Pyothorax, or empyema thoracis, is an accumulation of pus in the pleural cavity that is usually caused by bacterial pneumonia. It progresses through three stages - exudative, fibrinopurulent, and organizing. Symptoms include chest pain, cough, fever, and shortness of breath. Diagnosis involves chest x-ray, CT scan, and thoracentesis of pleural fluid. Treatment requires antibiotics, drainage of pus from the pleural space, and sometimes surgical procedures like VATS to debride the pleural space and allow for lung re-expansion. Complications can include bronchopleural fistula, spread of infection, and sepsis.

1. Pyothorax / Purulent Pleuritis / Empyema Thoracis
Prepared By:
Sharmin Susiwala

2.  Definition:
“ Pleural empyema (also known as
a pyothorax or purulent pleuritis) is an
accumulation of pus in the pleural cavity. ”
Empyema itself is not disease it is actually a condition
complicated by another disease

3.  Etiology:
o 2ndry to Bacterial Pneumonia Parapneumonic
effusion (non-infected Pleural Effusion) infected
(complicated) paraneumonic effusion Empyema.
o Other causes include:-
o Empyema thoracis can be caused by a number of
different organisms, including bacteria, fungi, and
amoebas, in connection with pneumonia.
o Common cause is pulmonary infection as a result of
aerobic bacteria such as Streptococcus pneumonia,
Staphylococcus aureus, E. coli, Klebsiella
pneumoniae, Hoemophilus influenzae.
o Chest trauma(blunt chest wound, chest surgery, lung
abscess, or a ruptured esophagus)
o Septicaemia (very rare blood borne infection)
o Subdiaphragmatic causes as liver abscess

4. o Iatrogenic: In rare cases, empyema can occur
after a needle is inserted through the chest wall to
draw off fluid in the pleural space for medical
diagnosis or treatment (thoracentesis).

5. Stages:
 There are three stages:
1. Exudative (Acute)
2. Fibrinopurulent(Transitional)
3. Organizing(Chronic)
Stage -1: “Exudative”
- Sterile pleural fluid develops secondary to inflammation
without fusion of the pleura; swelling of pleural
membranes
- Approximately in 7 days.
Stage- 2: “Fibrinopurulent”
- Thick,Opaque fluid with positive culture (pus)
- Deposition of thin fibrin layer over the pleura.
- Progressive loculation and formation of pouches in the
pleura.
- From 7 day to 21 days.

6. Stage-3 : “Organizing”
- scarring of the pleural space may lead to lung
entrapment
- Presence of very thick pus
- after 21 days

7.  Clinical Features:
 Symptoms of pleural empyema may vary in severity.
 Typical symptoms include:
 Chest pain, which worsens when you breathe in
deeply (pleurisy)
 Dry cough
 Excessive sweating, especially night sweats
 Fever and chills
 General discomfort, uneasiness, or ill feeling
(malaise)
 Shortness of breath

8.  Weight loss (unintentional)
 Clubbing may be present in cases of a chronic nature.
 There is a dull percussion note and reduced breath
sounds on the affected side of the chest.
 In severe cases, the patient may become dehydrated,
cough up blood, greenish–brown sputum, or run a
fever as high as 105F, or even fall into a coma

9. Diagnosis:
 Chest X-ray.
C-T scan.
 Thoracentesis
 Pleural fluid Gram stain and culture

10. On chest X-ray, empyema
thoracis will appear as a cloudy or
opaque area.

11. CT Scan

12.  Diagnosis is confirmed by thoracentesis
 Thoracentesis :
 This is a procedure which involves the insertion of a needle into
the pleural cavity through the back between the ribs on the
infected side, and a sample of fluid is withdrawn
 It is performed under local anesthetics
 If the patient has empyema, there will be leukocytosis, a high
level of protein, and a very low level of blood sugar.

13.  This is the most useful test that conducts analysis
of aspirated pleural fluid which shows:
 transudative effusions: lactate dehydrogenase
(LD) levels less than 200 IU and protein levels
less than 3 g/dl
 exudative effusions: ratio of protein in pleural fluid
to serum greater than or equal to 0.5, LD in pleural
fluid greater than or equal to 200 IU, and ratio of
LD in pleural fluid to LD in serum greater than or
equal to 0.6
 empyema: acute inflammatory white blood cells
and microorganisms
 empyema or rheumatoid arthritis: extremely
decreased pleural fluid glucose levels.

14. Management:
 Effective management require:
1. Control of infection and sepsis by antibiotics.
2. Evacuation of pus from pleural space.
3. Obliteration of the empyema cavity.
 Delay in drainage increase mortality from 3.4% to
16%.
 Empyema is treated using a combination of
medications and surgical techniques
 Early-course: aspiration, Abx, and sometimes
fibrinolytic therapy.
 Late-course: continuous drainage or surgical
debridement & decortication.

15.  Antibiotic therapy:
 Dependent on identification of causative organism
 Appropriate therapy requires isolation of organism
from blood, pleural fluid or sputum Empiric therapy
should be based on local epidemiology and should
cover S. pneumonia, S. pyogenes and S. aureus
 Treatment with medication involves intravenously
administering a two-week course of antibiotics.
 It is important to give antibiotics as soon as possible
to prevent first-stage empyema from processing to
its later stage.
 The antibiotics most commonly used are penicillin
and vancomycin

16.  Drainage of Empyema
 First step in treating acute empyema
 Performed under general anesthesia
 Done for the dependent rib
 Open all the intact cyst that leads to conversion of
empyema with free pus
 Then place intercostal tube for drainage and close the
wound
 Antibiotics should continue for 6 weeks
 Includes:
 Intercostal tube thoracostomy.
 Intrapleural instillation of streptokinase .
 V.A.T.S.
 Rib Resection Drainage.
 Eloesser Flap

17.  Rib Resection Drainage;
• Performed under general anesthesia
• when the pus is thick and loculated
• Open all the intact cyst that leads to conversion of empyema
with free pus
• Then place intercostal tube for drainage and close the
wound
• Antibiotics should continue for 6 weeks Chest Tube
 Fibrinolytic Therapy :
 Studies used Streptokinase or Urokinase
 Most effective in the early fibrinopurulent stage and
may make surgical drainage unnecessary
 Life-threatening complications rare
 Potential adverse effects includes: Bleeding
Bronchopleural fistula Fibrinolytic Therapy

18. Rib resection drainage

19. Videoscopic Assisted Thoracoscopy Surgery (VATS) :
 Minimally invasive
 Can be used at any stage
 Advantages includes: Allowance of direct visualization of pleura
and lung Optimal placement of chest tube
 Fibrinolysis & decortication can be performed.
 Retrospective case reviews suggest children with failure of
conventional CT therapy exhibit improvement after VATS
especially if performed early Videoscopic Assisted Thoracoscopy
Surgery (VATS)

Thoracostomy :
 Open drainage with pleural peel decortication
 Excision of the thick fibrous pleural rind and removal of infectious
material
 Longer & complicated procedure
 Reserved for late presenting empyema with significant fibrous
pleural rind, complex empyema & chronic empyema

20. Eloesser Flap Drainage

21. Decortication

22. Complications:
 Rupture into the lung;
BronchoPleural fistula
 Spread to the subcutaneous tissue;
Empyema Niscitanes
 Septicaemia & septic shock.