Post-Empyema Fibrothorax Definition
Post-empyema fibrothorax is a chronic complication of inadequately treated empyema characterized by the formation of a thick, inelastic fibrous peel (rind) encasing both the visceral and parietal pleural surfaces, which restricts lung expansion and causes restrictive lung disease. 1
Pathophysiology and Development
Post-empyema fibrothorax represents the end-stage of untreated or inadequately managed pleural infection, also termed "organized empyema." 1 This condition develops when:
- Fibrinous material deposited during the empyema organizing phase fails to resolve and instead matures into a thick, hard fibrous peel that encases the lung and restricts its ability to expand 1
- The process involves both visceral pleural surfaces (covering the lung) and parietal pleural surfaces (lining the chest wall), creating a rigid cage that prevents normal respiratory mechanics 1
- If not managed appropriately, this fibrous peel leads to chronic sepsis and restrictive lung disease 1
Clinical Significance
The British Thoracic Society guidelines emphasize that organized empyema with fibrothorax is relatively uncommon now, especially at initial presentation, due to earlier recognition and intervention. 1 However, when it does occur:
- Symptomatic patients with organized empyema and thick fibrous peel require formal thoracotomy and decortication (surgical excision of the pleural rinds) to achieve proper lung re-expansion 1
- Asymptomatic patients may not necessarily require surgery 1
- The decortication procedure requires sharp dissection and excision of both visceral and thick parietal pleural rinds, which carries risks including significant bleeding, lung parenchymal damage with air leaks, and possible nerve injuries 1
Diagnostic Imaging
CT scanning with intravenous contrast is the most useful imaging modality before surgery to define the thickness of the pleural peel relative to consolidated lung and to check for intralobar pathology such as lung abscesses. 1
Prevention
Early recognition of developing organization is essential to avoid the significant morbidity associated with fibrothorax. 1 The process of rapid evaluation and therapeutic intervention appears to reduce morbidity and mortality. 1
Important Caveat
Pleural thickening seen on contrast-enhanced CT scanning represents a "fibrinous" peel that may prevent lung re-expansion despite adequate drainage of the pleural space, but this pleural peel may resolve over several weeks in patients spared surgery. 1 Residual calcification, thickening of extrapleural tissues, and pleural scarring may persist long after empyema treatment. 1