Sunday, October 25, 2009

Para-pneumonic effusion and Empyema


Capillary Leak/ Exaudate stage

Bacterial Invasion/ Fibrinolytic stage

Organization/ Empyema stage


Micro-organisms à PMNs à O2 free radicals + products à endothelial injury à ñ capillary permeability à ñ interstitial/pleural pressure gradient (subpleural) à effusion


ññ endothelial injury with bacterial multiplication over whelming lymphatics, MQ, neutrophils


Continuous fibroblastic migration from visceral, parietal pl. à coagulable pleural matrix (inelastic membrane or pleural peel) à thick cavity 'e thick yellowish white opaque viscous pus

Fluid ccc:

· Ipsilateral,Small, Free

· Sterile (-ve gram and culture)

· Predominant PNLs

· PH > 7.2, exaudate

· Glucose > 60 mg

· LDH > 500 IU/L

· Appears in 2-5 ds of pneumonia onset

Fluid ccc:

· Cloudy fluid

· +ve gram and culture

for bacteria

· ññ PNLs, debris

· PH between 7-7.2

· Glucose < 40 mg/dl

· LDH > 1000 (lysis)

· In 5-10 ds of pneumonia onset

Fluid ccc:

· Pus ± foul smelling

· G-ve (30%), staph (10-25%), strept. malleri, anaerobes (bacteroids, peptost), mixed infection, or sterile pus in 1/3 cases

· Staph, H.I. in children

· In 2-3 weeks of pn.


I. Non significant parapneumonic effusion:

II. Typical exaudative effusion (uncomplicated):

III. Borderline complicated effusion:

IV. Simple complicated (Fibrinolytic):

V. Complex complicated effusion:

VI. Simple empyema:

VII. Complex empyema:

-Differential Diagnosis:




-Displaces bronchial, vascular markings

-Cross major fissures

-Unequal width of air-fluid level in P/A and lateral views

-No displacement

-Follows anatomical rules

-Equal width in both


-Smooth rounded outline

-Acute angle between empyema and pleural margin

-Compresses lung

-Pleural split sign à walls of visceral & parietal pleurae are separate (2 contrasts)

-Oval irregular outline

-Obtuse angle

-No compression

-No pleural split sign

*For full text --> download from: ParaPneumonic Effusion.pdf

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