Empyema

Background

• 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

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

• Fever
• Shortness of breath
• Anorexia
• Night sweats
• Pleuritic chest pain
• Hemoptysis
• Recent diagnosis and/or treatment for Pneumonia
• History of penetrating chest trauma or diaphragmatic injury

Differential Diagnosis

• Pneumonia
• Sarcoidosis
• Tuberculosis
• Pleural Effusion
• Granulomatosis with polyangiitis (wegener's)
• Pulmonary embolism

Evaluation

Work Up

• CBC
• CXR
• Thoracentesis
• Sputum Culture -- Acid Fast Bacilli (If TB suspected)
• Pulse Ox
• ABG interpretation
• Blood Cultures

Evaluation

• Aspiration of grossly purulent pleural fluid on thoracentesis and at least 1 of the following:
  • + 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

Management

• Treat underlying disease
• O2 if Hypoxemia
• Perform thoracentesis vs. chest tube if evidence of respiratory distress
  • May need Video-Assisted Thoracic surgery (VATS)
• Antibiotics
  • Piperacillin-tazobactam 3.375-4.5gm q6hr IV or imipenem 0.5-1gm q6hr
  • Consider adding vancomycin if patient 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)	Pneumothorax on mechanical ventilation Non-traumatic tension pneumothorax Malignant effusion	Bronchial-pleural fistulae (large air leak) Malignant fluid
Large (36-40 Fr)	Traumatic pneumothorax Empyema	Bleeding (Hemothorax/hemopneumothorax) Thick pus

See Also

• Pleural effusion
• Pneumonia
• Sarcoidosis
• Tuberculosis

References

Authors

Jordan Swartz, Aaron Snyder, Ross Donaldson, Claire, Neil Young, Daniel Ostermayer