Empyema:
Empyema is accumulation of thick pus in the pleural cavity. Primary infection of pleura does not arise so the pathology may either be in chest wall, mediastinum or the lungs which needs to be traced out. It is fairly common in infants.
Etiology
The common causative organisms are staphylococcus. Pneumococcus, streptococcus and H. influenzae. It may also occur due to repture or lung abscess or subphrenic abscess into the pleural space or extension of infection from mediastinum or osteomyelitis of the rib, infection during cardiothoracic surgery or penetrating injuries of chest.
Assessment
Clinical features resemble pneumonia and include fever with chills, dyspnoea, cough with sputum, chest pain and pleuritic pain which may be referred to abdomen and toxemia. In case,of severe respiratory distress child may be cyanotic. In later stage child may develop clubbing, anaemia and other manifestation of malnutrition. Chest signs include diminished movements of the affected side, widening and fullness or intercostal spaces, dull percussion note, diminished air entry and mediastinal shift to the opposite side.
Empyema may involve whole pleural space i.e. total empyema or only a part of it called as loculated or encysted empyema.
Diagnostic evaluation include X-ray chest showing diffuse density suggestive of pleural fluid. In most of the cases the opacities are basal and costophrenic angle is obliterated. Pleural tap is done to examine the pleural fluid biochemically and bacteriologically. If this shows, streptococcus, staphylococcus or pneumococcus, then empyema is due to complication of bacterial pneumonia. In aspiration pneumonia there will be mixed flora. Presence of E.coli in the pus shows repture of subphrenic abscess. Blood examination shows polymorphonuclear leukoyctosis with raised total count.
Management
Antibiotics are administrered as prescribed as soon as the diagnosis has been made. In such cases, closed chest drainage is indicated. If patient has fever, antipyretic drugs may be given and accurate temperature record should be maintained. Adequate fluid intake and high protein and high calorie diet must be given to the patient. If needed, blood transfusion is also given.
Thoracatomy or surgical drainage after rib resection is indicated if the patient continuesto have severe respiratory distress and when there is no improvement after 3 weeks of thereapy.