Empyema and Abscess Pneumonia Treatment & Management

Updated: Mar 18, 2015
  • Author: Michael A Ward, MD; Chief Editor: Robert E O'Connor, MD, MPH  more...
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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.


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.



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.

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 Surgery). Surgery is required in 10-15% of cases and is often indicated for complications, including severe hemoptysis or development of bronchopleural fistula or empyema, and abscesses larger than 6 cm, associated with obstructing neoplasms, or secondary to Pseudomonal infections. [21]

Interventional radiographic management has become a well-established treatment and is becoming an increasingly safe and effective means of treating lung abscesses. The success rate of CT-guided drainage of a lung abscess is up to 90% and is associated with fewer complications, less pain, and shorter hospital stays. [22]

Complicated parapneumonic effusions or empyemas require drainage in addition to medical therapy to ensure a good prognosis. Traditionally, a large caliber, chest thoracostomy tube has been placed to drain the fluid in an effort to avoid further surgical intervention. More recently, CT- or US-guided pigtail drainage catheters, smaller than 14F, have been used with comparable results but with much less pain. [22]

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. [23] However, some randomized clinical trials have reported opposite results, with these studies suggesting no benefit in outcomes with fibrinolytic therapy. [24]

If chest tube or pigtail catheter 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 or pigtail catheter drainage if respiratory symptoms are present 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. [25] One study advocated the use of VATS pleural evacuation as the initial intervention. [26] VATS was associated with a shorter hospital length of stay. Numerous children who were treated with tube thoracostomy still required VATS.