Empyema thoracis is the accumulation of pus in the pleural cavity. It develops in stages from an initial exudative stage with low LDH and normal glucose/pH, to a fibropurulent stage with fibrin deposition and loculations, and finally an organization stage with pleural peels. Symptoms include dyspnea, fever, cough and chest pain. Diagnosis is made by thoracentesis showing low glucose, high LDH and low pH. Management depends on stage and includes antibiotics, tube thoracostomy, VATS, decortication or open window thoracostomy. Complications are more common in chronic cases, including bronchopleural fistulas.

1. Empyema Thoracis
Dr. Anuj Mehta
DNB-CTU ,GKNM Hospital

2. • Accumulation of pus in the pleural cavity.
• Incidence: 5-10 % of hospitalized patient
with parapneumonic effusion.

3. ETIOLOGY

4. Pathology
• First or exudative stage:
has relatively low LDH, normal glucose and normal pH.
• Second or fibropurulent stage:
increased fibrin deposition, cellular debris and blood cells formation of fibrinous
membranes producing loculations.
• Third or organization stage:
fibroblasts grow into fibrin sheet coating the visceral and parital pleura "pleural peel"
causing entrapment of the lung.

5. Clinical Stages
• Acute :
Within the first 2 weeks of the onset.
• Chronic :
After 2 weeks or with the formation of the thick
peel and loculations.

6. COMPLICATIONS
more likely to develop during chronic stage

7. • Suspicion-Acute respiratory illnesses with associated pleural effusion.
• The most common initial manifestations - dyspnoea (82%), fever
(81%), cough (70%), and chest pain (67%).
• Tachycardia, malaise, anorexia, and weight loss
• very acutely or develop insidiously over weeks.
• Physical examination - diminished mobility of the involved
hemithorax, decreased breath sounds, and dullness on percussion.

8. Diagnosis
• 1- Pus obtained on thoracocentesis.
➢Glucose concentration < 40 mg/dl,
➢LDH > 3 times the upper limit of normal, and
➢PH < 7.2
• 2- Chest x ray:
➢Posteroanterior and lateral.
➢150- 200 ml needed to blunt costophrenic angle.

10. • 3- Ultrasonography:
Localize small amount of fluid and loculation
and identify pleural peel.

11. • 4- CT Scan:
Differentiating empyema, lung abscess,
subdiaphragmatic fluid
SPLIT PLEURA

12. Cohen and colleagues- empyema management depends on its
• cause,
• clinical stage,
• state of the underlying lung,
• presence or absence of a bronchopleural fistula, and the patient’s cli

16. Management
• Medical :
Non interventional therapy often contraindicated
Thoracocentesis and culture sensitivity based antibiotic
therapy generally successful for stage I NOT stage II or III.

17. • Surgical :
1) Tube thoracostomy (28-36 Fr.), connected to
negative suction of 20 mmHg
the tube withdrawn slowly several weeks until
removed.
2) Insertion of pigtail catheter (8 fr to 14 fr) with
administration of fibrinolytics such as streptokinase
or urokinase until the pleural space is cleared.
—> surgery contraindicated

18. 3) Thoracoscopy (VATS):
The next therapeutic option after fibrnolysis,
Advantages
• Visualisation
Determine if complete drainage of all empyema
Disruption of all adhesions and loculations.

19. • Decortication of the lung
• Space filling by muscle transplants, space collapse, and space steril

20. • 4) Decortication:
Via thoracotomy should be performed when third
stage is suggested by CT Scan.
i) Remove all purulent fluid, fibrinous debris,
thickened parietal pleura from the pleural space.
ii) Resection of visceral pleural peel.

21. Rib Resection Drainage and Open Thoracic Window
• resection of a short segment of rib over the most dependent part of
• the opening and deloculation of the space
• insertion of a large multi- fenestrated tube into the cavity.
• If the visceral pleura is thin and “stretchable,” space obliteration ma

22. A more permanent—> creation of an open-window thoracostomy.
Dr. Leo Eloesser in 1935
particularly useful for patients in whom long-term drainage may be required
Thourani and colleagues reported a series of patients who underwent a modifie

25. • Bronchopleural fistulas aggravate the course of empyemas and pre
• indicates persistent contamination of the pleural space,
• difficulties in the re-expansion of the lung,
• and possible aspiration in the remaining lung.

26. • coughing up of serosanguineous fluid or pus, fever, malaise, and gen
• CXR- small space may be enlarging or a newly formed air-fluid leve
• lowering or sudden disappearance of a pleural effusion or
• a mediastinal shift toward the contralateral side.
• A drop of at least two intercostal spaces is considered significant to
• The diagnosis of a bronchopleural fistula is usually made by
• bronchoscopy or by observing persistent air leak through the ches

27. Conservative
• suction drainage
• fibrin sealants applied through the rigid bronchoscope
• the flexible fiberoptic broncho-scope.
• re-closure of the bronchus,
• re- amputation of the stump,
• additional sealing of the pulmonary sutures,
• or additional resection may be advisable.

28. Secondary failures (the bronchial stump reopens )because of
local pressure by the purulent collection.In this situation,
drainage should be done initially, followed by definitive
management, which consists of bronchial re-closure, muscle
flap, or thoracoplasty.