الفهرس 
1. IntroductionOnly 14 pages are availabe for public view
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Abstract
Empyema thoracis is defined as an accumulation of pus within the pleural cavity. Community-acquired. Forty to 57% of patients with community-acquired pneumonia develop a parapneumonic effusion. Approximately 5 to 10% of parapneumonic effusions develop into empyema. Other causes of empyema include iatrogenic etiologies (≤20%) and trauma (3%) as undrained haemothoraces can become secondarily infected. Empyema can develop following iatrogenic intervention in the pleural space such as thoracic surgery (12%) or medical procedures such as chest drain insertion (4%), thoracentesis (pleural aspiration), tube thoracostomy (chest drain insertion), and aspiration of pneumothoraces or pleural effusions. Empyema develops in three stages. The first is the acute exudative phase with the early accumulation of fluid that is thin and easily drained. This is followed by the fibropurulent phase with fibrin deposition and the development of loculations. Finally, the disease enters the chronic organizing phase with very little fluid and a thick peel surrounding the lung often entrapping it. The microbiology of empyema differs from that of pneumonia, Empyema is frequently polymicrobial, and an organism is only identified in approximately 60% of pleural infections. The organisms cultured in empyema following community-acquired pneumonia are significantly different from those which develop following hospital-acquired pneumonia or iatrogenic aetiologies. In community-acquired infection, gram-positive aerobic bacteria are most common, particularly the Streptococcus milleri group, Streptococcus pneumoniae, and staphylococci. Anaerobes account for 16% of organisms cultured, although they are difficult to culture so may be involved in a greater percentage of cases. Most patients with empyema present with clinical manifestations of bacterial pneumonia. Their symptoms are characterized by an acute febrile response, pleuritic chest pain, cough, dyspnea, and possibly cyanosis. The inflammation process of the pleural space may cause abdominal pain and vomiting. Frequently, patients exhibit characteristic splinting of the affected side. Symptoms may be blunted, and fever may not be present in patients who are immunocompromised. Physical findings and presentation may vary depending on the organism and the duration of the illness. Pleural fluid analysis, pleural biopsy, chest radiographs PA and lateral, US and CT are the important investigations in the management of empyema. Pleural fluid analysis is important to confirm an empyema rather than simple pleural effusion by the glucose, LDH, protein level and pH. Pleural biopsy can determine the staging of disease accurately which will influence the management plane significantly. The appropriate management of complicated Para-pneumonic effusion or empyema remains controversial. Most cases are treated initially using antibiotics with or without repeated thoracentesis, closed thoracostomy with or without fibrinolytics. Surgical approaches such as open thoracotomy, decortication, and thoracoplasty are generally reserved for these patients with deteriorated clinical conditions after conservative treatment. Video-assisted thoracoscopic surgery (VATS) ,which plays a bridging role between medical and aggressive surgical management.Although these surgical procedures have been a major step forward in the search for lesser invasive approach for management of empyema thoracis, they still carry the risk of significant morbidity, lack free.