Secondary pneumonia and development of pleurisy
Purulent pleurisy (pleural empyema) rarely occurs in isolation. Most often, it develops against the background of secondary bacterial pneumonia. Pathogenic microorganisms overcome the defense barriers of lung tissue and initiate inflammation of the pleural leaves.
In addition to pleural damage, secondary pneumonia can trigger a number of severe complications affecting various body systems:
- Respiratory system: acute respiratory failure (ARF) and acute respiratory distress syndrome (ARDS).
- Infection generalization: development of sepsis and, in unfavorable courses, septic shock.
- Local destructive processes: formation of a lung abscess.
- Extrapulmonary lesions: involvement of the central nervous system (meningitis) and heart (myocarditis, myocardial dystrophy).
Lung abscess as a cause of empyema
The classical mechanism for the development of purulent pleurisy is the spread of infection from a focus of destruction in the pulmonary parenchyma—a lung abscess. When the abscess ruptures into the pleural cavity, infection of the pleura occurs, followed by the formation of empyema.
If treatment for the abscess is ineffective, the process may become chronic with the formation of an encysted focus. Other formidable complications of a lung abscess include:
- Pyopneumothorax: a condition inables the rupture of an abscess to be accompanied by the simultaneous entry of both purulent masses and air into the pleural cavity.
- Pulmonary hemorrhage: occurs due to arrosion (erosion) of a blood vessel passing through the wall of the purulent cavity.
- Septicopyemia: generalization of infection with the formation of metastatic purulent foci in other organs and tissues.
- Systemic consequences: with a prolonged chronic course of the purulent process, the development of adult respiratory distress syndrome and systemic amyloidosis is possible.
Surgical treatment: Pleurectomy with decortication
The main indication for pleurectomy with lung decortication is chronic pleural empyema. The goal of the surgery is to remove the purulent sac and free the lung from the fibrous deposits constraining it in order to restore normal ventilation.
Surgical technique
- Access: A lateral approach is used. Since the intercostal spaces narrow during chronic inflammation, the surgeon often has to resort to resection of the 5th or 6th rib.
- Isolation of the empyema sac: The parietal pleura, which is significantly thickened, is bluntly dissected and retractors are placed. If the empyema is total, the sac is separated throughout: from the pleural dome to the diaphragm, dorsally all the way to the spine, and ventrally to the lung root. Electrocoagulation and sponges moistened with warm saline are used for hemostasis.
- Opening and separation: The parietal wall of the purulent sac is incised, gradually moving to the visceral part until the lung tissue appears. The sac is gently separated with a gauze ball (sponge). Dense adhesions are carefully cut with scissors, trying not to injure the pulmonary parenchyma and avoiding air leaks.
- Completion: After complete removal of the pus-filled sac, final decortication is performed—removing the remaining fibrous films that prevent the lung from expanding. Two drains with multiple holes are installed in the pleural cavity.
Alternative methods and contraindications
Pleurectomy with decortication requires a thorough assessment of lung tissue condition. The intervention is considered contraindicated if the lung begins to tear during the dissection process or if it physically cannot expand due to deep fibrous parenchymal changes.
In situations where it is impossible to expand the lung, the surgeon chooses alternative surgical options:
- Performing a C-shaped thoracoplasty to reduce the volume of the pleural cavity.
- Performing pleuropneumonectomy—radical removal of the empyema sac en bloc together with the affected, non-functioning lung.
To remember lung abscess complications: PLEVS (Pyopneumothorax, Lung hemorrhage, Empyema of the pleura, Inflammation systemic/ARDS, Sepsis).
Class and exam questions
What is the difference between purulent pleurisy and pleural empyema?
In the context of these pathological processes, the terms are often used as synonyms. Pleural empyema is essentially purulent pleurisy characterized by an accumulation of pus in the pleural cavity.
What is pyopneumothorax and when does it occur?
This is a life-threatening condition in which pus and air simultaneously enter the pleural cavity. Most often, it is a complication of a lung abscess when it ruptures through the visceral pleura.
Why can't the lung breathe normally in chronic empyema?
During a chronic process, dense fibrous deposits (peel/rind) form on the visceral pleura, acting like a shell that physically prevents the lung from expanding during inspiration.
What is done if the lung cannot be expanded during decortication?
If the lung does not expand due to fibrosis or tears during dissection attempts, decortication is contraindicated. In this case, C-shaped thoracoplasty or complete removal of the lung along with the purulent sac (pleuropneumonectomy) is indicated.
What else to study on this topic
- Pathogenesis of acute respiratory failure in pneumonia.
- Mechanisms of septic shock development in purulent pleurisy.
- Causes and mechanisms of amyloidosis development in chronic suppuration.
- Features of hemostasis in thoracic surgery.
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