What are the American Thoracic Society (ATS) guidelines for empyema management?

American Thoracic Society (ATS) Guidelines for Empyema Management

The American Thoracic Society guidelines recommend a structured approach to empyema management including diagnostic sampling within 24 hours, appropriate antibiotic therapy, chest tube drainage, and early surgical referral if drainage fails within 5-8 days. 1

Diagnostic Approach

• Pleural fluid should be sampled within 24 hours in >95% of suspected pleural infection cases 1
• Pleural fluid pH should be measured with a blood gas analyzer at first diagnostic tap (unless visibly purulent) 1
• All pleural fluid samples assessed in blood gas analyzers must be heparinized 1
• Patients with persistent sepsis and residual pleural collection should undergo further radiological imaging 1

Treatment Algorithm

1. Initial Management:

   • Appropriate antibiotic treatment for all patients with pleural infection 1
   • Chest tube drainage for all infected pleural effusions (unless clear contraindication exists) 1

2. Assessment of Treatment Response:

   • Evaluate effectiveness of drainage and resolution of fever/sepsis 5-8 days after initiating chest tube drainage and antibiotics 1
   • Document assessment results in clinical notes 1

3. Surgical Referral:

   • Discuss with thoracic surgeon if effective pleural drainage is not achieved at 5-8 day assessment 1
   • Consider surgical treatment for patients with persisting sepsis and persistent pleural collection despite chest tube drainage and antibiotics 1
   • Failure of sepsis to begin resolution within 7 days is suggested as an appropriate period after which surgical opinion should be sought 1

Surgical Options

• Video-assisted thoracoscopic surgery (VATS) is appropriate for ATS stage II fibrinopurulent empyema 2
• Open decortication is recommended for chronic (ATS stage III) empyema 2
• For patients unable to tolerate general anesthesia, consider:
  • Re-imaging and placement of additional image-guided small bore catheters
  • Large bore chest tubes
  • Intrapleural fibrinolytic therapy
  • Local anesthetic surgical rib resection 1

Additional Considerations

• Nutrition: Ensure adequate nutritional support starting as soon as possible after pleural infection is identified (hypoalbuminemia is associated with poor outcomes) 1
• Bronchoscopy: Only perform in patients with high suspicion of bronchial obstruction 1
• DNase compounds: Not yet recommended as adjuncts in pleural drainage based on available evidence 1

Staging of Empyema

The ATS classifies pleural empyema into different stages based on natural disease course 3:

• Stage I: Exudative phase
• Stage II: Fibrinopurulent phase
• Stage III: Organizing phase (chronic)

This staging system helps guide appropriate management strategies, with more invasive approaches typically required for advanced stages.