Thoracic Empyema
Questions
1. Are the following statements true or false?
a. Tuberculous pleurisy and empyema are two names for conditions requiring similar
treatments.
b. All pleural effusions should be aspirated for diagnosis.
c. A parapneumonic effusion that has protein content greater than 3.0 g/dl is
an exudate and needs to be drained.
d. Chest drainage should not be initiated in stable patient with hemothorax
for fear of causing an empyema.
e. Since gram negative aerobes are common infecting agents in adult empyema
aminoglycosides should be routinely prescribed.
f. Patients with stage 3 empyemas can be effectively treated with tube thoracostomy.
g. All parapneumonic effusions with pH<7.2 require tube drainage.
2. You are asked to see a 5 year old boy with a right pleural effusion
coming on after 3 days of pneumonia treated with ampicillin. On examination
the child is febrile, dyspneic and restless. The chest xray shows opacification
of the right hemithorax with a slight medistinal shift to the left. What is
the best course of action?
a. Thoracentesis and adding cloxacillin to his antibiotics.
b. Immediate provision of oxygen, aspiration of right pleural space for pH,
protein and LDH levels, gram stain and culture, and change of antibiotics to
cefuroxime and metronidazole.
c. Same as “b” but thoracocentesis followed immediately by insertion
of 12 Fr thoracic drain to underwater seal.
d. performing immediate thoracotomy and drainage
3. After 7 days on ampicillin/clavulinic acid and metronidazole and
chest tube drainage a 3 year old girl with a left parapneumonic effusion is
still febrile. Chest xray shows residual fluid but the chest tube is not draining
anything. What is the best course of management?
a. Remove the chest tube and change the antibiotics.
b. Arrange for Ultrasound guided drainage of the pleural fluid.
c. Instill 250,000 IU streptokinase in 100 ml NS twice daily to chest tube.
d. Arrange for surgical drainage either by VATS or open thoracotomy.
4. A 45 year old man with AIDS has an empyema. You are in a remote
hospital without possibility of referral. The patient has been ill for several
weeks. Pleural aspiration shows thick pus. A chest xray shows a posterior fluid
collection that does not move. What is the single best course of action?
a. This patient has no chance of survival and should be given morphine and nothing
else.
b. The collection should be drained with a chest tube and he should be started
on cloxacillin and chloramphenicol.
c. The collection is best drained with a rib resection and Eloesser flap. Specimens
should be examined for AFB.
d. Start anti-retroviral therapy.
Answers to these questions will be provided next month!