What is the treatment for empyema thoracis?

Treatment of Empyema Thoracis

Initial management of empyema thoracis requires immediate broad-spectrum intravenous antibiotics combined with small-bore chest tube drainage under ultrasound guidance, with intrapleural fibrinolytics administered twice daily for 3 days to optimize drainage and reduce the need for surgery. 1, 2

Initial Medical Management

Antibiotic Therapy

• Start broad-spectrum intravenous antibiotics immediately targeting common pathogens (Streptococcus, Staphylococcus, and anaerobes including Bacteroides), then adjust based on culture results 1, 2, 3
• Continue antibiotic therapy for an extended duration of 2-4 weeks minimum, depending on clinical response 1
• Note that Staphylococcus aureus, particularly methicillin-resistant strains, is the most frequent cause of treatment failure 4

Chest Tube Drainage

• Insert a small-bore chest drain under ultrasound guidance rather than large-bore drains, as there is no evidence that large-bore drains provide any advantage and they cause more patient discomfort 2
• Connect the drain to a unidirectional flow drainage system, kept below the patient's chest level at all times 2
• Clamp the drain for 1 hour once 10 ml/kg are initially removed to prevent re-expansion pulmonary edema, but never clamp if bubbling 2
• Tube thoracostomy alone successfully resolves empyema in approximately 63% of cases 3

Intrapleural Fibrinolytic Therapy

• Administer intrapleural urokinase twice daily for 3 days for any complicated parapneumonic effusion or empyema, as this shortens hospital stay 2
• Dosing protocol: 40,000 units in 40 ml 0.9% saline for patients ≥10 kg, and 10,000 units in 10 ml 0.9% saline for patients <10 kg 2

Surgical Management Algorithm

Timing of Surgical Consultation

• Initiate early discussion with a thoracic surgeon if the patient fails to respond to chest tube drainage, antibiotics, and fibrinolytics within 48-72 hours 1
• The traditional 7-day window for surgical referral should be shortened to 48-72 hours based on modern practice patterns 5, 1

Specific Indications for Surgery

Surgery should be considered for: 5, 1, 2

• Persisting sepsis with persistent pleural collection despite antibiotics, chest tube drainage, and fibrinolytics
• Organized empyema with thick fibrous peel restricting lung expansion and causing chronic sepsis
• Multiloculated empyema not responding to medical management
• Bronchopleural fistula with pyopneumothorax
• Complex empyema with significant lung pathology (delayed presentation with significant peel and trapped lung)

Surgical Approach Selection

Video-Assisted Thoracoscopic Surgery (VATS):

• VATS is most appropriate for early surgery in the fibrinopurulent stage, offering less postoperative pain, shorter hospital stay, and better cosmetic results 5
• Contraindications include inability to develop a pleural window, presence of thick pyogenic material, and/or fibrotic pleural rinds 5
• Failure rate is higher in advanced organized empyema, which may then require conversion to open thoracotomy 5

Open Thoracotomy and Decortication:

• Reserved for late presenting empyema, chronic empyema, and organized empyema with thick fibrous peel causing chronic sepsis and restricted lung expansion 5, 1, 2
• Requires sharp dissection and excision of both visceral and thick parietal pleural rinds 5
• Despite traditional prejudice, modern series show rapid symptomatic recovery with drain removal on first or second postoperative day, fever resolution within 48 hours, and median hospital stay of only 4 days 6

Critical Pitfalls to Avoid

Do NOT Surgically Drain Coexisting Lung Abscesses

• A lung abscess coexisting with empyema should NOT be surgically drained, as empyema management and antibiotics will treat the lung abscess, and surgical drainage increases morbidity without improving outcomes 1, 7
• Most lung abscesses drain spontaneously through the bronchial tree 7

Persistent Radiological Abnormality Alone Is NOT an Indication for Surgery

• A persistent radiological abnormality in a symptom-free, clinically well patient is not an indication for surgery 5
• Complete radiographic resolution may take weeks to months 1, 2

Supportive Care

• Provide antipyretics for fever control and adequate analgesia, particularly with chest drains in place 1, 2
• Do NOT perform chest physiotherapy, as it provides no benefit in empyema 1, 2, 7
• Encourage early mobilization and exercise once clinically stable 1, 2, 7
• Monitor for secondary thrombocytosis, which is common and benign, requiring no specific treatment 1, 2, 7

Follow-Up

• Continue follow-up until complete clinical recovery and chest radiograph returns to near normal, which may take weeks to months 1, 2
• Consider underlying diagnoses such as immunodeficiency or cystic fibrosis in appropriate cases 2, 7