What is empyema (empyema is a condition characterized by the accumulation of pus in the pleural space)?

From the Guidelines

Empyema is a serious infection characterized by the accumulation of pus in the pleural space, the area between the lungs and the chest wall, typically developing as a complication of pneumonia, chest trauma, surgery, or the spread of infection from elsewhere in the body. The condition presents with symptoms including fever, chest pain, shortness of breath, and productive cough. Treatment requires a combination of appropriate antibiotics and drainage of the infected fluid. Antibiotics are typically broad-spectrum initially, such as a combination of a beta-lactam and coverage for anaerobes, then narrowed based on culture results 1. Drainage is accomplished through chest tube placement or surgical intervention like video-assisted thoracoscopic surgery (VATS) for more complex cases. The choice between these approaches depends on the stage and complexity of the empyema. Early and aggressive treatment is essential to prevent complications such as lung restriction, chronic infection, or sepsis. The underlying pathophysiology involves bacterial invasion of the pleural space, triggering an inflammatory response that leads to fibrin deposition, loculation of fluid, and eventual formation of a thick pleural peel that can restrict lung function if left untreated.

Key Considerations

• The management of empyema involves a multidisciplinary approach, including the use of antibiotics, chest tube drainage, and potential surgical intervention 1.
• The BTS guidelines for the management of pleural infection provide a framework for the evaluation and treatment of empyema, emphasizing the importance of early and aggressive intervention to reduce morbidity and mortality 1.
• The choice of antibiotics and drainage method depends on the severity and complexity of the empyema, as well as the patient's overall health status.
• Close monitoring and repeated pleural fluid sampling may be necessary to ensure adequate treatment and prevent complications.

Treatment Approach

• Broad-spectrum antibiotics should be initiated promptly, with adjustments made based on culture results and sensitivity testing 1.
• Chest tube drainage is indicated for patients with frankly purulent or turbid pleural fluid, or those with a pleural fluid pH < 7.2 1.
• Surgical intervention, such as VATS, may be necessary for more complex cases or those that fail to respond to chest tube drainage.
• The use of intrapleural fibrinolytic drugs may be considered in certain cases to improve pleural drainage 1.

From the Research

Definition of Empyema

• Empyema is defined as pus in the thoracic cavity due to pleural space infection and has a multifactorial underlying cause, although the majority of cases are post-bacterial pneumonia 2.
• It is a serious complication of bacterial pneumonia, which often causes substantial morbidity and mortality among patients 3, 4.

Causes and Treatment

• The majority of cases of empyema are caused by bacterial pneumonia 2.
• Treatment of empyema typically involves antibiotics and drainage of the pleural effusion 2, 3, 4, 5, 6.
• Intrapleural instillation of streptokinase or urokinase has been shown to be effective in facilitating the drainage of empyema and reducing the need for surgery 3, 4, 5, 6.

Diagnosis and Management

• Timely diagnosis of pleural space infection and rapid initiation of effective pleural drainage represent fundamental principles for managing patients with empyema 2.
• Ultrasound is particularly useful to identify early fibrin membranes and septations in the pleural cavity, conditioning treatment strategy 2.
• Empyema and large or loculated effusion with a pH < 7.20 need to be drained 2.
• Medical thoracoscopy (MT) appears to be safe and successful in multiloculated empyema treatment, and is lower in cost and better tolerated than video-assisted thoracic surgery (VATS) in frail patients 2.