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Semin Respir Crit Care Med 2019; 40(03): 361-374
DOI: 10.1055/s-0039-1694699
Review Article
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Medical and Surgical Management of Empyema

Mark S. Godfrey
1   Pulmonary, Critical Care and Sleep Medicine, Yale New Haven Hospital, New Haven, Connecticut
,
Kyle T. Bramley
1   Pulmonary, Critical Care and Sleep Medicine, Yale New Haven Hospital, New Haven, Connecticut
,
Frank Detterbeck
2   Section of Thoracic Surgery, Yale University School of Medicine, New Haven, Connecticut
› Author Affiliations
Further Information

Publication History

Publication Date:
16 September 2019 (online)

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Abstract

Infection of the pleural space is an ancient and common clinical problem, the incidence which is on the rise. Advances in therapy now present clinicians of varying disciplines with an array of therapeutic options ranging from thoracentesis and chest tube drainage (with or without intrapleural fibrinolytic therapies) to video-assisted thoracic surgery (VATS) or thoracotomy. A framework is provided to guide decision making, which involves weighing multiple factors (clinical history and presentation, imaging characteristics, comorbidities); multidisciplinary collaboration and active management are needed as the clinical course over a few days determines subsequent refinement. The initial choice of antibiotics depends on whether the empyema is community-acquired or nosocomial, and clinicians must recognize that culture results often do not reflect the full disease process. Antibiotics alone are rarely successful and can be justified only in specific circumstances. Early drainage with or without intrapleural fibrinolytics is usually required. This is successful in most patients; however, when surgical decortication is needed, clear benefit and low physiologic impact are more likely with early intervention, expeditious escalation of interventions, and care at a center experienced with VATS.

Keywords

empyema - pleural infection - tissue plasminogen activator - deoxyribonuclease - thoracoscopy - video-assisted thoracic surgery

Disclosure Statement

The authors have no relationship with a commercial company that has a direct financial interest in subject matter or materials discussed in the article or with a company making a competing product.