mucolytics;
• spa treatment.

Medical and social expertise... The terms of temporary disability can reach 2-4 months, and in the case of surgical treatment - 4-6 months. The criterion for the discharge of the patient from the hospital is the achievement of clinical recovery, and in the case of chronicity of the process, the achievement of clinical and radiological remission. The patient is contraindicated in the types of work associated with working in a dusty and gas-polluted room, with staying in unfavorable meteorological conditions (a sharp change in temperature, high humidity), with significant physical stress. With accessible types and conditions of work, patients are able to work. If necessary, after discharge, the patient must be transferred to "light work" through the clinical expert commission, or it is necessary to change the nature of the work.

Patients with suppurative diseases of the lungs and pleura can be recognized as disabled due to the severity of clinical manifestations (intoxication) and the narrowing of the range of available professions. In chronic pleural empyema, the II disability group is established. Patients who underwent surgery on the lungs are transferred to disability. After lobectomy surgery, any disability group can be established, depending on the degree of pulmonary insufficiency (or, in some situations, employment through a clinical expert commission without switching to disability is possible). After pleurectomy and decortication operations, patients are transferred to the III or II group of disability for a period of 1 year with subsequent re-examination (depending on the degree of pulmonary insufficiency). After pneumonectomy surgery, II and even I group of disability is established.