EMPYEMA THORACIS

  • In empyema thoracis there is pus in the pleural space. The condition may be classified as acute, sub-acute, or chronic, depending on the duration of the presence. Immunosuppression is commonly associated with chest diseases (investigate in suspicious cases).
  • Complications include chronicity with lung destruction, fistula formation, and chronic sinuses through the chest wall.

Clinical Features

  • Symptoms of underlying condition may be present.
  • Shortness of breath
  • Fever
  • Sweating
  • Diasphoresis
  • Tachypnoea
  • Tachycardia,
  • Dullness to percussion with reduced air entry on the affected side
  • Weight loss.

Investigations

  • Chest radiograph shows fluid in the affected side or an air fluid level.
  • Carry out thoracocentesis (pus should be taken for culture and sensitivity).

Management – General

  • Improve general condition of the patient, e.g., nutritional status.

Management – Specific

  • Antibiotics directed at the primary pathogen if known: Benzyl penicillin 1.2g IV 6 hourly, gentamicin 80mg 8 hourly IV for at least 2 weeks (take pus for culture and sensitivity and AAFB studies). Treatment choice depends on the sensitivity report.
  • Acute empyema: Tube thoracostomy drainage (underwater seal drainage)
  • Sub-acute empyema: Tube thoracostomy drainage
  • Chronic empyema: Tube drainage; which if fails to resolve proceed to thoracotomy and decortication
  • Anti-TB therapy where indicated. Refer to the national guidelines for tuberculosis treatment.
  • Admit for underwater seal drainage
  • Chest physiotherapy.

Continued Management

  • Order chest radiograph for a baseline investigation.
  • As above, continue with antibiotics and if no change is observed, proceed to chest tube insertion.
  • If chest tube drainage fails,
    • Continue the management or proceed to surgery.
    • Initiate thoracotomy and decortication.
    • Carry out Other procedures like pneumonectomy, skin flaps, etc., as indicated.
  • Remember iatrogenic causes of empyema lead to very severe morbidity. It is therefore imperative to observe strict sterility at all times while carrying out invasive procedures on or in the chest cavity.