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THORACIC EMPYEMA脓胸脓胸Company Logo教学大纲要求教学大纲要求v掌握：掌握：脓胸的发病原因脓胸的发病原因,病理变化病理变化,临床表现临床表现,诊断及治疗原则诊断及治疗原则 (1)脓胸的定义和分类脓胸的定义和分类 (2)致病菌和侵入途径致病菌和侵入途径 (3)病理分期病理分期,临床表现临床表现,诊断及治疗原则诊断及治疗原则Company Logo脓胸的病因和病理脓胸的病因和病理v掌握脓胸的定义掌握脓胸的定义v病理上慢性脓胸与急性脓胸的区别病理上慢性脓胸与急性脓胸的区别:急性脓胸以渗急性脓胸以渗出性病变为主出性病变为主,而慢性脓胸则以纤维蛋白机化及纤而慢性脓胸则以纤维蛋白机化及纤维板形成为标志维板形成为标志v病因学病因学:目前仍以肺炎球菌和链球菌多见目前仍以肺炎球菌和链球菌多见,但耐药但耐药性金黄色葡萄球菌性金黄色葡萄球菌,绿脓杆菌绿脓杆菌,厌氧菌和真菌感染厌氧菌和真菌感染大大增多大大增多v侵入途径侵入途径:(1)肺部化脓感染肺部化脓感染,(2)邻近感染扩散邻近感染扩散,(3)经经血液循环感染血液循环感染.Company Logov脓胸的病理过程脓胸的病理过程:(1)急性渗出期急性渗出期(期期)(2)纤维化脓期纤维化脓期(期期)(3)慢性机化期慢性机化期(期期)Company Logov临床表现临床表现:中毒症状中毒症状,呼吸系统症状呼吸系统症状.v诊断诊断:病史病史,体征与体征与X线线,CT,胸穿等可明确诊断胸穿等可明确诊断v治疗原则治疗原则:(1)支持治疗支持治疗 (2)控制感染控制感染 (3)排出脓液排出脓液,促进肺复张促进肺复张Company Logov常用手术方式常用手术方式:胸腔穿刺胸腔穿刺 胸腔闭式引流胸腔闭式引流 开放引流开放引流 胸膜纤维板剥除术胸膜纤维板剥除术 胸廓成形术胸廓成形术 胸膜肺切除术胸膜肺切除术Company LogoDefinitionv Thoracic empyema(脓胸)is the accumulation of pus within the pleural cavity.The pus（脓）is usually thick,creamy,and malodorous.Empyema occurs in the setting of underlying (1)suppurative lung disease(ie,pneumonia,lung abscess(肺脓肿),or bronchiectasis (支气管扩张),it is referred to as a parapneumonic empyema(60%of cases).Other causes of thoracic empyema are (2)surgery(20%);trauma(10%);esophageal rupture(食管破裂),other chest wall or mediastinal infections,bronchopleural fistula(气管胸膜瘘),extension of a subphrenic or hepatic abscess（隔下或肝脓肿）,and rarely,(3)hematogenous seeding(血源性播散)from a distant site of infection.Company LogoPathophysiologyv Empyemas are divided into three phases based on their natural history:acute exudative,fibrinopurulent,and chronic organizing.The acute exudative phase（急性渗出期急性渗出期）is characterized by the outpouring of sterile pleural fluid(incited by pleural inflammation),the pleura remains mobile during this phase.A fibrinopurulent phase（纤维化脓期纤维化脓期）develops subsequently,marked by an increase in the turbidity,and fibrin is deposited on the both pleural surfaces,thereby limiting the emypema but also fixing(trapping)the lung.The chronic organizing phase（慢性机化期慢性机化期）begins 728 days after the onset of the disease,the pleural exudate becomes quite thick and the pleural fibrin deposits thicken and begin to organize,further immobilizing the lung.Company Logo Bacteriologyv The bacteriology of thoracic empyema has evolved over the years.Prior to the discovery of penicillin in the 1940s,most empyema were caused by pneumococcus and streptococcus（肺炎球菌和链球菌）肺炎球菌和链球菌）.with modern antibiotics and improved anaerobic culture（厌氧培养）techniques,however,the most common isolates from adult empyemas are now anaerobic bacteria,particularly bacterioides species as well as fusobacterium（梭杆菌）and peptococcus（消化球菌）species.v Staphylococcus（葡萄球菌葡萄球菌）is the most common organism causing empyema in the recent years.Gram-negative bacteria also continue to be significant pathogens.Company LogoClinical findingsvAthough patients may rarely be completely asmptomatic,most patients with thoracic empyemas present with varying symptoms depending on the underlying disease process,the extent of the pleural involvement,and the immunologic state of the patient.vSymptoms:Patients typically complain of fever,pleuritic chest pain or a sense of chest heaviness,dyspnea,hemoptysis,and a cough usually productive of purulent sputum.Company LogovSigns of thoracic empyema include:anemia,tachycardia,tachypnea,diminished breath sounds with dullness to percussion on the involved side,clubbing of fingertips,occasionally pulmonary osteoarthropathy（肺性骨关节病）.Company LogoAssistant examinationvAlthough the medical history and physical examination often suggest the presence of thoracic empyema,the plain chest radiograph is the most important noninvasive diagnostic test,most commomly they appear as posterolateral“D”-shaped densities on x-ray.In large empyemas the mediastinum may be shiefted away from the affected side.CT or ultrasonography may be necessary to evaluate empyemas that are loculated（分腔）or that mimic（酷似）a lung abscess.Company LogoCompany LogoCompany LogoCompany LogoTreatmentvGoals for the treatment of thoracic empyema include:(1)control of the infection;(2)removal of the purulent material,with obliteration（消灭）and sterilization（灭菌）of the purulent space and reexpansion of the lung;(3)elimination（消除）of the underlying disease（原发病）process.Company LogovOptions for treatment include:repeated thoracentesis,closed tube thoracostomy,rib resection and open drainage;Decortication（纤维板剥除术）and empyemectomy（消灭脓腔）,Thoracoplasty（胸廓成形术）muscle flap closureTreatmentCompany LogoTreatmentCompany LogoTreatmentCompany LogoTreatment
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