What are the management options for persistent empyema (empyema is a collection of pus in the pleural space) after decortication (surgical removal of the restrictive layer of fibrotic tissue surrounding the lung)?

From the Guidelines

Persistent empyema after decortication requires prompt management with a combination of surgical and antimicrobial approaches, prioritizing intrapleural fibrinolytics as a first-line treatment to improve drainage and reduce morbidity, as recommended by the most recent guidelines 1. For patients with ongoing infection despite initial decortication, the primary goal is to restore effective pleural drainage and prevent further complications.

Key Considerations

• Intrapleural fibrinolytics, such as streptokinase, urokinase, or alteplase, can be used to lyse fibrinous strands in loculated empyemas, improving drainage and reducing the need for surgical intervention 1.
• Surgical intervention, including video-assisted thoracoscopic surgery (VATS) or open thoracotomy, may be necessary to remove residual loculations, debris, and infected tissue, but should be reserved for cases where intrapleural fibrinolytics are contraindicated or ineffective 1.
• Antimicrobial therapy should be tailored based on culture results, typically including coverage for anaerobes and gram-negative organisms, with a common regimen including piperacillin-tazobactam or meropenem, combined with vancomycin if MRSA is suspected, for 4-6 weeks total.

Additional Treatment Options

• Image-guided percutaneous drainage or placement of an indwelling pleural catheter may be considered as additional drainage options.
• Nutritional support is crucial, with high-protein supplements and possibly enteral feeding if oral intake is inadequate.
• Regular follow-up imaging with CT scans every 2-4 weeks is essential to monitor treatment response, and pulmonary rehabilitation should be initiated early to improve lung function and prevent further complications.

Recent Guideline Recommendations

• The British Thoracic Society guideline for pleural disease recommends considering intrapleural fibrinolytics in highly selected symptomatic patients with malignant pleural effusion (MPE) and septated effusion to improve breathlessness 1.
• Surgery can be considered for palliation of symptoms in a minority of patients with significantly septated MPE and associated symptoms, but should be weighed against the risks of morbidity and mortality.

From the Research

Persistent Empyema after Decortication

• Persistent empyema after decortication is a complex condition that requires careful management, as seen in studies 2, 3, 4, 5, 6
• The optimal timing of thoracoscopic drainage and decortication for empyema is still not clear, but early intervention is often recommended 4
• Decortication remains a highly effective treatment for chronic postpneumonic empyema and may identify underlying complications that could account for a patient's poor response to conservative treatment 5
• Morbidity and 30-day mortality after decortication for parapneumonic empyema and pleural effusion are significant concerns, with mortality occurring in 3.1% of patients and complications occurring in 39.3% of patients 6

Management Options

• Video-assisted thoracoscopic surgery (VATS) decortication is a common management option for empyema, with studies showing its effectiveness in reducing morbidity and mortality 2, 4, 6
• Interventional radiology guided chest tube insertion with intrapleural fibrinolytics is another management option, with studies comparing its effectiveness to VATS decortication 2
• Open decortication is also a management option, although it is often associated with higher morbidity and mortality compared to VATS decortication 6

Factors Affecting Outcome

• Symptom duration is a reliable preoperative factor in deciding the surgical management of empyema, with patients with symptom durations of less than 4 weeks showing better early results than those with symptom durations greater than 4 weeks 4
• Preoperative factors such as age, estimated glomerular filtration rate, chronic obstructive pulmonary disease, body mass index, American Society of Anesthesiologists level, and Zubrod score are associated with increased mortality, morbidity, discharge to transitional care, and prolonged length of stay 6