Empyema and Abscess Pneumonia in Emergency Medicine Treatment & Management

  • Author: Mark Zwanger, MD, MBA; Chief Editor: Robert E O'Connor, MD, MPH   more...
 
Updated: Jan 24, 2011
 

Prehospital Care

  • Supplemental oxygen should be given and an intravenous line started.
  • Appropriate airway management, including intubation, should be performed depending on the patient's clinical condition.
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Emergency Department Care

All patients should undergo pulse oximetry and evaluation of their respiratory status. If respiratory failure is found or likely to occur, intubation and mechanical ventilation is necessary. Supplemental oxygen should be started for any patient who is acutely short of breath or who is hypoxic based on pulse oximetric findings.

Once the diagnosis of a lung abscess is made, parenteral antibiotics should be started. Ideally, sputum and blood culture findings should be obtained prior to the initiation of antibiotics.

After the diagnosis of empyema is made, prompt drainage by means of tube thoracostomy with use of parenteral antibiotics should be initiated.

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Consultations

Treatment of lung abscesses or empyema is performed in-hospital, with consultations involving internists, pulmonologists, thoracic surgeons, and/or interventional radiologists. Treatment should be individualized.

Many clinicians advocate the administration of intrapleural fibrinolytics in patients with empyemas. Intrapleural fibrinolytics assist in the breakdown of fibrin bands that can cause loculation of the empyema and allow for better chest tube drainage of the infected material. A recent meta-analysis that included 761 patients showed that intrapleural fibrinolytic therapy confers significant benefit in reducing the requirement for surgical intervention for patients.[7] However, some randomized clinical trials have reported opposite results, with these studies suggesting no benefit in outcomes with fibrinolytic therapy.[3] If chest tube drainage and fibrinolytic treatment are unsuccessful, many authors recommend video-assisted thoracic surgery (VATS) next rather than the more traditional open thoracotomy. VATS is less invasive and well tolerated with outcomes that compare favorably with open thoracotomy.

In the pediatric population, the American Pediatric Surgery Association New Technology committee offers the following algorithm. Children with parapneumonic effusions and/or empyema must be treated with antibiotics along with chest tube drainage if there are respiratory symptoms from compressive effects of the fluid. If the illness progresses beyond 3-4 days, a loculated collection may be present and treatment with fibrinolytics or VATS would be the next step.[8] One study advocated the use of VATS pleural evacuation as the initial intervention.[9] VATS was associated with a shorter hospital length of stay. Numerous children who were treated with tube thoracostomy still required VATS.

Lung abscesses typically respond well to antibiotic therapy, but when that therapy is unsuccessful, the consulting clinician might consider percutaneous catheter drainage or endoscopic surgical resection of the involved area of the lung (see Lung Abscess, Surgical Perspective).

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Contributor Information and Disclosures
Author

Mark Zwanger, MD, MBA  Assistant Professor, Department of Emergency Medicine, Jefferson Medical College of Thomas Jefferson University

Mark Zwanger, MD, MBA is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and American Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Mark S Slabinski, MD, FACEP, FAAEM  Vice President, EMP Medical Group

Mark S Slabinski, MD, FACEP, FAAEM is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, and Ohio State Medical Association

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Paul Blackburn, DO, FACOEP, FACEP  Attending Physician, Department of Emergency Medicine, Maricopa Medical Center

Paul Blackburn, DO, FACOEP, FACEP is a member of the following medical societies: American College of Emergency Physicians, American College of Osteopathic Emergency Physicians, American Medical Association, and Arizona Medical Association

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Robert E O'Connor, MD, MPH  Professor and Chair, Department of Emergency Medicine, University of Virginia Health System

Robert E O'Connor, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American College of Physician Executives, American Heart Association, American Medical Association, Medical Society of Delaware, National Association of EMS Physicians, Society for Academic Emergency Medicine, and Wilderness Medical Society

Disclosure: Nothing to disclose.

References

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Histology of a lung abscess shows dense inflammatory reaction (low power).
A thick-walled lung abscess.
Pneumococcal pneumonia complicated by lung necrosis and abscess formation.
A lateral chest radiograph shows air-fluid level characteristic of lung abscess.
A 54-year-old patient developed cough with foul-smelling sputum production. A chest radiograph shows lung abscess in the left lower lobe, superior segment.
A 42-year-old man developed fever and production of foul-smelling sputum. He had a history of heavy alcohol use, and poor dentition was obvious on physical examination. Chest radiograph shows lung abscess in the posterior segment of the right upper lobe.
A 42-year-old man developed fever and production of foul-smelling sputum. He had a history of heavy alcohol use, and poor dentition was obvious on physical examination. Lung abscess in the posterior segment of the right upper lobe was demonstrated on chest radiograph. CT scan shows a thin-walled cavity with surrounding consolidation.
Chest radiograph of a patient who had foul-smelling and bad-tasting sputum, an almost diagnostic feature of anaerobic lung abscess.
Histology of a lung abscess shows dense inflammatory reaction (high power).
 
 
 
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