Empyema

Background

• Pleural space infections with positive Gram stain or culture OR parapneumonic effusions without pleural fluid sampling
• Stages
  1. Exudative
     • Free-flowing pleural effusion amenable to chest tube drainage; may only last <48hr
  2. Fibrinopurulent
     • Loculations develop making resolution w/ single chest tube drainage unlikely
  3. Organizational
     • Takes several weeks to develop; "pleural peel" restricts lung expansion

Causes

• Pneumonia
• Complications of chest or abdominal trauma
• Esophageal perforation
• Extension from lung abscess
• Osteomyelitis or other near pleural infections
• Hemothorax, chylothorax, or hydrothorax that becomes infected

Clinical Features

• Usually preceded by PNA
  • Suspect if symptoms of PNA do not resolve

Diagnosis

• Aspiration of purulent material on thoracentesis and at least 1 of the following:
  1. Positive Gram stain or culture
  2. Pleural fluid glucose <40
  3. pH <7.1
  4. LDH >1000

Treatment

• Treat underlying disease
• Perform thoracentesis versus chest tube if evidence of respiratory distress
• Antibiotics
  • Piperacillin-tazobactam 3.375-4.5gm q6hr IV or imipenem 0.5-1gm q6hr
  • Consider adding vancomycin if pt at risk for MRSA

Adult Chest Tube Sizes

Chest Tube Size	Type of Patient	Underlying Causes
Small (8-14 Fr)	Most spontaneous pneumothorax (primary and secondary) Most iatrogenic pneumothorax	Alveolar-pleural fistulae (small air leak) Iatrogenic air
Medium (20-28 Fr)	Traumatic pneumothorax Traumatic hemothorax ("any acute hemothorax visible on chest radiograph") Pneumothorax on mechanical ventilation Non-traumatic tension pneumothorax Malignant effusion	Trauma/bleeding (hemothorax/hemopneumothorax) Bronchial-pleural fistulae (large air leak) Malignant fluid
Large (36-40 Fr)	Empyema	Thick pus

See Also

• Pleural effusion

Source

• Tintinalli