Pleuraempyem und Lungenabszess: Aktuelle Therapiekonzepte

Zusammenfassung

Das parapneumonische Pleuraempyem wurde unter verschiedensten Aspekten in Stadien eingeteilt (American Thoracic Society [ATS] –  Einteilung nach der natürlichen Verlaufsform; Light-Klassifikation – Einteilung nach der Zusammensetzung des Ergusses / Empyem; American College of Chest Physicians [ACCP] – Einteilung nach Risikokategorie für ein schlechtes Ergebnis). Die Behandlung des Pleuraempyems soll in allen Einteilungen adaptiert an das jeweilige Stadium erfolgen. Das therapeutische Spektrum umfasst die alleinige Dränagenbehandlung, die Dränagentherapie mit Fibrinolytika, das thorakoskopische Debridement und die Dekortikation in offener bzw. minimalinvasiver Technik. Primäre Lungenabszesse entstehen in gesundem Lungengewebe und sind häufig Ausdruck einer Aspiration. Darüber hinaus kommen auch Abszesse ohne Aspiration vor. Zudem sind ambulant und nosokomial erworbene Abszesse sowie solche unter Immunsuppression zu unterscheiden. 90 % aller Lungenabszesse heilen unter adäquater Antibiotikatherapie folgenlos aus, 10 % benötigen eine interventionelle Katheter- oder Dränagebehandlung, nur 1 % benötigen eine thoraxchirurgische Behandlung aufgrund von Abszesskomplikationen unabhängig vom zuvor durchgeführten konservativen oder interventionellen Verfahren.

Abstract

Parapneumonic pleural empyema has been classified into different stages and classes. While the American Thoracic Society (ATS) classification is based on the natural course of the disease, Light has classified pleural empyema according to the radiological, physical and biochemical characteristics, and the American College of Chest Physician (ACCP) has categorised the patients with pleural empyema according to the risk of a poor outcome. According to this classification the management of the pleural empyema is based on the stage of the disease. Therapeutic strategies include chest tube, chest tube with fibrinolysis, thoracoscopic debridement and decortication in open or minimally invasive techniques. Primary lung abscesses develop in previously healthy lung parenchyma and are caused by aspiration. In addition, abscess formation can occur without aspiration, and important differences relate to community-acquired, nosocomial abscesses and those in the immunosuppressed host. 90 % of all lung abscesses can be cured with antibiotic treatment alone, 10 % have to be treated with an interventional catheter or chest tubes and only 1 % require thoracic surgery because of complications independent of the former conservative or interventional treatment strategies.

Schlüsselwörter

Pleuraempyem - Lungenabszess - chirurgische Technik - VATS - Thoraxchirurgie - Antibiotikatherapie

Key words

pleural empyema - lung abscess - surgical technique - VATS - thoracic surgery - antibiotic strategies

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