Empyema

EMPYEMA VS CHYLOTHORAX
EMPYEMA CHYLOTHORAX
CHYLE ACCUMULATES IN THE PLEURAL

DEFINITION PUS IN THE PLEURAL SPACE
SPACE
BACTERIAL PNEUMONIA
TRAUMA
CAUSES LUNG ABSCESS
TUMORS OF THE MEDIASTINUM
BRONCHIECTASIS
AEROBIC: FEVER, SPUTUM

PRODUCTION, CHEST PAIN,
LEUKOCYTOSIS DYSPNEA
PRESENTATION
LARGE PLEURAL EFFUSION
ANAEROBIC: WEIGHT LOSS, BRISK
LEUKOCYTOSIS, MILD ANEMIA
GROSS PURULENT PLEURAL

FLUID ANALYSIS MILKY FLUID
EFFUSION
POSITIVE BACTERIAL CULTURES INC TRIGLY >1.2 MMOL/L OR 110 MG/DL
TREATMENT OF CHOICE CTT CTT
LIGATION OF THE THORACIC DUCT

FIBRONOLYTIC AGENT
PERCUTANEOUS TRANSABDOMINAL
DEOXYRIBOSE
THORACIC DUCT BLOCKAGE
INDICATIONS FOR CTT INSERTION
• Loculated pleural fluid
• Pleural fluid pH <7.20
• Pleural fluid glucose <3.3 mmol/L (<60 mg/dL)
• Positive Gram stain or culture of the pleural fluid
• Presence of gross pus in the pleural space

TYPES OF
RESPIRATORY
FAILURE
I. TYPE I RESPIRATORY FAILURE
 Acute hypoxemic respiratory failure (generally PO <55-60 mmHg)

2
 Usually from alveolar flooding and subsequent intrapulmonary

shunting
 Alveolar flooding may be a consequence of:
o Pulmonary edema (cardiogenic or non-cardiogenic)
o Pneumonia
o Alveolar hemorrhage
o ARDS (low pressure pulmonary edema)
II. TYPE II RESPIRATORY FAILURE
 Hypercarbic respiratory failure (generally pCO >45-50 mmHg)

2
 Result of alveolar hypoventilation and leads to the inability to

eliminate carbon dioxide effectively
• Diminished CNS drive to breathe
• Reduced strength of neuromuscular function
• Increased overall load on the respiratory system


III. TYPE III RESPIRATORY FAILURE
 This form of respiratory failure occurs as a result of lung

atelectasis
 Also called perioperative respiratory failure: commonly found in

the perioperative period (usually from pain)
IV. TYPE IV RESPIRATORY FAILURE
 Results from hypoperfusion of respiratory muscles in patients in

shock (respiratory muscles normally consume <5% of the total
cardiac output and O delivery)
2
 Patients in shock often experience respiratory distress due to

pulmonary edema (e.g., patients in cardiogenic shock), lactic
acidosis and anemia – up to 40% of CO may be distributed to the
respiratory muscles
GOUT
• Mainstay of treatment during an acute attack is the administration
of anti-inflammatory drugs:
• NSAIDS
• Colchicine
• Glucocorticoids
COLCHICINE
• 0.6 tablet given every 8 hours with subsequent tapering
• 1.2mg tablet followed by 0.6mg in 1hr with subsequent day dosing

depending on response
• Temporarily discontinued promptly at the first sign of loose stools

NSAIDS
• Effective In 90% of patients
• Resolution of s/sx occurs in 5-8 days
• Most effective
• Indomethacin 25-50mg tid
• Naproxen 500mg bid
• Ibuprofen 800mg tid
• Diclofenac 50mg tid
• Celecoxib 800 mg followed by 400mg 12h later then bid

GLUCOCORTICOID
• Intramuscular or oral
• Prednisone 30-50mg as initial dose
• Gradually tapered with the resolution of the attack (effective in

polyarthricular gout)
• Single and few involved joints
• Intraarticular triamcinolone acetonide 20-40mg or

methyprednisolone 25-5-mg
2016 EULAR RECOMMENDATION
• Recommended first‐line options for acute flares
• colchicine (within 12 hours of flare onset) at a loading dose
of 1 mg followed 1 hour later by 0.5 mg on day 1, or
• an NSAID, oral corticosteroid (30–35 mg/d of equivalent
prednisolone for 3–5 days), or articular aspiration and
injection of corticosteroids.
• Prophylaxis is recommended during the first 6 months of
ULT, recommended prophylactic treatment is colchicine, 0.5–
1 mg/d, a dose that should be reduced in patients with renal
impairment
CPG
• Acute Gout
In the absence of contraindications , ie. gastrointestinal ulcers or renal

impairment, the use of colchicine, traditional non-steroidal anti-
inflammatory drugs (NSAIDs), OR selective cyclo-oxygenase 2 (COX-2)
inhibitors is recommended for the treatment of acute gouty arthritis.
Prednisone, initially at 30 mg and rapidly tapered over 6 days, can be

given as alternative if colchicine, traditional NSAIDs or COX-2 inhibitors
are contraindicated or not tolerated by the patient.
DONEC QUIS NUNC
• ULT is indicated in all patients with

• recurrent flares,
• tophi,
• urate arthropathy,
• renal stones
• Initiation of ULT is recommended close to the time of the first diagnosis in patients
• presenting at a young age (<40 years)
• with a very high SU level (>8.0 mg/dl; 480 μmol/l)
• with comorbidities (eg, renal impairment, hypertension, ischemic heart disease, or heart
failure)
• allopurinol is recommended for first‐line ULT, starting at a low dose (100 mg/d) and increasing by
100‐mg increments every 2–4 weeks if required, to reach the uricemia target (<6 mg/dl (360
μmol/l).
• If the SU target cannot be reached by an appropriate dose of allopurinol, allopurinol should be
switched to febuxostat or a uricosuric or combined with a uricosuric.
DONEC QUIS NUNC
Allopurinol should be started at 100 mg/day 2 weeks after the pain

and swelling of gouty arthritis has subsided
The dose is titrated by 50-100 mg/day every 2 to 4 weeks to achieve

serum uric acid < 6 mg/dl
The maximum dose of allopurinol is 300 mg/day.

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EMPYEMA VS CHYLOTHORAX

CHYLE ACCUMULATES IN THE PLEURAL

AEROBIC: FEVER, SPUTUM

GROSS PURULENT PLEURAL

POSITIVE BACTERIAL CULTURES INC TRIGLY >1.2 MMOL/L OR 110 MG/DL

TREATMENT OF CHOICE CTT CTT

LIGATION OF THE THORACIC DUCT

• Loculated pleural fluid

• Pleural fluid pH <7.20

• Pleural fluid glucose <3.3 mmol/L (<60 mg/dL)

• Positive Gram stain or culture of the pleural fluid

• Presence of gross pus in the pleural space

 Acute hypoxemic respiratory failure (generally PO <55-60 mmHg)

 Usually from alveolar flooding and subsequent intrapulmonary

 Alveolar flooding may be a consequence of:

o Pulmonary edema (cardiogenic or non-cardiogenic)

 Hypercarbic respiratory failure (generally pCO >45-50 mmHg)

 Result of alveolar hypoventilation and leads to the inability to

• Diminished CNS drive to breathe

• Reduced strength of neuromuscular function

• Increased overall load on the respiratory system

 This form of respiratory failure occurs as a result of lung

 Also called perioperative respiratory failure: commonly found in

 Results from hypoperfusion of respiratory muscles in patients in

 Patients in shock often experience respiratory distress due to

• 0.6 tablet given every 8 hours with subsequent tapering

• 1.2mg tablet followed by 0.6mg in 1hr with subsequent day dosing

• Temporarily discontinued promptly at the first sign of loose stools

• Effective In 90% of patients

• Resolution of s/sx occurs in 5-8 days

• Indomethacin 25-50mg tid

• Naproxen 500mg bid

• Ibuprofen 800mg tid

• Diclofenac 50mg tid

• Celecoxib 800 mg followed by 400mg 12h later then bid

• Prednisone 30-50mg as initial dose

• Gradually tapered with the resolution of the attack (effective in

• Single and few involved joints

• Intraarticular triamcinolone acetonide 20-40mg or

In the absence of contraindications , ie. gastrointestinal ulcers or renal

Prednisone, initially at 30 mg and rapidly tapered over 6 days, can be

• ULT is indicated in all patients with

Allopurinol should be started at 100 mg/day 2 weeks after the pain

The dose is titrated by 50-100 mg/day every 2 to 4 weeks to achieve

The maximum dose of allopurinol is 300 mg/day.

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