Empyema thoracis

Pleural empyema,
Pyothorax,
Purulent pleuritis
• Definition
• Etiology
• Stages
• Signs, symptoms
• Complications
• Diagnosis
• Management
Introduction
• Empyema Thoracis is defined as accumulation of pus in the
pleural space.
• Differentiate from lung abscess: Pus within lung parenchyma
Etiology

Post-op Lung (70%)

Mediastinal

Extrinsic

Abdomen
Parenchymal Mediastinal Extrinsic Abdomen Post operative:

ICTD,
Esophageal Penetrating Subphrenic
Parapneumonic pigtail
rupture trauma abscess
induced

Post
Paravertebral Undrained Liver
Lung abscess pneumonect
abscess hemothorax abscess
omy

hydatid
BP fistula Mediastinitis
rupture

Hydatid

Tuberculosis
Pathophysiology
Pneumonia
↓
A Sterile Simple Parapneumonic Effusion
↓
Effusion Becomes Infected
↓
Complicated Parapneumonic Effusion
↓
Frank Pus-empyema.
Pathophysiology: 3 phases
• Exudative (around 7 days):
• Increased capillary vascular permeability with exudation of proteinaceous
fluid leads to sterile collection.
• Majority resolve with antibiotic therapy
• Fibropurulent (7-21 days):
• In 5-10% patients, the effusion becomes infected with neutrophil buildup.
• Production of chemokines, cytokines, oxidants, and protease mediators.
• Deposition of thin fibrin layer over pleura, with progressive loculation.
• Pus becomes thicker and turbid, with positive pus culture
• Organizational (4-6 weeks):
• Decreased fibrinolysis and activation of the coagulation cascade leads to
thick cortex formation on pleura (Trapped Lung Effect)
• Frank loculated pus
• Calcification of pleura, chest wall deformity
Microbiology
• Streptococcus species (15-20%): 
Streptococcus milleri (in adults), S pneumoniae (in paediatric
population),

• Staphylococcus aureus (15-30%) and methicillin-

resistant Staphylococcus aureus (MRSA)

• Gram-negative organisms (20-50%):

Klebsiella, Acinatobacter, Pseudomonas, E.Coli

• Anaerobic involvement is common in empyemas but may be

difficult to detect on cultures.
• Mycobacterium tuberculosis.
Symptoms:
Depends on:
• infecting organism
• Patients’ immune status
Ranges from no symptoms, to systemic toxic features/septicemia
• Fever
• Cough/expectoration
• Pleuritic chest pain
• Dyspnea
• Easy fatiguability
• Loss of appetite, weight loss
• Night sweats
• Finger clubbing
 Complications:

Septicemia,
Septic Shock
Empyema Necessitans
Rupture into the Lung:
• Lung Abscess
• Hemoptysis
Laboratory Studies
• CBC: leukocytosis and a left shift.
• Sputum
• Gram staining,
• Culture And Sensitivity.
• Transtracheal aspiration for culturing (if sputum findings
are nondiagnostic)
• If tuberculosis is suspected, AFB testing.
• In the presence of fever, obtain a blood culture
• Pulse oximetry to assess oxygenation
• ABG or VBG analysis to assess respiratory adequacy
Laboratory Studies
Diagnostic Thoracocentesis:
 pH,
 Lactate Dehydrogenase (LDH),
 Glucose level,
 TNF levels,
 Cell Count with differential.
 Gram Stain,
 Culture and Sensitivity.
 Acid-fast Bacillus testing
Laboratory Studies
Findings:
• Grossly purulent pleural fluid
• Positive pleural fluid culture

pH level < 7.2

WBC > 50,000 cells/µL
Neutro count > 1,000 cells/µL
Glucose < 60 mg/dL
Protein > 2.5g/dL
LDH > 1,000 IU/mL
ADA levels > 40 U/L
Imaging Studies
• Chest XRay:
o pneumonia
o pulmonary abscess
o empyema
• Distinction of these conditions is important because lung
abscesses and pneumonia require medical treatment,
while empyema frequently requires definitive surgical
therapy
Imaging Studies: CXR
Imaging Studies: CT
Management
Prompt Drainage: Pigtail or ICTD

Parenteral Antibiotics

Fibrinolytics

Surgery (VATS/Open)

Thoracoplasty
Management
Pl. effusion

Clear Purulent

Not Loculated,
pH>7.2 pH<7.2
Loculated Organized

No surgical Recurrent Drainage,

Drainage
intervention Pleural Tap Fibrinolytics

Failure-
Antibiotics
Decortication
Fibrinolytics:

Indications:
• Loculations: acute or fibrinopurulent stage
• Incomplete drainage after ICTD

Contraindications:
• Chronic stage
• Empyema with BPF
• Post op Empyema
Fibrinolytics:

• Urokinase: 100,000 to 300,000 IU

• Streptokinase: 250,000 IU
• 10-20ml of Isotonic saline
• Insert through ICTD
• Leave inside for 24-48 hrs
• Then evacuate
• Constantly associated with fever
• Hemorrhagic complications
Open/VATS decortication
Indications:
• Persistent loculations
• Thick pleura entrapping lung
• Vital Capacity less than 70%

Target: breaking loculi, evacuating pus and debri, lavage, and freeing lung
to ensure lung reexpansion on-table.

Contraindications:
• Patients’ poor general status to withstand surgery
• Active TB,
• Acute/Fibrinopurulent stage
• Bronchial stenosis
Open/VATS decortication
1. Free lung:
• Hilum to hulum
• Apex to diaphragm
2. Interfissural dissection
3. Lavage
4. Seal air leak
5. Hemostasis
6. ICTD
7. Post op incentive spirometery
Thoracoplasty:

Indications:
Refractory empyema
Chronic drainage
Procedure:
Rib resection and open drainage
Eloesser flap
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