What is the treatment for persistent multiloculated empyema?

Treatment of Persistent Multiloculated Empyema

For persistent multiloculated empyema that has failed initial medical management (antibiotics, chest tube drainage, and fibrinolytics for 7 days), surgical intervention with video-assisted thoracoscopic surgery (VATS) should be pursued, with open thoracotomy and decortication reserved for organized empyema with thick pleural peel. 1, 2

Initial Assessment and Medical Management

When confronting persistent multiloculated empyema, first confirm that adequate medical therapy has been attempted:

• Broad-spectrum intravenous antibiotics targeting common pathogens (second-generation cephalosporin plus metronidazole, or meropenem plus metronidazole) must be administered, avoiding aminoglycosides due to poor pleural penetration 3
• Small-bore chest tube drainage with ultrasound guidance should be in place, connected to a unidirectional flow system 2, 3
• Intrapleural fibrinolytic therapy with urokinase (40,000 units in 40 ml saline for patients ≥10 kg, twice daily for 3 days) should have been administered 2, 3

Critical timeframe: If persisting sepsis with persistent pleural collection continues despite 7 days of this combined approach, early surgical consultation is mandatory 1, 2

Surgical Decision Algorithm

Indications for Surgery

Surgery should be pursued when any of the following are present:

• Persistent sepsis with ongoing pleural collection despite antibiotics, drainage, and fibrinolytics for 7 days 1, 2
• Bronchopleural fistula with pyopneumothorax 1, 2
• Complex empyema with significant lung pathology (delayed presentation with significant peel and trapped lung) 1
• Organized empyema in a symptomatic patient with thick fibrous peel causing chronic sepsis and restricted lung expansion 1, 2

Important caveat: A persistent radiological abnormality in a symptom-free, clinically well patient is NOT an indication for surgery 1, 2

Surgical Approach Selection

Video-Assisted Thoracoscopic Surgery (VATS)

VATS is the preferred first-line surgical approach for persistent multiloculated empyema in the fibrinopurulent stage 2, 4, 5

Advantages:

• Success rates of 91-100% in multiloculated empyema 6, 4, 5
• Shorter drainage time and hospital stay compared to tube thoracostomy alone 4
• Less postoperative pain and better cosmetic results 1
• Lower complication rates 4

Limitations and contraindications:

• Higher failure rate in advanced organized empyema 1
• Inability to develop pleural window access 1
• Presence of thick pyogenic material or fibrotic pleural rinds 1
• Organized empyema with separate 'pockets' not in communication often requires surgical approach 5

Open Thoracotomy and Decortication

Open thoracotomy with decortication is reserved for organized empyema with thick fibrous peel 1, 2, 7

Specific indications:

• Late presenting empyema with thick pleural peel 1, 2
• Chronic empyema causing restrictive lung disease 1
• Failed VATS requiring conversion 1
• Symptomatic organized empyema with trapped lung 1, 2

Success rate: 100% complete response in organized empyema, though with higher morbidity than VATS 8

Preoperative requirements:

• CT scanning with IV contrast to define pleural peel thickness versus consolidated lung 1, 7
• Verification of ability to tolerate lung resection and general anesthesia 7
• Nutritional optimization if malnourished 7

Alternative Approaches

Medical Thoracoscopy

Medical thoracoscopy can be considered as an intermediate option:

• Success rate of 91-92% in multiloculated empyema 6, 5
• Only 50% success in organized empyema, often requiring subsequent VATS or open surgery 5
• Lower cost and better tolerated in frail patients compared to VATS 9
• Complications occur in approximately 9% of cases 6

Percutaneous Catheter Drainage with Fibrinolytics

While persistent complex collections can be treated with instillation of fibrinolytic agents, meta-analyses conclude there is insufficient evidence to support routine use of fibrinolytics for empyemas 1

Common Pitfalls to Avoid

• Do not delay surgical referral beyond 7 days of failed medical management with persistent sepsis 1, 7
• Do not operate on radiological abnormalities alone in asymptomatic, clinically well patients 1, 2
• Do not attempt VATS in organized empyema with thick fibrotic peel, as this leads to conversion to open thoracotomy 1
• Do not use tube thoracostomy alone in multiloculated empyema, as success rates are only 66% compared to 95-100% with VATS 4

Monitoring and Follow-Up

• Continue antibiotics until clinical resolution with sterile cultures 3
• Follow patients until complete recovery with near-normal chest radiograph 2, 3
• Secondary scoliosis on imaging is common but transient and requires no specific treatment 2, 3