Empyema thoracis

Parapneumonic effusion and empyema thoracis remains a significant source of morbidity in children, though the overall incidence of empyema thoracis has decreased in the past two decades. These conditions pose a dilemma regarding evaluation and treatment for the treating physician. This article discusses the practical strategies in the management of empyema thoracis in children.     

EMPYEMA IN CHILDREN IN TROPICS

ABSTRACT. Thirty-six cases of empyema were diagnosed in children over a two year period, giving an overall incidence of 0.11 % of the total hospital admissions. Many of them had measles bronchopneumonia and most were malnourished. 16 children had penicillin resistant staphylococcal infection. 29 of them were treated with closed tube drainage. Thirteen died during the course of treatment, the majority within three days of admission. The rest were followed up over a period of up to six months and showed good recovery. Six of these patients developed pneumothorax during the course of treatment. Various combinations of Ampicillin, Cloxacillin, Gentamycin and Cotrimoxazole parenterally were used. Supportive treatment with blood transfusion was found to be beneficial.     

双侧局限性结核性脓胸I期手术临床疗效分析

目的 探讨Ⅰ期双侧局限性结核性脓胸胸膜剥脱术的安全性及临床疗效。方法 回顾性选取2012—2017年间我院收治的符合手术指征的双侧结核性脓胸150例,分为一期手术组（简称“一期组”）和分期手术组（简称“分期组”）各75例,并顺利施行胸膜剥脱术。回顾性分析两组间在术中出血量、术后引流量、左右侧拔管时间、术后住院时间、患者焦虑状况及住院费用方面的差异。分析一期组和分期组患者术前、术后3个月肺功能指标的差异,包括用力肺活量forced vital capacity（FVC）、第一秒用力呼气容积forced expiratory volume in the first second（FEV₁）、最大呼气峰流速peak expiratory flow rate（PEF）、最大通气量maximal voluntary ventilation（MVV）。肺功能测定结果均按“测定值/正常预计值×100%”表示,所获得计量资料以“ x ±s”表示,统计学处理采用t检验,以P<0.05为差异有统计学意义。结果 一期组的术中出血量为（728.2±159.4) mL、术后3 d引流量为（1 312.3±62.7） mL、左右侧拔管时间为（6.4±1.5） d、（6.5±1.5） d,与分期组的（731.3±151.0） mL、（1 293.7±60.5） mL、（6.3±1.5） d、（6.3±1.7） d比较,差异无统计学意义（P>0.05）。一期组的术后哌替啶用量（15.3±1.2) mg、状态焦虑评分（40.5±2.0)、术后住院时间（11.1±1.9) d、手术及术后总费用（24 351.3±1 254.3) 元与分期组为（20.2±1.5) mg、（44.6±2.3)、（17.7±1.3) d、（30 446.2±1 406.9） 元比较, 差异均具有统计学意义（P<0.05）。75例一期手术组中,术前、术后3个月肺功能检测指标比较,包括FVC分别为（71.40±3.70）%、（91.20±4.60）%、FEV₁分别为（63.20±2.40）%、（84.80±2.60）%、PEF分别为（64.00±2.60）%、（72.40±2.70）%、MVV分别为（62.10±3.70）%、（ 84.70±4.70）%,差异均有统计学意义（P<0.05）。结论 双侧局限性结核性脓胸行一期手术,安全有效,一期组患者的术后哌替啶用量、状态焦虑评分、住院时间及费用优于分期组。     

胸膜腔内注入尿激酶对复杂性肺炎旁胸腔积液和脓胸的治疗

目的 :观察胸膜腔内注入尿激酶 (UK)对复杂性肺炎旁胸腔积液 (CPE)和脓胸 (PE)治疗效果的影响。方法 :将 35例收治的肺炎旁胸腔积液和脓胸患者随机分成两组 ,治疗组 19例 ,对照组 16例。治疗组于胸腔引流后将溶解于 10 0mlNS中的尿激酶 10 0 0 0 0U注入胸膜腔内 ,每日 1次 ,共 3d。对照组于胸腔引流后直接注入NS 10 0ml,每日 1次 ,共 3d。同时两组均给予抗生素治疗。结果 :治疗组治疗前 3d的胸水引流量为 (970± 75 )ml,对照组为 (2 80± 5 5 )ml(P <0 .0 1)。治疗组体温下降 ,胸片明显进步 ,住院天数减少 (治疗组 13.2± 1.4d ,对照组 18.6± 2 .5d) (P <0 .0 1)。结论 :胸膜腔内注入尿激酶短期内能显著增加胸腔积液的引流量 ,缩短患者的胸腔引流天数 ,减少患者的发热和住院天数 ,X线胸片明显好转 ,明显提高治愈率 ,与对照组相比有显著差异。     

Pediatric empyema--an algorithm for early thoracoscopic intervention.

INTRODUCTION: The management of pediatric empyema remains controversial. We contend that early thoracoscopic intervention results in shorter hospital stays, decreased morbidity, and superior outcomes. We propose an algorithm using early image-guided thoracoscopy as an effective treatment for pediatric empyema. METHODS: Consecutive pediatric empyemas treated from November 1997 to April 2001 using a prospective management algorithm were reviewed. Demographic data, days to diagnosis, days to surgery, length of stay, chest tube days, complications, and follow-up were recorded. RESULTS: Twenty-two children with 24 empyemas were treated using this algorithm. Their mean age was 49 months. Mean days to diagnosis was 11 and from diagnosis to surgery was 3. Imaging included chest radiography (CXR) in all, ultrasound in 17 (77%), and computed tomography (CT) scan in 13 (59%). One thoracoscopy was converted to a mini-thoracotomy because of difficulty with ventilation. Chest tube removal averaged 3 days with an average length of stay of 13 days. One patient required a second thoracoscopy for recurrent empyema, and 1 patient developed a contralateral empyema. No other complications or deaths occurred. Follow-up in 19 of 22 (86%) children at 5 months revealed no recurrences or mortality. CONCLUSION: This treatment algorithm, using early image-guided thoracoscopy, is a safe and effective means of managing pediatric empyema, while shortening hospital stay and avoiding the morbidity of thoracotomy.     

Local treatment of empyema in children: a systematic review of randomized controlled trials

The aim of the study is to systematically evaluate data from randomized controlled trials (RCTs) on the efficacy of using intrapleural fibrinolytic agents in the treatment of complicated parapneumonic effusions or empyema in children. The Cochrane Library, MEDLINE and EMBASE databases were searched in July 2009. Four RCTs, involving 194 children, were included. In two RCTs, intrapleural fibrinolytic treatment was compared with normal saline. One of these RCTs showed a significantly reduced hospital stay in those treated with urokinase compared with those treated with normal saline. Otherwise, no fibrinolytic agent had an effect on any other outcome. Two RCTs that compared fibrinolytic treatment with video‐assisted thoracoscopic surgery (VATS) revealed no benefit of VATS. Conclusion: There is little evidence that intrapleural fibrinolysis is more effective than normal saline in the local treatment of complicated parapneumonic effusions or empyema in children. There is no evidence that VATS is more effective than fibrinolytic treatment. Only a limited number of trials were available for analysis, so some caution must be exercised in interpreting the strength of the evidence presented.     

Conjoint muscle free flap for obliteration of an upper thoracic empyema cavity

Successful obliteration of an empyema cavity with vascularized flaps can, on occasion, best be accomplished using a free tissue transfer. A conjoint free muscle flap captures the immunological attributes of muscle necessary in the infectious milieu of these defects, augments the potential flap volume required to fill these often large defects, yet relies on only a single recipient site for the requisite microanastomoses. These advantages are demonstrated by a case using a combined latissimus dorsi/serratus anterior conjoint muscle free flap to obliterate a chronic upper thoracic empyema cavity. The internal mammary vessels were the most readily accessible recipient site, and should be considered an important alternative when managing these challenging wounds of the upper chest.     

Laparoscopic cholecystectomy in patients with empyematous cholecystitis: an outcome analysis

Background  

Laparoscopic cholecystectomy (LC), the procedure of choice for elective cholelithiasis, is now also used in the management of acute cholecystitis. Empyema of the gallbladder is unexpectedly encountered in a proportion of these patients. This paper describes our experience with LC in the treatment of patients with empyema of the gallbladder.     

电视胸腔镜脓胸廓清术治疗结核性脓胸

目的探讨电视胸腔镜脓胸廓清术治疗结核性脓胸的疗效。方法 2004年1月～2011年6月对82例早期结核性脓胸(病史2周～2个月,处于渗出期和纤维机化早期)行电视胸腔镜脓胸廓清术,在胸腔镜下分离粘连,清理脓苔,刮除脏、壁层胸膜上干酪样物、坏死和肉芽组织,剥除增厚的纤维板,术中反复冲洗,术后充分引流、注药,同时全身抗结核治疗。结果 82例电视胸腔镜脓胸廓清术均顺利完成,术后5～7 d顺利拔管。术后1个月复查CT示脓腔消失,肺脏膨胀良好;术后1个月痰查结核菌无阴转阳者,术前阳性2例分别于术后1、3个月转阴。术后1个月用力肺活量、第1秒用力肺活量、肺总量与术前相比明显改善(P<0.05)。结论电视胸腔镜脓胸廓清术治疗纤维素期和纤维机化早期的结核性脓胸是安全、有效的方法。