Empyema Thoracis

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Definition
• Presence of pus or microorganisms in the pleural fluid

• Microorganisms may be seen on smear examination or on

culture
• In the absence of microorganism,
• The pH of pleural fluid is less than 7.2
• Lactic dehydrogenase (LDH) is more than 1000 IU/L
• Glucose is less than 40 mg/dl

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Causes
•Empyema thoracis can occur in connection with:
•Pneumonia
•Pneumococcal pneumonia presents with effusion in 40% patients,
empyema occurs only in 5%
•Chest wounds
•Chest surgery
•Lung abscess
•A ruptured esophagus

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Organisms
• Staphylococcus aureus
• H.influenzae
• Streptococcus pneumoniae and
• Streptococcus pyogenes
• Anaerobes and enterobacter
• Common in mixed infections
• Aspiration pneumonia is the most common cause
• Followed by lung abscess, sub diaphrag-matic abscess, and spreading
infection from adjacent sites, e.g. periodontal, retropharyn-geal,
peritonsillar and neck abscesses

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Stages of Empyema
• Exudative stage (1-3 days )

• Fibrino purulent stage (4 to 14 days)

• Organizing stage (after 14 days)

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The Stages of Empyema
• Stage I - “Exudative”
• Sterile pleural fluid develops secondary to inflammation without
fusion of the pleura

• Stage II - “Fibrinopurulent”
• A fibrinous peel develops on both pleural surfaces limiting lung
expansion

• Stage III - “Organizing”

• In-growth of capillaries & fibroblasts into the fibrinous peel

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Exudative stage (1-2 wks)
• Immediate response with outpouring of the fluid
• Low cellular content
• It is simple parapneumonic effusion with normal pH and glucose
levels
• pleural fluid/serum protein ratio more than 0.5
• pH more than 7.30
• glucose more than 60 mg/dl
• LDH(lactate dehydrogenase) less than 1000 IU/L(IU: international unit)
• Gram stain and culture is negative for micro-organism.

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Fibrino purulent stage (3-6 wks)

• Large number of poly-morphonuclear leukocytes and fibrin

accumulates
• Fluid pH and glucose level fall while LDH rises
• Accumulation of neutrophils and fibrin
• Effusion becomes purulent and viscous leading to
development of empyema
• There is progressive tendency towards loculations and
formation of a limiting membranes.

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Fibrino purulent stage (Cont…)
• Pleural fluid analysis
• Purulent fluid or pH less than 7.20
• LDH more than 1000 IU/L
• Glucose less than 40 mg/dl
• Gram stain and culture reports show
microorganism

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Organizing stage (after 6 wks)
• Fibro-blasts grow into exudates on both the visceral and parietal
pleural surfaces
• Development of an inelastic membrane "the peel"
• Thickened pleural peel may prevent the entry of anti-microbial
drugs in the pleural space and in some cases can lead to drug
resistance.
• Thickened plMost common in S. aureus infection
• eural peel can restrict lung movement and it is commonly
termed as trapped lung

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Cont.

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Clinical features
Symptoms and Signs
• In empyema thoracis, patients usually exihibit symptoms of
pneumonia, including
• Fever
• Fatigue
• Cough
• Shortness of breath
• Chest pain

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Symptoms and Signs(Cont…)
• In severe cases
• The patient may become dehydrated
• Cough up blood
• Greenish–brown sputum
• Run a fever as high as 105F
• Fall into a coma

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Diagnosis
CXR
• Large pleural effusion can be diagnosed in posteroanterior view
• Obliteration of CPA – atleast 200-300ml of fluid

• Lateral decubitus view with affected side inferior facilitates

recognition of smaller volumes of fluid

• X-ray in different positions helps to recognize the extent of

parenchymal infection and may reveal loculated fluid

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Cont.

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Chest Ultrasound(USG)
• Very useful tool for
• diagnosis
• guidance of thoraco-centesis or pleural catheter
placement

• Sonography can distinugish solid from liquid pleural

abnormalities with 92% accuracy compared to 68% accuracy
with chest X-ray

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USG (Cont…)
• When both are combined accuracy rises to 98%

• USG shows limiting membranes suggesting the presence of

loculated collections even when they are invisible by CT scan

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Pleural Fluid Analysis
Thoracentesis: Transudate vs. Exudate
1. Gross Appearance
2. Cell Count & Differential
3. Gm Stain, C & S
4. Cytology
5. LDH
6. Protein
7. Glucose, Amylase

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Cont.
• Indications
• In general, a parapneumonic effusion should be sampled if it meets any of the
following criteria
• It is free-flowing but layers >10 mm on a lateral decubitus film
• It is loculated
• It is associated with thickened parietal pleura on a contrast enhanced CT scan, a finding
that is suggestive of empyema

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Cont.
 Transudate
 Straw-colored, clear, odorless fluid with a WBC less than 1000 /ul
• Pleural Membranes are Intact
• Secondary to Altered Starling Forces
• Low in Protein & other Large Molecules
• Causes
• CHF, Cirrhosis, Nephrotic Syndrome, Hypoalbuminemia, Constrictive Pericarditis,
SVC Obstruction, Pulmonary embolism

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Cont.
• Exudate
• Characterized by Increased Protein & LDH
[Pleural Fluid vs. Serum Levels]
• Secondary to Disruption of Pleural Membrane or Obstruction of Lymphatic
Drainage
• Causes
• Infections, Malignancy, vasculitic Disease, GI Disease

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Cont.
 Criteria for “Exudative Effusion” (Light’s criteria)

Parameter Value

1. Pleural Protein : Serum Protein > 0.5

2. Pleural LDH : Serum LDH > 0.6

3. Pleural LDH > 200

Only need 1 critical value to establish the diagnosis of exudate

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Treatment
Goals of treatment

1. Control of infection
2. Drainage of pus
3. Expansion of lungs

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Treatment Options
• Non-Operative
• Antibiotics
• Thoracocentesis
• Chest tube
• Fibrinolysis

• Operative
• VATS
• Thoracotomy + decortication

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Emperical antibiotics
• Anti Staph antibiotic + Cephalosporin + Aminoglycoside

• In suspected anaerobic infections Clindamycin should be added

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Antibiotics
• Parenteral therapy should be continued for 48-72 hours after
fever subsides and then oral therapy can be used to complete
the course.
• Overall duration of treatment: 4-6 wks

• Antibiotic should be continued until

• Patient is afebrile
• WBC count is normal
• Radiograph shows considerable clearing
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Empyema drainage

• Indications for drainage

• Frank pus
• Loculated fluid
• PH less than 7.20
• Glucose less than 40 mg/dl
• LDH more than 1000 IU/L
• Smear positive fluid

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Decortication

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Cont.

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Cont.

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THANK YOU!

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