Empyema thoracis, characterized by pus in the pleural space, often follows unresolved pneumonia and can arise from various infections, trauma, or complications from thoracic surgery. It progresses through three phases: exudative, fibrino-purulent, and organizing, each requiring different diagnostic and treatment approaches, including antibiotics, drainage, and potential surgical intervention. Key clinical features include chest pain, fever, and dyspnea, with diagnosis supported through imaging and fluid analysis.

1. Empyema Thoracis
Dr. Sunil K S Gaur
Senior Resident

2. Introduction
 “Pus in the plural space”
 End stage of pleural infection from any cause
 Hippocrates credited with first description of natural history and
treatment
 Streptococcal or Pneumococcal – m/c
 Gram negative and anaerobic
 Tubercular

3. Aetiology
 Unresolved pneumonia – m/c
 Other pulmonary infections – bronchiectasis, tuberculosis, fungal infections, lung
abscess
 Trauma – haemothorax becomes infected, oesophageal injury
 Complication of any thoracic operation
 Pus under the diaphragm
 Osteomyelitis of ribs or vertebrae

4. Pathology

5. Pathology
 Presence of thick pus and
 Thick cortex of fibrin and coagulum over the lung
 When presents de novo it usually follows pneumonia, and three phases
are described:
1. Exudative phase (1-3 days)
2. Fibrino- purulent phase (4-14 days)
3. Organizing/Chronic phase (after 14 days)

6. 1. Exudative phase
 Protein-rich (>30 g/L) effusion
 If this becomes infected with the organisms from the lung the scene is set for empyema
 Increased neutrophils in fluid
 However normal glucose, LDH level and pH
 Antibiotics may be all that is required
 Aspiration or drainage to dryness in addition is preferred

7. 2. Fibrino-purulent phase
 Pleural fluid becomes thick & fibrin deposits over the pleural surfaces
 Bacterial stains present, frank pus
 pH and glucose levels become low
 LDH, neutrophils and protein levels increase
 Drainage at this stage is prudent as antibiotics alone are ineffective

8. 3. Organizing/Chronic Phase
 Fibrin converted in to fibroblasts, new capillary ingrowth begins
 Causes the lung to be trapped by a thick peel or ‘cortex’
 Effusion grossly purulent, thick like curd
 Contraction of thorax - scoliosis
 Surgical management may be required

9. Clinical features

10. Clinical Features
 History
 Malaise
 Chest pain
 Fever
 Cough
 Dyspnea
 Loss of appetite
 Weight loss

11. Clinical Features (contd.)
Examination:
Inspection:
Asymmetric chest expansion
May be discharging wound
Tracheal deviation may be seen
Bulging ICS
Palpation:
Raised local temperature in acute
phase
Local tenderness
Decreased tactile fremitus

12. Clinical Features (contd.)
Examination:
Percussion:
Dull note
Auscultation:
Egophony
Pleural friction rub
Decreased breath sounds

13. Diagnosis

14. Diagnosis
 X-ray chest
 Erect PAand Lateral views
 Fluid in pleural cavity seen as opacity
in dependent part
 Erect lateral view – Minimum 50 ml
 Erect PA view – Minimum 175 ml
 Physical examination – Minimum 300
ml

15. Diagnosis (contd.)
 Ultrasonography:
 Amount of fluid, and loculations are
imaged
 USG guided diagnostic/therapeutic
thoracocentesis
 Can detect physiological amount of
pleural fluid, i.e. 5 ml
 100% sensitivity for effusion >100 ml

16. Diagnosis (contd.)
 CT scan:
 Reference standard in plural diseases
 Distinguish pleural with parenchymal
abnormalities
 Determine precise location, extent
and loculations
 Split pleura sign – Enhancing,
thickened visceral and parietal
pleural layers separated by an
intervening layer of low attenuation
fluid

17. Diagnosis (contd.)
 Aspiration and Pus analysis:
 Gram staining
 Culture & sensitivity
 AFB/ZN staining
 CBNAAT for mycobacterium
 KOH mount for fungal
 Blood tests:
 CBC – TLC, DLC
 Blood sugar – to rule out DM
 Culture & sensitivity
 CRP
 Arterial blood gas

18. Treatment

19. Treatment Options
Non-surgical
 Moist O2 inhalation
 Chest physiotherapy
 Antimicrobials
 NSAIDs
 Anti-pyretics
 Pleural tap
 Mechanical ventilation
Surgical
 Chest tube drainage
 Talc pleurodesis
 Fibrinolysis
 VATS + Debridement
 Thoracotomy + Decortication

20. Treatment Phase 1
 USG guided pleural tap – Diagnostic + Therapeutic
 Chest tube insertion
 Antibiotics/ATT
 Chest physiotherapy
 Thoracocentesis without pleural drain placement is not
recommended in empyema

21. Treatment Phase 2
 Chest tube insertion + Fibrinolysis (or)
 VATS + debridement + Chest tube in
situ
 Antibiotics/ATT
 Chest physiotherapy
 Fibrinolytic agent – Streptokinase,
urokinase

22. Treatment Phase 3
 Thoracotomy + Decortication + Chest
tube in situ
 Antibiotics/ATT
 Chest physiotherapy
 If feasible, VATS is a good option

23. Surgical management of pleural
effusions and infections

24. Thoracoscopy
 Direct-vision thoracoscope was used for many years
 Use was limited mainly to performing biopsies
 had a limited view
 uncomfortable to use for any length of time
 one hand used up for holding the thoracoscope

25. VATS (Video-assisted
thoracoscopic surgery)
 Camera is attached to the thoracoscope,
which can be operated by an assistant with
the image displayed on a screen
 Surgeon’s hands are freed
 Can manipulate instruments with both hands
to perform a variety of procedures
 lung is isolated using a double lumen tube
 the patient is positioned disease side up, and
the pleural cavity is entered

26. VATS
(contd.)

27. VATS - Benefits
 Less blood loss
 Small scar
 Less postoperative morbidity
 Decreased need of post-op mechanical ventilation
 Earlier chest physiotherapy
 Reduction in 30 days mortality

28. Drainage and Talc Pleurodesis
 Early in its evolution, requires drainage
 Direct visualization of the pleural cavity
for complete drainage
 Excellent talc insufflation to achieve
pleurodesis in malignant pleural effusion
 Multiple pleural biopsies can be taken
for undiagnosed cases

29. Debridement of empyema
 Once the fluid component becomes
fibrinopurulent and loculated it requires
surgical debridement
 Can often be achieved through a VATS
approach
 Fluid and debris are vigorously
debrided, freeing the lung and allowing
for re-expansion

30. Decortication
 fibrous cortex or peel from the
entrapped underlying lung is removed
 usually performed through a
posterolateral thoracotomy
 though in selected cases it can be
performed as a VATS procedure
 requires careful dissection to remove the
parietal and visceral cortex
 taking care not to damage the visceral
pleura

31. Complications

32. Complications
 Septicemia and MODS
 Respiratory failure
 Secondary scoliosis
 Empyema necessitans
 Bronchopleural fistula
 Pericarditis
 Peritonitis

33. Empyema
necessitans
 Extension of a pus out of the pleura and
into the neighboring chest wall and soft
tissues
 Fluctuant swelling over chest wall
 Now rare; only in immuno-compromised
 Tx – Closed drainage; rest same

34. Bronchopleural fistula
 Abnormal connection between airway
and pleural cavity
 Leads to cough with copious amounts of
purulent expectoration
 Tx – Adequate drainage of empyema
+/- repair

35. Thank
you!