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Management of empyema Role of a surgeon

D. K. Gupta, Shilpa Sharma
Department of Pediatric Surgery, All India Institute of Medical Sciences, New Delhi, India

Correspondence: D. K. Gupta, Department of Pediatric Surgery, All India Institute of Medical Sciences, New Delhi, India.
E-mail: [email protected]

ABSTRACT
Postpneumonic empyema still remains quite common in developing countries, especially during the hot and humid months. While most
cases would respond to antibiotic therapy, needle aspiration and intercostal drainage, few cases require further surgical management.
The most common nontubercular etiological agent is Staphylococcus. Tubercular etiology is not uncommon in India, especially due to
delayed presentation, multiresistant strains, mismanaged cases, and noncompliance with antitubercular treatment amidst malnutrition
and anemia. Clinical symptoms, a skiagram chest followed by thoracentesis are enough for diagnosis. Pleural fluid is usually diagnostic
and helps in choosing the appropriate antibiotics. Further investigations and management depends on the stage of the disease.
Thoracentesis alone may be sufficient for the exudative phase. In fibrinopurulent stage, a properly sized and well-placed tube thoracostomy
with underwater seal is curative in most cases. Interventional radiologists have placed small-bore catheters, specifically directed to the
loculated collection and have used fibrinolytics like urokinase, streptokinase, and tissue plasminogen activator (TPA) to break loculations,
ameliorate fibrous peel formation, and fibrin deposition.
Thoracoscopic debridement and thoracoscopic decortication is an alternative with distinct advantages over thoracotmy and are indicated
if there was no response with intercostal drainage procedure. In the organizing stage, a thoracotomy (for decortication) would be
required if there is a loculated empyema, underlying lung disease or persistently symptomatic effusions. Timely institution of proper
management prevents the need for any surgical intervention and avoids long-term morbid complications.

KEY WORDS: Children, Empyema, Surgery

Empyema thoracis constitutes approximately 510% cases ETIOLOGY

seen by a pediatrician in India. Culture positivity has
decreased significantly over the years as the patients re- The etiological factors include: pneumonia viral, bac-
ceive antibiotics before presentation. terial, tubercular, mycotic; postoperative infection; lung
abscess; trauma; subphrenic abscess; generalized sepsis;
Tube drainage is used in 8090% of fibro-purulent cases, adjacent infections retropharyngeal or mediastinal ab-
and is successful in 7080% cases. At a tertiary center, scess; Esophageal perforation; foreign body; cystic fibro-
approximately 10% of cases need limited thoracotomy, sis; endotracheal tumor; instrumentation.
and 35% require decortication. Surgery is mainly required
by children with persistent pleural sepsis after 10 days of Parapneumonic effusions are predominently exudative
tube drainage. Delaying surgery has a significantly higher and occur in 5070% of patients admitted with a compli-
potential of requiring decortication. cated pneumonia. Host factors that contribute to altera-
tions in pleural permeability, such as noninfectious in-
Definition flammatory diseases, infection, trauma, or malignancy,
may allow accumulation of fluid in the pleural space,
Empyema is a localized or free collection of purulent which becomes secondarily infected.[1]
material in the pleural space as a result of combination
of pleural dead space, culture medium of pleural fluid, BACTERIOLOGY
and inoculation of bacteria. It is an advanced
parapneumonic effusion. The most common bacteria implicated for

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 Gupta DK, et al: Management of empyema

postpneumonic, nontubercular empyema are Staphylo- ment such as tube thoracostomy.

coccus aureus, Pneumococci, E. coli, Pseudomonas, Kleb- 3. Organizing (chronic) stage. A thick pleural peel is
siella, and anaerobes. formed by resorption of fluid and as a result of
fibroblast proliferation. The lung parenchyma be-
The cultures are sterile in 3050% of the cases due to comes entrapped, forming a fibrothorax. This stage
antibiotics. Staphylococcus aureus is now the most com- usually occurs within 24 weeks after the initial pres-
monly retrieved organism.[2][4] The increasing incidence entation.
of methicillin-resistant Staphylococci reported from the
developed countries has also been recognized in the In- The pleural inflammatory response leads to an increased
dian scenario.[5],[6] Postoperative and post-traumatic em- procoagulant activity and depressed fibrinolytic activity,
pyemas may contain Bacteroides or Pseudomonas causing fibrin deposition. Loculations are thus formed
aeruginosa.[1] Anaerobes have also been recognized as with fibrin strands covered by fibroblasts that proliferate
important cause of childhood and adolescent empyema.[7] and deposit basement membrane proteins over the pleura.
Tubercular empyema is common in India and usually as- These proteins prevent the separation of the visceral and
sociated with lung disease. Tuberculosis being rampant parietal pleura and lead to the formation of a pleural peel.
in India may present as acute empyema. In cases of late Following timely initiation of proper antibiotic therapy,
diagnosis, noncompliance with antitubercular treatment, the inflammatory process resolves. Re-epithelialization
and resistant strains of mycobacterium, it is usually a of the pleura occurs with the migration of pleural mes-
chronic disease with underlying parenchymal involve- othelial cells into areas of denudation. However, inappro-
ment. priate or delayed treatment leads to exuberant pleural
inflammation resulting in pleural fibrosis, and restrictive
PATHOPHYSIOLOGY lung disease.

In 1962, the American Thoracic Society described three The fluid is turbid and contains > 15 000/dl white blood
stages of empyema, which continue to be applied in the cells. The aspirated pleural fluid may be investigated for
classification of the disease. cell count, differential count, Gram stain, glucose, LDH,
pH, protein, amylase, lipid stain or triglycerides, and se-
The progression of pleural fluid collection evolves gradu- rologic studies. Bacterial, mycobacterial, and fungal cul-
ally from stages 13 [Table 1].[8] tures of the fluid may be sent, but the treatment should
1. Exudative (acute) stage. The pleural inflammation be initiated on the basis of the clinical course. Pleural
results in increased permeability and a small fluid col- fluid latex agglutination [or counter
lection. The fluid is thin, contains few cellular ele- immunoelectrophoresis (CIE) for specific bacteria] may
ments mostly neutrophils, and is often sterile and be helpful if the cause of the infection cannot be ascer-
amenable to thoracentesis. This stage lasts only 24 tained from culture results.
72 h and then progresses to the fibrinopurulent stage.
2. Fibrinopurulent (transitional) stage. It is characterized TREATMENT
by the invasion of the organism into the pleural space,
progressive inflammation, and polymorphonuclear The objectives of treatment are to
(PMN) leukocyte invasion. There is an accumulation control infection,
of protein and fibrinous material with formation of drainage of the purulent fluid, and
fibrin membranes, which forms partitions or eradication of the sac to prevent chronicity and allow
loculations within the pleural space. This stage lasts re-expansion of the affected lung to restore function.
for 710 days and often requires more aggressive treat-
The therapy instituted depends on the causative factor,
Table 1: Features of three stages of empyema stage of empyema, state of the underlying lung, presence
Transitional Acute Chronic of bronchopleural fistula (BPF) if any, ability to obliter-
Viscosity + ++ +++ ate the space, and the condition of the patient. The treat-
WBC + ++ +++
LDH + ++ +++
ment needs to be individualized and it depends on the
PH +++ ++ + available clinical, radiological, and laboratory evidence.
Glucose +++ ++ + General measures include increase in the protein and fluid
Lung expansion +++ ++ + intake. Physiotherapy and breathing exercises will help

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 Gupta DK, et al: Management of empyema

in early re-expansion of the lung following evacuation of rected to the loculated pleural fluid collections, has helped
the fluid. to facilitate drainage. Radiologists can lyse adhesions di-
rectly using imaging during the tube placement. Inter-
Thoracentesis ventional radiologists have used fibrinolytics such as uroki-
nase, streptokinase, and tissue plasminogen activator
Thoracentesis may provide, both significant diagnostic (TPA) in complicated empyemas with loculations and
information and therapeutic relief for parapneumonic ameliorated fibrous peel formation and fibrin deposi-
effusions. In cases of streptococcal infection, the pus is tion.[10][12]
very thin and the volume is also small, with fluid pH above
7.2, glucose above 40 mg/dl and with LDH levels below Surgical treatment
1000 IU/l. In such cases, only a diagnostic needle aspira- Surgical treatment is required for chronic empyema, that
tion suffices. Performing thoracentesis before the initia- may be caused by delayed medical attention, inadequate
tion of antibiotics increases the diagnostic yield of the antibiotic therapy, inadequate drainage, presence of for-
fluid cultures and allows more specific antimicrobial eign body, infliction of postresectional space, and chronic
therapy. In cases of tubercular etiology, the antitubercu- pulmonary infection such as mismanaged tuberculosis.
lar chemotherapy should be started immediately, and the Other causes of ICD failure include improper position-
pus in the pleural space aspirated through a wide-bore ing of tube, improper selection of tube size, inadequate
needle. Occasionally a repeat aspiration may be required. physiotherapy, and presence of BPF. Multiloculated em-
In many cases, no other treatment is necessary. pyema or persistently symptomatic effusion is likely to
require surgical intervention.
The patient receives intravenous antibiotics for 10
14 days followed by oral antibiotics for 13 weeks. An- Rib resection
titubercular treatment is mandatory for tubercular em- Although the incidence for resorting to rib resection has
pyema. A 6-month course with 4+2 drugs or a 9-month gone down in the past decade or so, still rib resection
course with 3 drugs is recommended. The treatment may becomes mandatory to gain adequate access while deal-
be required for a longer time in cases with associated Potts ing with the chronic cases. Rib resection becomes neces-
spine. sary if the pus is thick and loculated, or if the patient
remains toxic after intercostal tube drainage. This not
The most controversial area in the management of only provides adequate exposure but also allows one to
parapneumonic effusions is the identification of patients, evacuate the pus, break up loculations and adhesions, and
who would benefit from pleural drainage and the choice assess the need for decortication. After cleaning the cav-
of the appropriate drainage.[9] However, long-term follow- ity thoroughly, a tube may be placed in its most depend-
up studies show no differences in pulmonary function or ent portion and attached to underwater seal drainage. A
exercise capacity between groups managed by antibiot- properly placed intercostal tube would be as effective as
ics and antibiotics and drainage alone and these alone two or three tubes.
and those who underwent drainage procedures in the early
stages of empyema. Open drainage
In chronic cases with a regular discharge of thick pus, a
Tube thoracostomy wide bore tube may be left in place, open to atmospheric
pressure. This is helpful in adolescents with chronic tu-
Chest tube drainage with an underwater seal is done for bercular empyema, in whom the daily output has reduced
cases in stage 2. Diagnostic thoracentesis and chest tube to approximately 25 ml or so after a prolonged (3
drainage are effective therapy in more than 50% of pa- 5 weeks) chest tube drainage.
tients. Prompt drainage of a free-flowing effusion prevents
the development of loculations and a fibrous peel. Most Decortication
children with nontubercular empyema heal well in the Thoracotomy is done to remove the pleural peel and lyse
long run, even without immediate surgical intervention. the adhesions if the patient does not respond promptly
When inserted in early stages of empyema, ICD may be to the treatment as mentioned above. Decortication com-
sufficient if kept for 56 days. If the fluid is not free flow- prises removal of the organized inflammatory membrane.
ing, further radiological imaging may be required. It comprises of two types of procedures:
1. removal of the visceral peel alone, and
Interventional radiology 2. empymectomy comprising of extrapleural dissection
The placement of small-bore catheters, specifically di- outside the parietal pleura and removal of the com-

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 Gupta DK, et al: Management of empyema

plete cavity. Indications for pulmonary resection in cases of tubercu-

lar empyema.
Length of hospital stay, duration of antibiotics, and long- 1. Persistently positive sputum cultures with cavitation
term morbidity are reduced by this more aggressive ap- after 6 months of continuous optimal chemotherapy
proach with rapid resolution of symptoms, but it is a major with two or more drugs. Resistant tuberculosis should
operative procedure with increased cost and short-term be ruled out. Relative indications for surgical inter-
morbidity.[13] Thoracotomy and decortication is very ef- vention such as severe cavitation, bronchiectasis, or
fective, with a reported 95% success rate for patients with bronchial stenosis may contribute to the failure of
fibrinopurulent effusions, and is likely to remain a treat- chemotherapy in some patients.[17]
ment of choice for advanced empyema. 2. Localized pulmonary disease caused by atypical My-
cobacterium or Mycobacterium tuberculosis with broad
Video-assisted thoracoscopic surgery resistance to chemotherapy (localized disease is de-
Preoperative CT scan will help to assess the location and fined as that encompassing 12 segments of the lung).
thickness of pleural peels and enable to site thoracoscopic 3. A mass lesion of the lung in an area of tubercular in-
ports more effectively. volvement. This helps for simultaneous diagnosis of
the mass lesion and treatment of tuberculosis.[18]
Although video-assisted thoracoscopic surgery (VATS) is 4. Massive life-threatening hemoptysis or recurrent se-
a new and useful dimension added in the management vere hemoptysis.[19]
of empyemas, the facilities and the expertise remain lim- 5. A broncho-pleural fistula that does not respond to
ited to the masses, especially in the developing countries. tube thoracostomy.
Thoracoscopic debridement closely imitates open thora-
cotomy and drainage. However, it is usually inadequate COMPLICATIONS
and not suitable in late stages of empyema where the
encasing thick pleura needs to be removed. Empyema necessitans
A swelling appears over the chest wall, which is in com-
Thoracoscopic decortication has also been done by a few munication with the underlying empyema. It has a posi-
enthusiastic and experienced surgeons. The VATS has tive cough impulse. It usually does not require any addi-
proved to be an effective and less invasive replacement tional treatment and heals spontaneously with adequate
for the limited decortication procedure.[14][16] However, treatment of the underlying empyema.
the drawbacks may include suboptimal decortication of
the parietal pleura in the event of bleeding and inadvert- Fibrothorax, is a rare complication seen in adolescents who
ent lung injury. It may, thus, not be beneficial for cases have presented very late.
with very thick pleura (stage 3).
Broncho-pleural fistula (BPF) already covered in JIAPS
Lobectomy and pneumonectomy discussion.
Surgical excision of a lobe or the whole lung, though not
described frequently in the Western literature, remains Long-term effects
an important component of the management in our coun- Despite the variability in presentation, most patients re-
try, where tuberculosis is rampant and neglected cases of cover without sequelae. A number of studies have dem-
empyema are not uncommon. In a few patients, even af- onstrated resolution of the radiographic abnormalities in
ter adequate decortication, the lung does not expand 36 months following therapy, with little to no symp-
owing to underlying necrosis. In such cases, resection of toms reported at follow-up examination.
the affected lung segment will be prudent. The institu-
tional experience would show that the lung excision (com- Pulmonary function testing performed following hospi-
plete or in part) is frequently required not only to excise talization has not shown marked abnormalities, irrespec-
the diseased lung but also to prevent the other lung from tive of the clinical course. The only abnormality observed
being flooded with the secretions from the infected lung. may be slight expiratory flow limitation. Mild obstruc-
Also, rib excision may sometimes be required to have a tive abnormalities were the only findings observed in pa-
good access to thorax in the advanced cases of empyema tients evaluated 12 years ( 5) following recovery from
with crowding of the ribs. Rarely, the cases may be so empyema. In advanced stages of empyema, few patients
difficult that even a second look thoracotomy is required silently suffer restrictive lung disease and abnormal
before a lobectomy could be performed successfully. spirometry. Some increased bronchial reactivity has been

145 J Indian Assoc Pediatr Surg / Jul-Sept 2005 / Vol 10 / Issue 3

 Gupta DK, et al: Management of empyema

reported at later follow-up examinations; however, lung 5. Gorak EJ, Yamada SM, Brow JD. Community-acquired methicillin-
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Tuberculosis should be ruled out in developing countries, mal saline in the treatment of complicated parapneumonic effu-
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complications that may later require major surgical re- tive Versus Nonoperative Therapy for Pediatric Empyema: A Meta-
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