Pleural empyema from the point of view of a thoracic surgeon

Abstract

Background. Pleural empyema (PE) is the presence of pus in the pleural cavity. The causes of PE include the diseases of adjacent organs (75 %), direct contamination of the pleural cavity during injuries or operations (20 %), and hematogenous dissemination of infection (5 %).
 Objective. To describe the modern views on the treatment of EP.
 Materials and methods. Analysis of literature sources on this topic.
 Results and discussion. Radiography, computed tomography, and ultrasound can be used to diagnose PE. To detect PE, radiography should always be performed in two projections, paying special attention to the posterior sinus and the space above the diaphragm. Computed tomography shows pleural layers’ separation and a “pregnant woman” symptom. Ultrasound can distinguish fluid, pleural thickening and pulmonary infiltration, as well as determine the optimal point for puncture. The ultimate goals of PE treatment include the obliteration of the pleural cavity or creating conditions for the formation of a sterile residual cavity. In case of acute PE, drainage, washing, and antibiotic therapy are applied; correction of concomitant diseases is carried out. Drainage of the pleural cavity should be preceded by a puncture of the pleural cavity to obtain pathological contents. The appearance and odor of the fluid obtained by puncture are the most important indicators of the pathology. Drainage can be performed at the point where the pus was obtained, or in the VII-VIII hypochondrium along the posterior axillary line. Drains from polyvinylchloride with a diameter of 6-8 mm are applied. The length depends on the task. Videothoracoscopy is a modern method of treating PE. This method is minimally invasive, removes fibrin and pus, destroys adhesions, connects cavities and provides drainage at the optimal point. To wash the pleural cavity, it is advisable to use decamethoxine or povidone-iodine. With regard to antibiotic therapy, levofloxacin or third-generation cephalosporins are used in combination with an antianaerobic drug, or carbapenems or glycopeptides.
 Conclusions. 1. PE is often a secondary infectious process caused by adjacent structures’ infection. 2. Pleural cavity sanitation during videothoracoscopy and drainage are the main methods of PE treatment. 3. Antibiotic therapy and pleural lavage are integral components of PE treatment.