1) The document discusses the diagnosis and management of chronic empyema, beginning with the definition, causes, stages, and clinical presentation. 2) Diagnostic evaluations including imaging like chest X-ray, CT, and ultrasound are described, as well as biochemical analysis of pleural fluid. 3) Treatment options are provided for each stage of empyema, including thoracocentesis, chest tube drainage, fibrinolytics, VATS, decortication, and window thoracostomy. Antibiotic recommendations are also covered.

1. Chronic empyema: Diagnosis and
management
By
Dr. Aditya Yadav
MS Gen Surgery

2. Empyema Thoracis
• Defined as “pus in the
plural space”.
• Ancient disease.
• Hippocrates credited with
first description of natural
history and treatment.
• Open thoracic surgery was
advocated by Hippocrates
for complex chronic
empyema.
The American Association for Thoracic Surgery consensus guidelines, 2017

3. • Occurs after a reactive pleural effusion as a
consequence of a lung infection & systemic
infection.
• Streptococcal or pneumococcal pneumonia most
common cause.
• Gram negative and anaerobic organisms are
other common cause.
The American Association for Thoracic Surgery consensus guidelines, 2017

4. • Chronic pulmonary TB - major causative agent in low
socioeconomic society.
• Other causes are
Thoracic Trauma & Surgery.
Mediastinal diseases, cervical and thoracic spine
infections.
Upper GI pathology
Bronchogenic Carcinoma
The American Association for Thoracic Surgery consensus guidelines, 2017

5. Anatomical Consideration:
Visceral pleura -
• develop from splanchnopleural layers of the lateral
plate mesoderm.
• Arterial supply and Venous drainage - the bronchial
vessels.
• Autonomic neural innervation.
Standring, S.,& gray H. (2016), Gray’s Anatomy: the anatomical basis of clinical practice, 41th
ed. Edinburgh:Churchil Livingstone/Elsevier

6. Parietal pleura
• Develops from somatopleural layer.
• Somatic arterial supply and drained by pulmonary
veins.
• Neural innervation by intercostal nerve and
phrenic nerve.
• The lymphatic drainage - deep pulmonary plexus
within the interlobar and peribronchial spaces.
Standring, S.,& gray H. (2016), Gray’s Anatomy: the anatomical basis of clinical practice, 41th ed.
Edinburgh:Churchil Livingstone/Elsevier

7. Production and reabsorption of pleural fluid
Source: Bailey & Love’s SHORT PRACTICE of SURGERY 26th ed

8. Pathophysiology
• 5-10 liter pleural fluid is produced in 24 hours.
• Most pleural fluid is reabsorbed through
lymphatics of the parietal pleura.
• Visceral pleura is relatively impermeable to
plural fluid proteins.
• Left pleural cavity is smaller than right due to cardiac
asymmetry, hence more effusions are seen in right.
Sabiston, David C., and Courtney M. Townsend. 2016. Sabiston Textbook of Surgery : the Biological Basis of Modern
Surgical Practice. Philadelphia :Elsevier Saunders, p1604-1610.

9. • Pleural effusion develops when balance between
accumulation and reabsorption disturbs.
• This imbalance occurs with -
 hydrostatic pressure,
 Negative intrapleural pressure,
 capillary permeability,
 plasma oncotic pressure,
Interrupted lymphatic drainage.
Sabiston, David C., and Courtney M. Townsend. 2016. Sabiston Textbook of Surgery : the Biological Basis of
Modern Surgical Practice. Philadelphia :Elsevier Saunders, p1604-1610.

10. • Exudates are important in empyema .
• Light’s criteria.
Sabiston, David C., and Courtney M. Townsend. 2016. Sabiston Textbook of Surgery : the Biological Basis of
Modern Surgical Practice. Philadelphia :Elsevier Saunders, p1604-1610.

11. Stages :
• Exudative stage (1-3 days )
• Fibrino- purulent stage (4 to 14 days)
• Organizing stage (after 14 days)
Sabiston, David C., and Courtney M. Townsend. 2016. Sabiston Textbook of Surgery : the Biological
Basis of Modern Surgical Practice. Philadelphia :Elsevier Saunders, p1604-1610.

12. Stage I (Exudative Stage):
• Pleural fluid is thin & oedema over both pleura.
• Pleural membrane inflamation -> Increased
permeability.
• Increased neutrophils in fluid, however normal
glucose , LDH level and pH.
Sabiston, David C., and Courtney M. Townsend. 2016. Sabiston Textbook of Surgery : the Biological Basis of Modern
Surgical Practice. Philadelphia :Elsevier Saunders, p1604-1610.

13. Stage II (Fibrino- purulent stage )
• Pleural fluid becomes thick & fibrin deposits over
the pleural surfaces.
• Bacterial stains present , frank pus, neutrophils
increase.
• pH and glucose levels become low.
• LDH and protien levels increase.
Sabiston, David C., and Courtney M. Townsend. 2016. Sabiston Textbook of Surgery : the Biological Basis
of Modern Surgical Practice. Philadelphia :Elsevier Saunders, p1604-1610.

14. Stage III (Organizing phase/ chronic phase)
• Fibrins converted in to fibroblasts, new Capillary
ingrowth begins.
• Effusion grossly purulent, thick like curd
• Entrapment of lung.
• Contraction thorax
Sabiston, David C., and Courtney M. Townsend. 2016. Sabiston Textbook of Surgery : the
Biological Basis of Modern Surgical Practice. Philadelphia :Elsevier Saunders, p1604-1610.

15. Presentation:
• General malaise
• Fever
• Loss of appetite
• Weight loss
• Cough
• Dyspnea
Sabiston, David C., and Courtney M. Townsend. 2016. Sabiston Textbook of Surgery : the Biological
Basis of Modern Surgical Practice. Philadelphia :Elsevier Saunders, p1604-1610.

16. Signs :
Inspection:
• Asymmetric chest expansion
• May be Discharging wound
Palpation:
• Raised local temperature in acute phase
• Local Tenderness
• Crepitus

17. Percussion:
• Dullness.
(Chest percussion penetrates to a maximum depth of 6 cm)
Auscultation:
• Decreased tactile fremitus.
• Egophony.
• Pleural friction rub.
• Decreased breath sounds.

18. A. Radiology
Chest X-Ray
Ultrasonography
CT Scan
B. Pleural fluid
 Routine and microscopy
 ADA
 ϒ-Interferon
 RT PCR
 CBNAAT
 Biochemical
Diagnosis:
• History and Clinical examination,
• Routine blood investigation
• Specific examination

19. Patients at risk for empyema (Class I, LOE B) ?
• All patients presenting with signs and symptoms
of pneumonia, or unexplained sepsis.
• Failure of a community or nosocomial pneumonia
to respond clinically to appropriate antibiotic
therapy.
The American Association for Thoracic Surgery consensus guidelines, 2015

20. Chest Xray-
• Erect and Lateral views
• Loculations present as lenticular shaped
opacities.
• Complex parapneumonic effusion are often
loculated, may be missed on chest Xray.
The American Association for Thoracic Surgery consensus guidelines, 2017

27. For pleural fluid detection-
• Erect lateral view- Minimum 50 ml.
• Standard PA view- Minimum 175 ml*.
• Physical examination- Minimum 300 ml.
• Supine AP radiograph has lesser sensitivity than
lateral decubitus view. .
Ricardo Franco, Paul H. et al. Ultrasound in the diagnosis & management of pleural effusion. 2016. J
Hosp Med, Texas.
*The American Association for Thoracic Surgery consensus guidelines, 2017.

28. Ultrasonography:
• 2-5 MHz phased array transducer for scanning
intercostal space.
• Amount of fluid , and loculations are imaged.
• As an add in USG guided diagnostic/therapeutic
thoracocentesis.
Ricardo Franco, Paul H. et al. Ultrasound in the diagnosis & management of pleural effusion. 2016. J
Hosp Med, Texas.

29. • Can detect physiological amount of pleural fluid,
i.e. 5 ml.
• 100% senitivity for effusion >100 ml.
• Ultrasound should be routinely performed in addition to
conventional chest X-ray. both for diagnostic purposes
and image-guidance for pleural interventions. (Class I,
LOE B)
• Reducing pneumothorax risk from 9% to 4%.
Ricardo Franco, Paul H. et al. Ultrasound in the diagnosis & management of pleural effusion. 2016. J Hosp Med, Texas.

30. CT scan:
• Reference standard in plural diseases.
• Distinguish pleural with parenchymal
abnormalities as well as involved and opposite
lung paranchyma.
• Determine precise location, extent and
loculations.
Ricardo Franco, Paul H. et al. Ultrasound in the diagnosis & management of pleural effusion. 2016. J
Hosp Med, Texas.

31. • Enhancing, thickened visceral and parietal
pleural layers separated by an intervening
layer of low attenuation fluid (Split pleura
sign)

32. Limitation of chest CT
• Lower sensitivity in distinguishing small effusions
from pleural thickning.
• Lower sensitivity for detection plural fluid septation
than ultrasound.
• One avarage CT scan exposure (7 mSv) radiation
equivalent dosage of 350 chest radiographs.
Chest CT scan should be obtained when pleural space infection
is suspected. (Class IIa, LOE B)
The American Association for Thoracic Surgery consensus guidelines, 2017
Ricardo Franco, Paul H. et al. Ultrasound in the diagnosis & management of pleural effusion. 2016. J Hosp Med, Texas.

33. Biochemical :
Pleural fluid should be analyzed for
• Cytology, cell counts, Gram stain, culture for
aerobic, anaerobic, and fungal organisms,
tuberculosis testing.
• Simultaneous pleural and serum protein, glucose,
LDH, and pH.
Sabiston, David C., and Courtney M. Townsend. 2016. Sabiston Textbook of Surgery : the Biological Basis
of Modern Surgical Practice. Philadelphia :Elsevier Saunders, p1604-1610.

34. • Obtain pleural fluid cultures only from direct
aspiration or drainage procedure, not from
previously inserted tubes or drains. (Class I, LOE B)
• Inoculate freshly drained pleural fluid into aerobic
and anaerobic blood culture vials in addition to
standard, sterile containers used for gram stain
and culture. (Class I, LOE B)
• Swab culture should not be used.
The American Association for Thoracic Surgery consensus guidelines, 2017

35. Pus, Gm + stain, +
culture in pleural
fluid
pH< 7.2, with
suspected pleural
space infection
predicts a
complicated
clinical course.
Pleural fluid LDH >
1000 IU/L, glucose
< 40 mg/dL or a
loculated pleural
effusion.-> unlikely
to resolve with
antibiotics alone
ICD then surgical
intervention if
required.
ICD then surgical
intervention if
required.
Thoracostomy
Class I, LOE B Class I, LOE B Class IIa, LOE B
The American Association for Thoracic Surgery consensus guidelines, 2017

36. Management
Objective:
• Evacuation of pus.
• Treatment of underlying disease.
• Restoration of lung volume
Sabiston, David C., and Courtney M. Townsend. 2016. Sabiston Textbook of Surgery : the Biological Basis
of Modern Surgical Practice. Philadelphia :Elsevier Saunders, p1604-1610.

37. Treatment Options
• Non-Operative
 General measures
 Antibiotics
 Thoracocentesis
 ICD
 Fibrinolysis
• Operative
 Decortication
 Window thoracostomy
 2 stages surgery
(window thoracostomy
followed by
thoracomyoplasty)
The American Association for Thoracic Surgery consensus guidelines, 2017

38. Treatment according to stages
• Stage I:
– Thoracocentesis
– Antibiotics/ATT
– Chest physiotherapy
The American Association for Thoracic Surgery consensus guidelines, 2017

39. • British Thoracic Society guidelines recommend
that all thoracocentesis be performed under USG.
• Success rate 66-90 % in stage I patients along
with antibiotics and physiotherapies.
• Minimum effusion depth of 1.5cm is required to
perform diagnostic thoracocentesis.

40. • Thoracocentesis without pleural drain placement is
not recommended in empyema (LOE C)
• Routine drain flushing is recommended if small bore
catheters are used. (Class I, LOE B)
The American Association for Thoracic Surgery consensus guidelines, 2017

41. Stage II
 ICD + antibiotics/ATT + chest physiotherapy
 VATS+ antibiotics/ATT + chest physiotherapy
• VATS should be the first line approach in all
patients with stage II acute empyema (Class IIa,
LOE B)
The American Association for Thoracic Surgery consensus guidelines, 2017

42. • Study shows equivalent success rates with use of
tubes <14 F and tubes >14 F.
• In our setup, patient present in mixed stage
rather pure stage II.
The American Association for Thoracic Surgery consensus guidelines, 2017

43. • Fibrinolytic agent—Streptokinase (250,000 U and
urokinase 100000 U)
• Intrapleural fibrinolytics may be used for
complicated pleural effusions (but not routinely)
and early empyemas but definitive management
continues to be surgical adhesiolysis with or
without decortication (Class IIa, LOE A)
The American Association for Thoracic Surgery consensus guidelines, 2017

44. Stage III
– VATS+ antibiotics/ATT + chest physiotherapy
– Decortication + antibiotics/ATT + chest
physiotherapy
– In Indian scenario, most patient need open
thoracotomy but in pyogenic cases VATS is good
option.

45. The American Association for Thoracic Surgery consensus guidelines, 2017

46. Antibiotics…
• 2nd and 3rd gen i.v. cephalosporine with
metronidazole, or i.v. aminopeniciline and β-
lactamase inhibitor.
• In nosocomial/post procedural empyema, against
MRSA and Pseudomonas aeruginosa (e.g. vancomycin,
cefepime, and metronidazole orvancomycin and
piperacillin/tazobactam) (Class IIa, level C)
The American Association for Thoracic Surgery consensus guidelines, 2017

47. • Whenever possible, choose antibiotic therapy
based upon culture results. (Class I, LOE C)
• Consider continuing anaerobic coverage
empirically unless specified.(Class IIa, LOE C)
• Avoid aminoglycosides in the management of
empyema. (Class I, LOE B)
• There is no role for intrapleural administration of
antibiotics. (Class I, LOE C)
The American Association for Thoracic Surgery consensus guidelines, 2017

48. • Surgical removal of thick, inelastic, restrictive
pleural peel via thoracotomy.
• All fibrous tissue is removed from the visceral
pleural peel and pus is subsequently drained from
the pleural space.
• Approached via open thoracotomy or VATS.
Decortication

49. • Decortication is reasonable in patients with
chronic empyemas who are medically operable to
tolerate major thoracic surgery. (Class IIa , LOE B)
The American Association for Thoracic Surgery consensus guidelines, 2017

50. • For frail and ill patients, neither VATS nor an open
thoracotomy may be appropriate.
• 2 or 3 rib resections may be considered to
obliterate any infection in the residual space by
bringing the chest wall down to fill the space.
Window thoracostomy
The American Association for Thoracic Surgery consensus guidelines, 2017

51. • Removal of segments of the rib in the most
dependent position to allow for drainage
internationally.
• In our setup, one rib higher segment is
selected as drainage and domiciliary sponge
dressing is explained.
• This method is more cost effective and wound
management is more feasible.

52. • Pedicled muscle flaps or omentum can be
useful to fill empyema cavities or close a
bronchopleural fistula. (Class IIa , LOE C)
The American Association for Thoracic Surgery consensus guidelines, 2017

53. • Adequate visualization despite limited access to
the thorax.
• For patients who have marginal pulmonary
reserve.
• Management of pulmonary, mediastinal, and
pleural pathology.
Video Assisted Thoraco-Scopy（VATS）
The American Association for Thoracic Surgery consensus guidelines, 2017

54. Benefits:
• Less blood loss
• Shorter operating time
• Less postoperative morbidity
• Earlier return to normal activity than with
thoracotomy.
• Reduction in 30 days mortality.
The American Association for Thoracic Surgery consensus guidelines, 2017

55. Complications:
• Persistent air leak.
• Bleeding from pulmonary vessels.
• Intercostal nerve damage.
• Complications from single-lung ventilation,
• Postoperative reexpansion pulmonary edema
• Tumor implantation following VATS.

56. Contraindication:
• Unable to tolerate one lung ventilation
• Severe coagulopathy.
Drawbacks:
• Increased operative time
• Increased cost
• Steeper learning curve
• Often requiring additional procedure.
The American Association for Thoracic Surgery consensus guidelines, 2017