eMedicine Specialties > Radiology > Chest

Empyema: Follow-up

Author: Marc Tobler, MD, Staff Physician, Department of Diagnostic Radiology, Scott and White Memorial Hospital and Clinic
Coauthor(s): J Michael Holbert, MD, Associate Professor, Department of Radiology, Scott and White Memorial Hospital and Clinic
Contributor Information and Disclosures

Updated: Aug 14, 2007

Intervention

The main clinical decision is determining the appropriate time to drain the empyema. Appropriate imaging may help the clinician in choosing and timing intervention. Choosing the appropriate time to perform drainage is a difficult clinical decision.

In 2000, the American College of Chest Physicians reviewed the literature and issued a consensus statement on the medical and surgical treatment of parapneumonic effusions. In the setting of a parapneumonic effusion, the following findings suggest a moderate or high risk for a poor outcome: large, free-flowing effusion (at least half of a hemithorax); loculated effusion or effusion with thickened parietal pleura; positive cultures or Gram stains; pleural pus; and pH < 7.20. When these findings are present, drainage is recommended.

Light's criteria define transudative and exudative effusions. Other investigators have tried to clarify when an exudative effusion should be drained. Laboratory indications for consideration of drainage are the following:

  • pH < 7.20
  • Glucose level < 60 mg/dL
  • Lactate dehydrogenase (LDH) level > 600 IU/L
  • Bacteria on Gram staining

Thoracentesis

Ultrasonography or CT guidance is often used to improve the success of a thoracentesis. Single thoracentesis and a course of antibiotics may be effective at the earliest stages of empyema formation. If the effusion recurs, placement of a chest tube or small-bore catheter for continuous drainage is the next step. The placement of a small-bore catheter (thin-walled, 8-16F catheter) is also often accomplished under ultrasonographic or CT guidance. The small-bore catheter is often more comfortable for the patient than the traditional thoracostomy tube.

Surgical interventions

In the past, a few loculations in an empyema often indicated the need for surgical intervention because the loculations did not drain well. Fibrinolytics increase the success rate of catheter drainage by decreasing the viscosity of the effusion and by dissolving some adhesions. Fibrinolytic therapy has reduced the need for surgery.

Surgical intervention is still required for effusions with multiple loculations that are difficult to drain and for effusions that have not responded to catheter drainage. Empyema at the organizing stage requires surgical intervention.

Surgical interventions may include the following:

  • Thoracoscopic debridement
  • Video-assisted thoracoscopic surgery (VATS): This relatively new intervention has reduced the frequency of open surgery.
  • Open thoracotomy for debridement: This approach is effective when the deposition on the pleural surface remains gelatinous.
  • Open surgical decortication: This technique is the most invasive intervention. It is required when thick pleural peels are present on the visceral pleura. The pleural peel prevents reexpansion of the lung if it is not removed.

Medicolegal Pitfalls

  • Prompt diagnosis and intervention reduce patient mortality.
  • Delaying diagnosis or intervention could worsen the clinical course.
 


More on Empyema

Overview: Empyema
Imaging: Empyema
Follow-up: Empyema
Multimedia: Empyema
References
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References

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Further Reading

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Keywords

organizing effusion, complicated effusion, loculated effusion, pleural pus, intrapleural pus, pleural-space infection

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Contributor Information and Disclosures

Author

Marc Tobler, MD, Staff Physician, Department of Diagnostic Radiology, Scott and White Memorial Hospital and Clinic
Marc Tobler, MD is a member of the following medical societies: American Medical Association
Disclosure: Nothing to disclose.

Coauthor(s)

J Michael Holbert, MD, Associate Professor, Department of Radiology, Scott and White Memorial Hospital and Clinic
J Michael Holbert, MD is a member of the following medical societies: American College of Chest Physicians, American College of Radiology, American Roentgen Ray Society, and Radiological Society of North America
Disclosure: Amirsys Royalty Other

Medical Editor

Judith K Amorosa, MD, FACR, Clinical Professor and Program Director, Department of Radiology, University of Medicine and Dentistry of New Jersey, Robert Wood Johnson Medical School; Consulting Staff, Department of Radiology, Robert Wood Johnson University Hospital
Judith K Amorosa, MD, FACR is a member of the following medical societies: American College of Radiology, American Roentgen Ray Society, Association of University Radiologists, Radiological Society of North America, and Society of Thoracic Radiology
Disclosure: Nothing to disclose.

Pharmacy Editor

Bernard D Coombs, MB, ChB, PhD, Consulting Staff, Department of Specialist Rehabilitation Services, Hutt Valley District Health Board, New Zealand
Disclosure: Nothing to disclose.

Managing Editor

W Richard Webb, MD, Chief of Thoracic Imaging, Professor, Department of Radiology, University of California at San Francisco
Disclosure: Nothing to disclose.

CME Editor

Robert M Krasny, MD, Consulting Staff, Department of Radiology, The Angeles Clinic and Research Institute
Robert M Krasny, MD is a member of the following medical societies: American Roentgen Ray Society and Radiological Society of North America
Disclosure: Nothing to disclose.

Chief Editor

Barry H Gross, MD, Professor, Department of Radiology, University of Michigan Medical School; Professor, University of Michigan Cancer Center
Barry H Gross, MD is a member of the following medical societies: American College of Chest Physicians, American College of Radiology, American Roentgen Ray Society, Association of University Radiologists, Michigan State Medical Society, Physicians for Social Responsibility, Radiological Society of North America, and Society of Thoracic Radiology
Disclosure: Nothing to disclose.

 
 
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