Imp. Empyema thoracis with pneumothorax Lt.

Transcription

1 Present illness On ICD : pus 200 ml. + air Imp. Empyema thoracis with pneumothorax Lt. จ งrefer จงrefer รพ. จ งหว ด จงหวด

2 Present illness รพ. จ งหว ด CBC : Hb 9.5 g/dl, Hct 27 % WBC 10,400 cells/mm 3 (N 83%,L 13%,M 4%) Platelet 413,000 cells/mm 3 UA : spec prot 2+,RBC 10-20/HPF, WBC 2-3/HPF BUN 35 Cr 1.8 ESR 81 mm/hr

3 Present illness Ceftriaxone x 3 days ไม ด ข น ย งม ไข ตลอด เปล ยนยาเป น Amoxicillin/clavulanate + Metronidazole?

4 Causative bacteriology of empyema Aerobic bacteria Staphylococcus aureus Streptococcus pneumoniae Streptococcus pyogenes Haemophilus influenzae type b Escherichia coli Klebsiella species Pseudomonas aeruginosa

5 Causative bacteriology of empyema Anaerobic bacteria Microaerophilic streptococci Fusobacterium nucleatum Bacteroides melaninogenicus Bacteroides fragilis Peptococcus Peptostreptococcus Catalase-negative, non-spore-forming, gram-positive bacilli

6 A guide to antimicrobial therapy for parapneumonic effusion and empyema Infecting agent A. Aerobic bacteria Drug and dosage (/kg/day) route and duration 1. Staphylococci a. Cloxacillin mg, divided in 3-6 doses, IV initially, for 3-4 weeks b. Clindamycin mg/kg, divided in 3-4 doses 2. Haemophilus influenzae a. Cefotaxime 200 mg/kg, g, max 8 g/day divided in 4 doses or b. Ceftriaxone mg/kg divided in 1-2 doses or c. Chloramphenicol mg/kg divided in 4 doses 3. Pneumococcus and Penicillin G 250, , U/kg divided in 4-6 doses streptococci 4. Escherichia coli and Klebsiella Cefotaxime same as A.2.a. 5. Pseudomonas aeruginosa a. Ticarcillin mg/kg divided in 4-6 doses or b. Ceftazidime mg/kg maximum 6 g/day divided in 3 doses with c. Tobramycin 5-7 mg/kg divided in 3 doses B. Anaerobic bacteria 1. Bacteroides fragilis Clindamycin mg/kg, divided in 3-4 doses 2. All except B. fragilis a. Same as B.1 or Penicillin G same as A.3.

7 A guide to antimicrobial therapy for parapneumoniceffusion i and empyema IV antibiotic should be used until the constitutional symptoms have resolved for several days/ able to off ICD Total duration of antibiotics: 3-6 weeks Depend on clinical condition of patients, not abnormal chest x-ray findings

8 Present illness Amoxicillin/clavulanate x 6 days + Metronidazole x 8 days clinical improve ไข ลดลงด ไม หอบเหน อย ผล pleural fluid C/S : No growth Hemoculture : No growth On ICD x 9 days Off ICD, F/U CXR หล ง หลง off ICD ไม ม pneumothorax, pleural effusion จ ง D/C และผ ป วยมาตรวจตามน ดโรคไตท ร.พ. หล งกล บบ านได 5 ว น วน

9 Physical examination ตรวจร างกายแรกร บ Vital signs BT 36.7 ºC PR 80 bpm RR 22 /min BP 130/90 mmhg Measurement Height cm (P 3 rd ) Weight 41 kg (P 10 th )

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11 Physical examination GA: A Thai girl, good consciousness, no dyspnea, moon face HEENT: mildly pale, no jaundice, pharynx and tonsils not injected Neck: no lymphadenopathy

12 Physical examination Chest: subcutaneous emphysema entire ant. and lat., decreased BS at LLL, hyperresonance on percussion Lt. lung CVS: pulse full and regular, normal S1 S2, no murmur

13 Physical examination Abdomen: soft, no hepatosplenomegaly Extremities: no pitting edema, capillary refill 2 second, no clubbing Neuro : intact

14 Laboratory investigation CBC : Hb 10.9 g/dl, Hct 32 % WBC 15,200 cells/mm 3 (N 84%,L 11%,M 5%) Platelet 392,000 cells/mm 3 ESR: 48 mm/hr. UA: ph 7, sp.gr , protein 3+, sugar normal, WBC 1-2 /HPF, RBC 3-5 /HPF BUN : 29 Cr 0.9

15 Laboratory investigation

16 Laboratory investigation

17 Diagnosis? Loculated pleural effusion

18 Bacteria Fungus Virus & Others Immunosuppress S.aureus, Aspergillus spp. CMV, VZV, ive therapy Listeria Mucor spp. toxoplasma (renal, liver, lung spp. Histoplasmosis i spp. transplant) M.tubercu spp. HSV losis s Cryptococcus Nocardia spp. PCP

19 Determine pleural fluid volume Differentiate loculated pleural fluid from free pleural fluid Identify the best site for thoracentesis/ t intercostal drainage Differentiate pleural thickening from effusion

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21 Management Oxygen cannula 3 LPM Start Cefotaxime IV Set pleural tapping under ultrasound guide Finding: Pus 80 ml.

22 Differentiate pleural pathology and parenchymal a pathology ogy MRI: no advantage over CT in evaluation of pleural diseases

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24 CT chest : fibrosis with pneumatocele, loculated hydropneumothorax at LLL

25 Laboratory investigation Pleural l tapping Pus 80 ml. RBC 0, WBC 402,300 cells/mm 3 (PMN 99%, Mono 1%) Sp.gr protein 4.5 g/dl (serum protein 8.3 g/dl) LDH >10,000 (serum LDH 290) Sugar 7 mg/dl (blood sugar 102 mg/dl) G/S and AFB : not seen organism

26 Modified AFB Beaded branching filaments

27 Laboratory investigation Pleural fluid culture : Nocardia spp.

28 Management

29 Nocardiosis Immunocompetent t children: cutaneous/lymphocutaneous disease Immunocompromised patients: t CGD, organ transplantation, HIV, long-term corticosteroid therapy: have invasive disease Infection begins in the lung: acute, subacute or chronic Aerobic gram-positive bacteria Beaded, d branched, weakly gram positive, variably acid fast rods

30 Nocardiosis Treatment: trimethoprim-sulfamethoxazole Duration of treatment: 6-12 months or at least 3 months after apparent cure IF not respond to trimethoprim- sulfamethoxazole : clarithromycin, amoxicillin- calvulanate, imipenem or meropenem may be beneficial

31 18ก.ย. 19ก.ย. 20 ก.ย. 21 ก.ย. 22 ก.ย. 23 ก.ย. 24 ก.ย Pleural tapping CT Cefotaxime iv Cotrimoxazole12 MKD X6 months ICD Hb WBC 15,200 26,500 N84L11 N73 L13M6 Plt 392, ,000

32 Indication Complicated pleural effusion Empyema thoracis Massive pleural effusion Once constitutional symptoms have improved and chest drainage < 30 ml/day, chest tube should be removed

33 18ก.ย. 19ก.ย. 20 ก.ย. 21 ก.ย. 22 ก.ย. 23 ก.ย. 24 ก.ย Pleural tapping CT Cefotaxime iv Cotrimoxazole12 MKD X6 months ICD X 9 days Hb WBC 15,200 26,500 N84L11 N73 L13M6 Plt 392, ,000

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35 Intrapleural fibrinolytic enzyme Streptokinase or urokinase Age < 1 year 10,000 units in 10 ml NSS instilled chest tube Age > 1 year 40,000 units in 40 ml NSS instilled chest tube twice daily with 4 hour dwell time for 3 days

36 Surgical treatment Video-assisted thoaracoscopic surgery (VATS) Indication: Complicated parapneumonic effusion Thoracotomy and decortication Indication: Organized empyema with uncontrolled infection

37 Prognosis Good prognosis Mortality rate 6-12 % 60-83% of patients: CXR normal in 3 months > 90% of patients: CXR normal in 6 months PFT : restrictive/obstructive e/obst e disease, no symptoms with normal exercise tolerance