chronic empyema
Introduction
Introduction to chronic empyema The course of acute empyema is more than 6 weeks. The cellulose in the pus deposits in the viscera, the parietal pleura, and gradually thickens, forming a thick fibrous plate, so that the lung can not expand, the abscess can not shrink, leading to chronic pus The opening of the chest, over time, thickening of the fibrous layer due to scar tissue contraction can lead to thoracic spinal deformity, mediastinal shift and respiratory dysfunction. basic knowledge The proportion of illness: 0.005% Susceptible people: no special people Mode of infection: non-infectious Complications: respiratory failure, arrhythmia, malignant tumor, swelling, abscess
Cause
Chronic empyema cause
Acute empyema treatment is not timely 35%):
During the acute empyema, the selection of antibiotics is not appropriate, or the dosage is not adjusted in time and the sensitive antibiotics are replaced during the treatment. The formation of pus is still more. If the position of the drainage tube is high or low, the depth is not suitable and the diameter is too thin. Or the drainage tube is distorted and blocked, and the drainage is not smooth, and all forms chronic empyema.
Thoracic foreign body residue (22%):
If there is a foreign body, such as metal fragments, bone fragments, broken clothes, etc., remaining in the chest cavity after trauma, or foreign matter remains after surgery, the empyema is difficult to heal, even if the circulation is smooth, the pathogen can not be removed due to the residual foreign matter. The source cannot be cured.
Other disease factors (20%):
If empyema is secondary to lung abscess, bronchospasm, esophageal fistula, liver abscess, underarm abscess, spinal osteomyelitis and other diseases, before the primary lesion is not cured, empyema is also difficult to cure, forming a chronic empyema.
Specific infection (15%):
Tuberculous infection, fungal infection, and amoebic empyema are all likely to form chronic empyema.
Pathogenesis
Chronic empyema is characterized by thickening of the pleura, a large amount of cellulose deposited on the surface of the pleura. With the invasion of fibroblasts and vascular endothelial cells, the cellulose layer is gradually thickened, mechanized and calcified, up to several centimeters thick, visceral pleura Tightly wrapped in the lungs, seriously affecting the respiratory movement of the lungs, the thoracic cage is also thickened by the parietal pleura, the contraction of the fibrous scar tissue is invaginated, the ribs are gathered, the intercostal space is narrowed, the scoliosis is curved, the mediastinum is pulled to the affected side, and the diaphragm is fixed. , thus severely restricting respiratory function, long-term lung atrophy can cause bronchial deformation, poor drainage, secondary infection can be complicated by bronchiectasis and pulmonary fibrosis, loss of re-expansion ability and gas exchange capacity, leading to respiratory dysfunction and hypoxia, pus The chest may also invade adjacent lung tissue, producing bronchopleural fistula or esophageal pleural sputum. When a large amount of pus enters the bronchi, the patient may suffocate and die. Long-term chronic infection, liver, spleen, kidney and other organs may undergo amyloidosis. It is characterized by hepatosplenomegaly, liver and kidney failure, and sometimes clubbing (toe).
Prevention
Chronic empyema prevention
Empyema, especially chronic empyema, is a consumptive disease, so it should be highly valued for supportive treatment, giving high-energy diet, supplementing lost protein, maintaining water, electrolytes, acid-base balance, small amount of intermittent blood transfusion or plasma, etc. In order to be important, we should actively use bronchial antispasmodic drugs to benefit from phlegm and Chinese medicine treatment, and actively treat the primary disease.
Complication
Chronic empyema complications Complications, respiratory failure, arrhythmia, malignant tumor, swelling, abscess
Common complications of chronic chest disease are:
(1) Respiratory failure and arrhythmia
Fibrous exfoliation is becoming the preferred procedure for all types of empyema, but there is also a risk of complications, which may be due to the fact that this procedure can greatly improve lung function, thus selecting patients with low pulmonary function for restrictive ventilation disorders. Relaxation, if the preoperative assessment of pulmonary pathological lesions is insufficient, it is easy to cause respiratory failure. Reasonable surgical selection has an important role in preventing postoperative respiratory failure and avoiding perioperative death. In addition, if the thoracic surgery is used, the ribs are removed too much. There is a risk of post-operative respiration after pleural puncture; contralateral lung infection after pleural pneumonectomy, preoperative low lung function, if the patient has a history of old pleurisy on the contralateral side, it is easy to cause diaphragmatic activity to cause respiratory failure, so early identification is necessary. , such as extensive wheezing in the lungs, respiratory rate > 30 times öm in, with assisted breathing exercise, PaO 2 < 60mmHg or PaCO 2 > 60mmHg, and early symptoms of pulmonary encephalopathy, early tracheotomy, assisted breathing, surgery Post-arrhythmia In addition to the original heart disease, hypoxemia is the main cause.
(2) intraoperative and postoperative bleeding
Due to the wide range of empyema, and often combined with more complicated intrapulmonary lesions, the surgical stripping surface is wide, which is easy to cause intraoperative and postoperative hemorrhage. Some experts pointed out that the most vulnerable lesions are emphysema except for chest wall oozing. For the subclavian arteriovenous and superior vena cava, this group of intraoperative major hemorrhage occurs in the above blood vessels, so to avoid damage to the blood vessels in addition to familiar anatomical relationship, careful exfoliation, surgical procedures are very important, to use the longitudinal medial surface adhesion is loose Features, combined with a small vascular area, easy to post difficult, Xu Xu deep, where the difficulty of stripping is mostly intrapulmonary lesions or abscesses, should be isolated first, then sharply separate superficial cheese stove, abscess, cavity, in the pleura In pneumonectomy, the pulmonary vascular penetrating suspension method is safe and reliable in practice. The key to prevent postoperative bleeding is to stop bleeding carefully during the operation, and the pulmonary vessels are reliably ligated, and the intercostal vascular suture is not neglected. It is not possible to completely stop bleeding because of pressure bandaging, and the examination of coagulation function before surgery is also crucial.
(3) self-destructive empyema
The disease is a common complication of tuberculous empyema. The wall pleural rupture of tuberculous empyema, spontaneous discharge of its contents, can enter many parts, the most common is the subcutaneous tissue of the chest wall, CT can simultaneously show lesions inside and outside the chest, Both are thick-walled enveloped effusions and can show enthalpy between the two.
(4) pleural malignancy
Complicated pleural malignant tumor is relatively rare, although its pathogenesis is unknown, but chronic inflammation is the most important factor, its pathological type is more, the diagnosis is relatively difficult, such as the following signs can suggest this complication: 1 increased chest density; 2 chest wall soft tissue swelling, fat line blurred, or both; 3 bone destruction near the empyema; 4 calcified pleural extensive internal movement; 5 new empyema plane in the cavity of the empyema, CT examination should be performed at this time It can be found that there is soft tissue density around the empyema, and the enhanced scan is enhanced. The diagnosis of pleural tumor and self-destructive empyema should be noted in the diagnosis. The tumor often has necrosis or degenerative cystic change, but the CT value can be compared with empyema. Similarly, it is important to find the shape of the soft tissue mass, the thickness of the wall is irregular and the soft tissue density in the cavity is convex, which may indicate pleural malignancy. Sometimes CT is difficult to make a clear diagnosis of pleural malignancy, but it can provide biopsy. Part.
(5) In addition to the above complications, residual empyema after chronic empyema, stump fistula after pleural pneumonectomy, intractable sinus, etc. have also been reported.
Symptom
Chronic empyema symptoms Common symptoms Thin stools, fatigue, scoliosis, abscess, intercostal space, narrowing, low fever
The diagnosis of chronic empyema is not difficult. Patients have a history of acute empyema and a process of chronic empyema. However, it is necessary to find out the general and local conditions of the patient and the cause of chronic empyema. Patients often have weight loss. Anemia, decreased plasma protein, and varying degrees of chronic systemic poisoning symptoms, such as low fever, fatigue, poor appetite, etc. Chronic empyema patients due to long-term chronic infection, liver, kidney, splenomegaly, renal dysfunction, part of empyema can invade the lungs , the formation of bronchopleural palsy, can also directly penetrate the pleura to invade, through the intercostal space, form a dumbbell-shaped abscess, and even penetrate the skin to form pleural skin fistula, there are bronchopleural fistula, cough a lot of purulent, and body position 3 related, when combined with skin sputum, there is pus overflow from the fistula, the body can be seen in the affected side of the chest wall subsidence, thoracic respiratory mobility is limited, the intercostal space is narrowed, some patients have scoliosis, chest percussion is a real sound, auscultation Reduced or disappeared breath sounds, mediastinal shift, scoliosis and clubbing (toe).
Chronic empyema due to long-term empyema, a large amount of cellulose deposition and gradually mechanized, can form 2cm thick, even thicker fiberboard, so the chest wall is invaginated, the ribs gather, the rib space narrows, the rib itself changes in a triangle, the spine direction The lateral side curve and the diaphragm are also fixed due to the limitation of the thickened pleural fiberboard. Therefore, the respiratory movement is greatly affected and severely weakened. At the same time, due to the contraction of the fiberboard, the mediastinum is pulled to the affected side, affecting patients with blood circulation. A clubbing (toe) occurs due to chronic hypoxia.
According to the history, clinical manifestations and imaging signs, the diagnosis of chronic empyema is not difficult, but it is important to analyze and examine the clinical data, and further to determine the cause and pathological properties of chronic empyema, in order to facilitate thorough treatment.
Examine
Chronic empyema examination
(1) X-ray: the pleural thickening of the affected side, the narrow intercostal space, the increased density of the large piece of the hair, the shifting of the mediastinum to the affected side, the increase of the transverse sputum, the high-voltage piece or the body slice can show the hypertrophic pleura. The situation of the abscess and lung tissue, if there is a liquid level, indicates that there is a lung leak, or there is still bronchopleural sputum, combined with the positive lateral chest radiograph to determine the size and location of the abscess, when there is liquid level, the application The horizontal position of the lateral position can show the position of the bottom of the abscess. The abscess can show the location of the abscess, the size and the presence or absence of broncho-pleural sputum. The chest CT and MRI can help to determine whether there are other lesions in the chest. .
(2) CT examination: can further clarify whether the lung tissue has lesions, such as tuberculosis, bronchiectasis, cysts or abscesses, which is of great help to the development of surgical plans. If there are intrapulmonary lesions, it is often necessary to perform thoracotomy and lobectomy or even pneumonectomy. Or add thoraplasty.
(3) B-mode ultrasound examination: in the liquid darkness of pleural effusion, because there are many cellular components in the liquid, often accumulate with each other to form flocs, so the sound image shows strong and weak, the division is not All of the small echoes, and a slight floating phenomenon, such as the patient quickly moving the body, see the liquid fairy echo floating enhancement, and even tumbling up and down, very easy to identify.
(4) The difference between the empyema and the simple pleural hypertrophy is that there is no echo in the liquid dark area after the gain is increased, and the echo in the pleural hypertrophy area is enhanced, showing the characteristics of substantial tissue.
(5) Chronic empyema if there is no thoracic or closed thoracic drainage, chest should be worn, thoracic puncture is very helpful for diagnosis, pleural effusion is purulent effusion, pus cells are more; pleural fluid culture has pathogens It is found that the culture should include both aerobic and anaerobic conditions; if the normal culture is sterile, it needs to be cultured by Mycobacterium tuberculosis, and the pneumococcal empyema secondary to pneumonia is mostly yellow or yellowish green and thick. Streptococcal empyema, its pus is thin and pale yellow; Staphylococcus aureus empyema, pus thick and yellow; Pseudomonas aeruginosa empyema, pus is pale green; E. coli, feces Alcaligenes empyema, pus often with fecal odor; anaerobic streptococci, Clostridium, spirochete spastic empyema, pus often have a strong stench of foul smell; such as gas-producing bacteria Sexual empyema, the formation of pus pneumothorax, highly suspected bronchopleural fistula, can be injected into the abscess of 1% methylene blue 2ml after pumping, observe the cough of sputum, such as sputum is blue, which proves the bronchi The presence of pleural palsy.
Blood routine: positive cells are pigmented anemia, the total number of white blood cells is slightly high, hypoproteinemia, neutrophils are elevated, and patients with advanced disease often have liver and kidney dysfunction due to amyloidosis of the liver and kidney.
Diagnosis
Diagnosis of chronic empyema
The diagnosis of chronic empyema is not difficult. Patients have a history of acute empyema and a process of chronic empyema. However, it is necessary to find out the general and local conditions of the patient and the cause of chronic empyema. Patients often have weight loss. Anemia, plasma protein reduction, and varying degrees of chronic systemic symptoms, such as low fever, fatigue, poor appetite, etc., the body can see the chest wall subsidence of the affected side, thoracic respiratory mobility is limited, the intercostal space is narrowed, and some patients have scoliosis The chest is diagnosed with a real sound, and the auscultation of the breath sound is reduced or disappeared.
Chest X-ray showed thickening of the affected side of the pleura, narrowing of the intercostal space, mediastinal shift to the affected side, and the chest cavity became smaller. If there is metal foreign body or calcification, it can be clearly shown. If there is a gas-liquid plane, it means that there is bronchopleural fistula or esophagus., when the abscess is small or only the sinus is present, the iodized oil can be injected and the positive lateral slice can be injected to show the extent of the abscess and the presence or absence of bronchopleural palsy; or the contrast agent can be observed through the oral iodine oil to see if there is any contrast agent entering the chest cavity. It can be confirmed whether there is no esophageal fistula and the location and size of the fistula. If there is suspected bronchiectasis, bronchography should be performed.
