外科学教学课件：THORACIC EMPYEMA脓胸

THORACICEMPYEMA

脓胸CompanyLogo教学大纲要求掌握：脓胸的发病原因,病理变化,临床表现,诊断及治疗原则(1)脓胸的定义和分类(2)致病菌和侵入途径

(3)病理分期,临床表现,诊断及治疗原则CompanyLogo脓胸的病因和病理掌握脓胸的定义病理上慢性脓胸与急性脓胸的区别:急性脓胸以渗出性病变为主,而慢性脓胸则以纤维蛋白机化及纤维板形成为标志病因学:目前仍以肺炎球菌和链球菌多见,但耐药性金黄色葡萄球菌,绿脓杆菌,厌氧菌和真菌感染大大增多侵入途径:(1)肺部化脓感染,(2)邻近感染扩散,(3)经血液循环感染.CompanyLogo脓胸的病理过程:(1)急性渗出期(Ⅰ期)(2)纤维化脓期(Ⅱ期)(3)慢性机化期(Ⅲ期)CompanyLogo临床表现:中毒症状,呼吸系统症状.诊断:病史,体征与X线,CT,胸穿等可明确诊断治疗原则:(1)支持治疗(2)控制感染(3)排出脓液,促进肺复张CompanyLogo常用手术方式:胸腔穿刺胸腔闭式引流开放引流胸膜纤维板剥除术胸廓成形术胸膜肺切除术CompanyLogoDefinitionThoracicempyema(脓胸)istheaccumulationofpuswithinthepleuralcavity.Thepus（脓）isusuallythick,creamy,andmalodorous.Empyemaoccursinthesettingofunderlying(1)suppurativelungdisease(ie,pneumonia,lungabscess(肺脓肿),orbronchiectasis(支气管扩张)),itisreferredtoasaparapneumonicempyema(60%ofcases).Othercausesofthoracicempyemaare(2)surgery(20%);trauma(10%);esophagealrupture(食管破裂),otherchestwallormediastinalinfections,bronchopleuralfistula(气管胸膜瘘),extensionofasubphrenicorhepaticabscess（隔下或肝脓肿）,andrarely,(3)hematogenousseeding(血源性播散)fromadistantsiteofinfection.CompanyLogoPathophysiologyEmpyemasaredividedintothreephasesbasedontheirnaturalhistory:

acuteexudative,fibrinopurulent,andchronicorganizing.Theacuteexudativephase（急性渗出期）

ischaracterizedbytheoutpouringofsterilepleuralfluid(incitedbypleuralinflammation),thepleuraremainsmobileduringthisphase.Afibrinopurulentphase（纤维化脓期）

developssubsequently,markedbyanincreaseintheturbidity,andfibrinisdepositedonthebothpleuralsurfaces,therebylimitingtheemypemabutalsofixing(trapping)thelung.Thechronicorganizingphase（慢性机化期）

begins7~28daysaftertheonsetofthedisease,thepleuralexudatebecomesquitethickandthepleuralfibrindepositsthickenandbegintoorganize,furtherimmobilizingthelung.CompanyLogo

BacteriologyThebacteriologyofthoracicempyemahasevolvedovertheyears.Priortothediscoveryofpenicillininthe1940’s,mostempyemawerecausedbypneumococcusandstreptococcus（肺炎球菌和链球菌）.withmodernantibioticsandimprovedanaerobicculture（厌氧培养）techniques,however,themostcommonisolatesfromadultempyemasarenowanaerobicbacteria,particularlybacterioidesspeciesaswellasfusobacterium（梭杆菌）andpeptococcus（消化球菌）species.Staphylococcus（葡萄球菌）isthemostcommonorganismcausingempyemaintherecentyears.Gram-negativebacteriaalsocontinuetobesignificantpathogens.CompanyLogoClinicalfindingsAthoughpatientsmayrarelybecompletelyasmptomatic,mostpatientswiththoracicempyemaspresentwithvaryingsymptomsdependingontheunderlyingdiseaseprocess,theextentofthepleuralinvolvement,andtheimmunologicstateofthepatient.Symptoms:Patientstypicallycomplainoffever,pleuriticchestpainorasenseofchestheaviness,dyspnea,hemoptysis,andacoughusuallyproductiveofpurulentsputum.CompanyLogoSignsofthoracicempyemainclude:anemia,tachycardia,tachypnea,diminishedbreathsoundswithdullnesstopercussionontheinvolvedside,clubbingoffingertips,occasionallypulmonaryosteoarthropathy（肺性骨关节病）.CompanyLogoAssistantexaminationAlthoughthemedicalhistoryandphysicalexaminationoftensuggestthepresenceofthoracicempyema,theplainchestradiographisthemostimportantnoninvasivediagnostictest,mostcommomlytheyappearasposterolateral“D”-shapeddensitiesonx-ray.Inlargeempyemasthemediastinummaybeshieftedawayfromtheaffectedside.CTorultrasonographymaybenecessarytoevaluateempyemasthatareloculated（分腔）orthatmimic（酷似）alungabscess.CompanyLogoCompanyLogoCompanyLogoCompanyLogoTreatmentGoalsforthetreatmentofthoracicempyemainclude:

(1)controloftheinfection;(2)removalofthepurulentmaterial,withobliteration（消灭）andsterilization（灭菌）ofthepurulentspaceandreexpansionofthelung;(3)elimination（消除）oftheunderlyingdisease（原发病）process.CompanyLogoOptionsfortreatmentinclude:

repeatedthoracentesis,closedtubet