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THORACIC EMPYEMA
Dr Phillipo Leo Chalya
M.D. [Dar]; M.MED surg [Mak]
Surgeon Specialist - BMC

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OUTLINE
Definition
Historical background
Etiology
Bacteology
Classification
Pathophysiology
Clinical presentation
Work up
Treatment
Complications

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DEFINITION
Present of pus in the pleural cavity
It is not a primary disease
It is secondary to other underlying
diseases
It is a complication of other diseases

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HISTORICAL BACKGROUND
For centuries, ET has been recognized as
a serious problem
Around 500 BC, Hippocrates
recommended treating ET with open
drainage
In 1876,Hewitt described a method of
UWSD
In early 20th
century surgical therapies for
ET i.e. thoracoplasty and decortication
were introduced

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ETIOLOGY
Classified as
– Local causes
– Systemic causes

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Local causes
Chest wall causes
– Osteomyelitis of ribs / thoracic vertebrae
– Penetrating wounds
– Thoracic wall abscess
Pleural causes
– Pneumothorax
– Haemothorax

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Pulmonary causes
– Pneumonia
– Bronchitis
– Pulmonary TB
– Lung abscess
– Bronchiectasis
Sub-diaphragmatic causes
– Subphrenic abscess
– Hepatic abscess
Iatrogenic causes
– Esophageal perforation during esophagoscopy
– Pleural tap
– Postpneumonectomy
– Postthoracotomy

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Systemic causes
Septicaemia

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BACTEOLOGY
Staphylococcus aureus
Steptococcus pneumoniae
Escherichia Coli
M. Tuberculosis
Aerobacter aerogenes
Proteous
Salmonella
etc

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CLASSIFICATIONS
Anatomical classification
Clinical classification
Pathological classification

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Anatomical classification
Total thoracic empyema
– The whole pleural cavity is involved
Localized or encysted thoracic
empyema
– Only part of the thoracic cavity is involved

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Clinical classification
Acute thoracic empyema
– In which there is profound toxemia and shock
– Patient presents with high grade fever, cough with
pleuritic chest pain and shallow breathing
Sub-acute thoracic empyema
– This is less severe form of presentation in patients
who was on antibiotics for pneumonia
Chronic thoracic empyema
– This usually results from mismanagement of the
acute form

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Pathological classification
Exudative (early) empyema
Fibrino-purulent (established) empyema
Organizing empyema

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PATHOPHYSIOLOGY
According to the American Thoracic
Society [1962], the development of
thoracic empyema passes through 3
stages:-
– Exudative stage
– Fibrino-purulent stage
– Organizing stage

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Stage I: Exudative (early) stage
This is purely an inflammatory process
in which there is an increase in
permeability of small blood vessels
leading to exudation of fluid in the
pleural cavity
The fluid is very thin with low cellular
content and underlying lung that re-
expands readily

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Stage II: Fibrino-purulent
(established) stage
This stage is characterized by:-
– large number of polymorphonuclear
leucocytes
– deposition of fibrin on both visceral and
parietal surfaces of the involved pleura
– Bacterial invasion of the pleural space
– Tendency towards loculation formation

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Stage III: Organizing stage
In this case fibroblasts appear in the
now heavier fibrin coating of the pleural
membranes
The fluid (exudates) is quite thick

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CLINICAL PRESENTATION
Symptoms
– Cough
– Pleuritic chest pain
– Breathlessness
– ±Haemoptysis
– Fever
– Rigors
– General body weakness

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Signs
Febrile
Dyspnoea
Toxic
Chest examination
– Evidence of fluid in the chest cavity-stony
hard percussion note

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WORK UP
Lab studies
– Haematological investigations
• Haemoglobin
• WBC count + ESR
• ELISA test for HIV
– Bacteriological investigations
• Sputum for AFB
• Sputum for culture and sensitivity
• Pus for culture and sensitivity

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Imaging investigations
– Chest x-ray
– Abdominal USS to rule out hepatic abscess
– CT scan of the chest
• Help to delineate the pleural fluid loculations
• Can also detect airway or parenchymal
abnormality e.g. endobronchial obstruction or the
presence of lung abscess
Diagnostic procedures
– Aspiration of pus to confirm diagnosis

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TREATMENT
Objectives of treatment
– To control the primary infection by
appropriate medications
– Evacuation of purulent content of the
empyema sac and eradication of the sac to
control chronicity i.e. to obliterate
empyema space
– Re-expansion of the underlying lung to
restore function
– To prevent complications

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Modalities of treatment
– Depends on the stage of the empyema
– Divided into:-
• Non-surgical therapy
– Antibiotics
– Intrapleural thrombolytic agents
– Needle aspiration (Thoracocentesis)
• Surgical therapy
– Thoracoscopy
– Closed chest drainage (underwater seal
drainage-UWSD)
– Open chest drainage (rib resection)
– Decortications
– Thoracoplasty

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Needle aspiration (thoracocentesis)
This is both diagnostic and therapeutic
It may be adequate only in exudative
stage (stage I)

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Closed chest drainage (UWSD)
This is done if the fluid (pus) in the
pleural sac is thicker to evacuated by
simple needle aspiration
It applied only in stage I & II

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Open chest drainage (Rib resection)
In this case, 2-3 ribs are resected to
allow evacuation of pus, break up
loculations and adherence, wash the
cavity and put UWSD to prevent re-
accumulation of empyema
This is done if the pus is too thick to be
evacuated by UWSD

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Decortications
In this case, thoracotomy is done and
peel out the cortical layer over the
parietal and visceral surfaces

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Thoracoplasty
In this case ribs are taken away to
compress the chest
Due to high mortality and morbidity the
procedure has been ABANDONED

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COMPLICATIONS
Respiratory insufficiency
Systemic septicaemia
Septic emboli to the brain
Broncho-pleural fistula
Lung collapse
Empyema necessitans
Amyloidosis

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SPECIAL THANKS TO
SADRU MOHAMED
FOR MAKING THESE SLIDES
AVAILABLE HERE
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+255759212578