Empyema Thoracis

Abstract

Empyema Thoracis is collection of purulent material within the pleural cavity as a result of pneumonia or by secondary infection of the pleural cavity. The pathogenesis of empyema is a continuum. The presentation is dependent on host immune responses to type and virulence of bacterial infection and management instituted. Necrotic pneumonia is increasingly encountered and is the cause of bronchopleural fistula. Radiological diagnosis is achieved with ultrasonography, however, CT scan gives more accurate delineation of pleural collection, lung and mediastinal pathology.

Inadequate management of empyema can lead to necrotic pneumonia in collapsed consolidated lung. Clinical presentation is related to lower respiratory tract infection with decreased air entry, pyrexia and varying degree of respiratory compromise depending on the size of pleural collection and lobar lung consolidation. The principle aim in empyema management should be adequate drainage in order to achieve full expansion of the lung. Failure to recognise inadequate management strategy results in progression of empyema disease process into organizational state. Active monitoring of the management strategy, early recognition of failure to re-expand the lung and continuing infection avoids morbidity and occasionally mortality associated with empyema thoracis.

Various management strategies are employed depending on the institutional experience. Many published outcomes are biased toward institutional experience. Insertion of ultra-sound guided intercostal pig-tail catheter and fibrinolytic instillation may play a role in the management of empyema, however, it should be actively monitored and any failure should be referred for surgical intervention. Many recent studies have shown early intervention using thoracoscopic techniques have shown improved outcomes and reduced hospital stay. Complicated empyema associated with bronchopleural fistula should be managed with early intervention with decortication and insertion of an appropriate muscle flap onto the fistula. The chapter discusses the management of bilateral empyema, secondary empyema and tuberculous empyema.