Pleural Empyema - Treatment

Treatment

Definitive treatment for pleural empyema entails drainage of the infected pleural fluid or pus. A chest tube may be inserted, often using ultrasound guidance. Intravenous antibiotics are given.

Chest tubes in the setting of pleural empyema have a tendency to be clogged by the thick pus. To combat this problem, surgeons will often place one or more large bore chest tubes. Insufficient drainage of the pleural empyema, particularly in loculated empyema, can lead to re accumulation of pus and infected material, a worsening clinical picture, organ failure and even death. Thus managing chest tube function is particularly important in the treatment of a pleural empyema. To improve the chest tube drainage, fibrinolytics and DNA enzyme can be given intrapleurally through the chest tube to break the fibrinous septation and to reduce the pus viscosity. Although these adjunct treatments are proven effective, its administration may cause rare but life-threatening intrapleural hemorrhage and hypersensitivity reaction.

If this is insufficient, surgical debridement of the pleural space may be required. This is frequently done using video-assisted thoracoscopic techniques but if the disease is chronic, a limited thoracotomy may be necessary to fully drain the pus and remove the fibrinopurulent exudate from the lung and from the chest wall. Occasionally, a full thoracotomy, formal decortication and pleurectomy are required. Rarely, portions of the lung have to be resected.

An earlier form of treatment involved surgical removal of most of the ribs on the infected side of the thorax, causing a permanent collapse of the lung and obliteration of the infected pleural space. This would leave the patient with a large portion of the upper chest removed, giving the impression that the shoulder had been detached from the body. Rarely performed today, the surgery was common during World War I.