Hx: 20 yo male presents in respiratory distress. History from the patient’s family is significant for worsening shortness of breath for a week. He has a history of some form of chronic lung disease that the family notes is not asthma, but is treated with bronchodilators and inhaled steroids. He has been using his home meds without relief for the past 5 days. No fever but there is worsening cough productive of green sputum. Family reports that he went to an urgent care center today and was referred to the emergency department. The patient can not give any more history due to his distress.
PMHx: Chronic Lung Disease
SocHx: No tobacco, alcohol, or drugs
Exam:
- Vitals: HR 143, BP 110/60, temp 98.0, RR 30, O2 sat 96% nasal cannula at 4L
- General: sitting up in stretcher, leaning forward, in obvious distress
- Skin: diaphoretic
- HEENT: normal
- Respiratory: tachypneic, bilateral end expiratory wheezes, poor air movement, decreased breath sounds on the left, no SQ air, no tracheal deviation. Positive accessory muscle use, tripod position breathing, has difficulty speaking more than one word between breaths.
- Cardiovascular: tachycardia, regular, poor pulses but present all extremities, no lower extremity edema
- Abdomen: soft, non-distended, non-tender
- Extremities: no deformity
- Neurological: Cranial nerves intact. Normal movement and sensation all extremities.
Interventions:
- Albuterol and Atrovent nebulizer treatments.
- BiPAP (non-invasive positive pressure ventilation).
- IVs x 2 are placed
- Cardiac monitor is placed
- IV fluid resuscitation.
- Peripheral blood cultures are obtained and broad spectrum antibiotics are given.
Diagnostics:
- Chest Xray (See image) – shows a large left pleural effusion and a right middle lobe infiltrate
- CBC significant for WBC 39000
- Lactic acid 2.5
Hospital Course:
- After one hour of BiPAP therapy, he is not significantly improving. There has been some decreased work of breathing but tachycardia and tachypnea remain.
- ABG reveal pH 7.33/ pco2 40/ pO2 102.6/ HCO3 20 on 40% oxygen with BiPap at 13 cm H2O ins. /6 cm H2O PEEP.
- Repeat lactic acid now 4.4
- Consultation with multiple specialists is obtained resulting in decision to insert chest tube.
- The patient has a chest tube placed (see image below) by thoracic surgery with over 1800ml fluid out.
- Initial analysis of the fluid reveals: cloudy, yellow, 0 rbc. 12640 WBC: differential percents 1 eos, 1 lymphs, 4 mono, 94 segs, 0 baso. Glucose <5 mg/dl, LDH 1337, protein 6.5 g/dl, ph 6.825
- The patient is admitted to the ICU
- Repeat lactic acid post chest tube insertion is 2.0
- Further review of patient’s history at outside institutions reveals a diagnosis of bronchiectasis.
- By the end of day 2, 2500ml of pleural fluid has drained and the patient is remarkably improved.
- Chest tube is removed day 4 without complication. No further intervention from thoracic surgery is needed.
- Blood cultures eventually grow methicillin resistant staph aureus (MRSA)
- The patient is ultimately discharged home in good condition with a diagnosis of pneumonia and empyema.
Discussion:
Pleural effusions (para-pneumonic effusions) are common. Up to 40% of bacterial pneumonia presentations have an associated pleural effusion. Most are small and resolve spontaneously with antibiotic treatment of the pneumonia. However, effusions become complicated when bacteria infect the fluid. They are categorized into three groups:
- Uncomplicated effusions : these are sterile, exudative (predominantly neutrophils), and resolve with appropriate treatment of the associated pneumonia. However, ultrasound guided thoracentesis can be helpful in large fluid collections. If drained, fluid should be clear to slightly hazy. Fluid cultures are negative.
- Complicated effusions : these reflect bacterial migration into the effusion. Higher neutrophil counts are seen along with other fluid changes such as low glucose, increased LDH (>1000 IU/L), and decreased pH. Bacterial counts are low and cultures are often negative. Complicated effusions do not resolve spontaneously with antibiotic therapy and require drainage. There may be loculations present in these effusions and multiple chest tubes may be required.
- Empyema : this represents increased bacterial infection of the effusion leading to development of purulence (pus) in the space, often with locultations and thickening of the pleural lining. Fluid is thick, and opaque. Cultures may be positive however the presence of anaerobic organisms or antibiotic therapy prior to drainage may lead to negative cultures. Consultation with thoracic surgery is recommended as treatment often requires placement of multiple chest tubes, thoracoscopic debridement, and sometimes decortication.
Bacteriology is often mixed in empyema with a combination of aerobic and anaerobic organisms. Staph Aureus, Strep Pneumoniae, Klebsiella, Haemophilus and Pseudoomonas are the most aerobic organisms. Bacteroides and Peptostreptococcus species are the most common anaerobes. The most frequent cause of empyema today is bacterial pneumonia at 70% with previous surgery and trauma representing the remaining 30%.
Resources:
Up-To-Date
EMedicine/Medscape