• Pleural space infections with + Gram stain/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 with single chest tube drainage unlikely
    3. Organizational - Takes several weeks to develop; "pleural peel" restricts lung expansion


Clinical Features

Differential Diagnosis


Work Up


  • Aspiration of grossly purulent pleural fluid on thoracentesis and at least 1 of the following:[2]
    • + Gram stain or culture
    • WBC count > 50,000 cells/µL (or polymorphonuclear leukocyte count of 1,000 IU/dL)
    • Pleural fluid glucose <60
    • pH <7.2
    • LDH >1000 IU/mL


Adult Chest Tube Sizes

Chest Tube Size Type of Patient Underlying Causes
Small (8-14 Fr)
  • Alveolar-pleural fistulae (small air leak)
  • Iatrogenic air
Medium (20-28 Fr)
  • Trauma/bleeding (hemothorax/hemopneumothorax)
  • Bronchial-pleural fistulae (large air leak)
  • Malignant fluid
Large (36-40 Fr)
  • Thick pus


  • Admit

See Also


  1. Barmparas G, DuBose J, Teixeira PG, Recinos G, Inaba K, Plurad D. Risk factors for empyema after diaphragmatic injury: results of a National Trauma Databank analysis. J Trauma. Jun 2009;66(6):1672-6
  2. http://emedicine.medscape.com/article/807499-overview
  3. Inaba Et. al J Trauma Acute Care Surg. 2012 Feb;72(2):422-7.
  4. Advanced Trauma Life Support® Update 2019: Management and Applications for Adults and Special Populations.