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.