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1.  Empyema Thoracis 
Epmyema thoracis is associated with high mortality ranging between 6% to 24%. The incidence of empyema is increasing in both children and adults; the cause of this surge is unknown. Most cases of empyema complicate community- or hospital-acquired pneumonia but a proportion results from iatrogenic causes or develops without pneumonia. Parapneumonic effusions (PPE) develop in about one half of the patients hospitalized with pneumonia and their presence cause a four-fold increase in mortality. Three stages in the natural course of empyema have long been described: the exudative, fibrinopurulent, and organizing phases. Clinically, PPE are classified as simple PPE, complicated PPE, and frank empyema. Simple PPE are transudates with a pH > 7.20 whereas complicated PPE are exudates with glucose level <2.2 mmol/l and pH < 7.20. Two guidelines statements on the management of PPE in adults have been published by the American College of Chest Physicians (ACCP) and the British Thoracic Society (BTS). Although they differ in their approach on how to manage PPE, they agree on drainage of the pleural space in complicated PPE and frank empyema. They also recommend the use of intrapleural fibrinolysis and surgical intervention in those who do not show improvement, but the level of evidence for the use of intrapleural fibrinolysis is not high highlighting the need for more research in this area. A recently published large randomized trial has shown no survival advantage with the use of intrapleural streptokinase in patients with pleural infection. However, streptokinase enhances drainage of infected pleural fluid and may still be used in patients with large collection of infected pleural fluid causing breathlessness or ventilatory failure. There is emerging evidence that the combination of intrapleural tPA/DNase is significantly superior to tPA or DNase alone, or placebo in improving pleural fluid drainage in patients with pleural space infection. A guideline statement on the management of PPE in children has been published by the BTS. It recommends the use of antibiotics in all patients with PPE in addition to either video-assisted thoracoscopic surgery (VATS) or tube thoracostomy and intrapleural fibrinolysis. Prospective randomized trials have shown that intrapleural fibrinolysis is as effective as VATS for the treatment of childhood empyema and is a more economic treatment and therefore, should be the primary treatment of choice.
PMCID: PMC2998927  PMID: 21157522
empyema; management; intrapleural fibrinolysis; drainage; surgery
2.  Empyema thoracis: a problem with late referral? 
Thorax  1993;48(9):925-927.
BACKGROUND--Patients are often referred to thoracic units for management of empyema after the acute phase has been treated with antibiotics but without adequate drainage. This study evaluates the effects of delay in surgical treatment of empyema thoracis on morbidity and mortality. METHODS--Thirty nine consecutive patients were studied from January 1991 to June 1992. Two groups (group 1, 16 patients; group 2, 23 patients) were compared depending on the time spent under the care of other specialists before referral to the thoracic unit (group 1, seven days or less; group 2, eight days or more). The reasons for delay in referral were analysed. RESULTS--Four patients were treated conservatively with chest drainage alone (all in group 1). Thirty five patients required rib resection and drainage of their empyema (group 1, 12 patients; group 2, 23 patients). Nineteen (all in group 2) of the 35 patients who had rib resections went on to have decortication. The commonest cause of empyema was post-pneumonic (37 out of 39 patients). Staphylococcus aureus was the commonest organism isolated. Misdiagnosis (five patients), inappropriate antibiotics (six patients), and inappropriate placement of chest drainage tubes (three patients) all contributed to persistence and eventual progression of empyema. The overall mortality was 10% and mortality increased with age. The median stay in hospital was 9.5 days (range 7-12 days, n = 4) for patients treated with closed tube drainage only; 18 days (range 10-33 days, n = 16) for patients who had undergone rib resections and open drainage; and 28 days (range 22-49 days, n = 19) for patients who underwent decortication. The likelihood of having a staged procedure (antibiotics, closed tube drainage, open drainage with rib resection, and finally decortication) increased when closed tube drainage was persevered with for more than seven days. The total hospital stay was positively related with the time before referral for surgical treatment. Anaemia, low albumin concentrations, and worsening liver function were found in group 2 compared with group 1. CONCLUSIONS--Early adequate operative drainage in patients with empyema results in low morbidity, shorter stays in hospital, and good long term outcome. These patients should be treated aggressively and early referral for definitive surgical management is recommended.
PMCID: PMC464779  PMID: 8236076
3.  Surgical Strategy of Complex Empyema Thoracis 
The optimal treatment of empyema thoracis has been widely debated. Proponents of pleural drainage alone, drainage plus fibrinolytic therapy, videoassisted thoracoscopic surgical (VATS) debridement, and open thoracotomy each champion the efficacy of their approach.
This study examines treatment of complex empyema thoracis between June 1, 1994, and April 30, 1997. Twenty-one men and 9 women underwent 30 drainage/decortication procedures (14 open thoracotomies and 16 VATS) in treatment of their disease. Effusion etiology was distributed as follows: infectious -14; neoplastic-associated - 7; traumatic - 3; other - 6.
The mean preoperative hospital stay was 14 ±8.8 days, (11.4 ± 6.5 days for VATS vs 16.8 ± 10.2 days for thoracotomy). Hospital stay from operation to discharge for thoracotomy patients was 10.0 ± 7.2 days (median 8.5 days) and for VATS patients 17.6 ± 16.8 days (median 11 days). These differences were not statistically significant. Duration of postoperative thoracostomy tube drainage was 8.3 ± 4.6 days for thoracotomy patients and 4.7 ± 2.8 days in the VATS group (p = 0.01). Operative time for the thoracotomy group was 125.0 ± 71.7 minutes, while the VATS group time was only 76.2 ± 30.7 minutes. Estimated blood loss for the thoracotomy group was 313.9 ± 254.0 milliliters and for the VATS group 131.6 ± 77.3 milliliters. Three of the 30 patients (10.0%) required prolonged ventilator support (>24 hours). Morbidity included one diaphragmatic laceration (VATS group) and one thoracic duct laceration (thoracotomy). Two VATS procedures (6.7%) required conversion to open thoracotomy for thorough decortication.
The surgical approach to empyema thoracis is evolving. In the absence of comorbid factors, the significantly lower requirement for chest tube drainage time in the VATS patients suggests that this modality is an attractive alternative to thoracotomy in the treatment of complex empyema thoracis.
PMCID: PMC3021260  PMID: 11051186
Complex empyema thoracis; Videoassisted thoracoscopic surgery (VATS)
4.  Empyema thoracis: A clinical study 
Annals of Thoracic Medicine  2007;2(1):14-17.
Empyema thoracis is a disease that, despite centuries of study, still causes significant morbidity and mortality.
The present study was undertaken to study the age-sex profile, symptomatology, microbiologic findings, etiology and the management and treatment outcome in a tertiary care hospital.
A prospective study of empyema thoracis was conducted on 40 consecutive patients with empyema thoracis admitted to the tuberculosis and chest diseases ward of a teaching hospital.
The demographic data, clinical presentation, microbiological findings, etiology, the clinical course and management were recorded as per a planned pro forma and analyzed.
The peak age was in the range of 21-40 years, the male-to-female ratio was 3.4:1.0 and the left pleura was more commonly affected than the right pleura. Risk factors include pulmonary tuberculosis, chronic obstructive pulmonary diseases, smoking, diabetes mellitus and pneumonia. Etiology of empyema was tubercular in 65% cases and nontubercular in 35% cases. Gram-negative organisms were cultured in 11 cases (27.5%). Two patients received antibiotics with repeated thoracentesis only, intercostal chest tube drainage was required in 38 cases (95%) and more aggressive surgery was performed on 2 patients. The average duration for which the chest tube was kept in the complete expansion cases was 22.3 days.
It was concluded that all cases of simple empyema with thin pus and only those cases of simple empyema with thick pus where size of empyema is small should be managed by aspiration/s. Cases failed by the above method, all cases of simple empyema with thick pus and with moderate to large size of empyema and all cases of empyema with bronchopleural fistula should be managed by intercostal drainage tube connected to water seal. It was also observed that all cases of empyema complicated by bronchopleural fistula were difficult to manage and needed major surgery.
PMCID: PMC2732064  PMID: 19724669
Closed tube thoracostomy; empyema; parapneumonic effusion
5.  A rare presentation of aspergillus infection as empyema thoracis 
A 57-year-old diabetic and hypertensive man presented with a short history of fever, dry cough and right side chest pain. A chest radiograph showed right pleural based homogenous shadow in middle and lower zones with obliteration of right costo-phrenic angle suggestive of right side effusion. Aspiration of pleural fluid revealed frank pus for which inter-costal tube drainage was performed. Due to persistence of empyema, the patient was subjected to thoracoscopy. Thoracoscopy showed multiloculated empyema. Thoracoscopic pleural biopsy and fluid showed septate fungal hyphae. Thoracotomy and parietal pleurectomy, with resection of part of right lower lobe, was carried out. Pleural fluid, pleural and lung tissue culture grew Aspergillus fumigatus. The patient showed good recovery with voriconazole after thoracotomy.
PMCID: PMC2878709  PMID: 20539768
Aspergillosis; aspergillus empyema; multiloculated empyema
6.  Empyema thoracis: Surgical management in children 
Empyema thoracis can produce significant morbidity in children if inadequately treated. Correct evaluation of the stage of the disease, the clinical condition of the child and proper assessment of the response to conservative treatment is crucial in deciding the mode of further surgical intervention. This ranges from intercostal chest tube drainage and video-assisted thoracoscopic surgery to open decortication. Surgical decortication becomes mandatory in neglected cases; it gives very gratifying results ameliorating the disease rapidly and is well tolerated by young patients. This article reviews the current literature and discusses the important considerations while managing these patients. Indications for surgery are highlighted, based on our large experience at a tertiary care center.
PMCID: PMC2847142  PMID: 20376247
Chest tube drainage; empyema thoracis; fibrinolytic agents; open decortications; thoracocentesis; video-assisted thoracoscopic surgery
7.  ICD Versus VATS as Primary Treatment in Fibrinopurulent Stage of Empyema Thoracis 
Background and Objectives: Empyema thoracis is a condition in which pus collects in the pleural cavity. The optimal treatment of Empyema thoracis especially in the fibrinopurulent phase (Stage II) remains controversial. While the Inter Costal Drainage (ICD) is less invasive and cheap, it is not clearly proved that it is better than the Video Assisted Thoracoscopic Surgery (VATS) in terms of conversion into thoracotomy, morbidity and duration of hospital stay. No large randomized trial is available for comparing the two treatment strategies in the condition.
Methodology: This study was a prospective comparative study of ICD insertion versus VATS as primary intervention in the fibrinopurulent stage of Empyema thoracis, which was conducted over a period of 2 years (Dec 2008 to Nov 2010), in a tertiarry care Medical College Hospital. With an incidence of around 5-10% and a considerable burden in our hospital, the study was taken up to compare the efficacy of ICD versus VATS, in terms of morbidity and cost effectiveness and to identify the optimal way of managing the condition. The study included a total of 40 patients with each group consisting of 20 patients.
Sampling: Purposive sampling technique.
The Statistical Methods Used: Descriptive statistics, Frequencies, Crosstabs, Independent sample t-test.
Results: It was found that VATS was better than the conventional ICD insertion in terms of the variables like mean duration of hospital stay (p<0.05), mean duration of the chest tube in situ (p<0.05), mean cost of the treatment (p<0.05), complications (p<0.05) and failure rate (p<0.05) which were statistically significant.
Conclusion: Our study concluded that Video Assisted Thoracoscopic Surgery is better than conventional ICD tube insertion as a primary mode of treatment in the fibrinopurulent stage of Empyema thoracis.
PMCID: PMC3919299  PMID: 24551657
VATS; Thoracotomy; Decortication; Computed tomography thorax
8.  Empyema thoracis: lack of awareness results in a prolonged clinical course 
Canadian Journal of Surgery  2001;44(4):284-288.
To assess the hypothesis that empyema thoracis (ET) is a problem often not optimally treated. Long delays in diagnosis are common, long hospital stays are typical and recovery with surgery is relatively rapid.
A chart review.
The Regina Health District associated hospitals, a tertiary referral centre.
The charts of 34 consecutive patients having primary respiratory tract disease and seen during the 6-year period Apr. 1, 1991, to Mar. 31, 1997, were identified.
Outcome measures
Patient presentation, time until diagnosis of ET, number of radiologic investigations, microbiologic features, treatment methods, postoperative course and mortality.
The mean delay in diagnosis, defined as the time of admission to the time of correct diagnosis, was 44.2 days (range from 0 to 573 days) and the mean delay until thoracic surgery referral was 47.4 days (range from 0 to 578 days). On average each patient underwent CT 10.1 times, had 2.6 percutaneous drainage procedures and 2.0 chest tube insertions. The mean time from the first percutaneous chest drainage to the date of diagnosis was 29.8 days (range from 0 to 564 days). Of the 26 patients who underwent CT, the mean time from the first CT of the chest to the date of diagnosis was 9.5 days (range from 0 to 75 days). Cultures of pleural fluid grew no organisms in 17 patients; in the remaining 17 patients cultures grew 23 different microorganisms. Of 26 patients who were referred for surgical opinion, 18 underwent decortication; 8 were not considered to be surgical candidates. Pathological examination showed 17 cases of inflammatory empyema and 1 case of mesothelioma (unrecognized clinically). The mean length of hospital stay postoperatively was 15.2 days.
Early suspicion of ET facilitates its treatment, resulting in fewer investigations and shorter hospital stays. When percutaneous drainage does not eliminate pleural effusions, empyema must be considered. Recovery from surgical decortication is rapid in comparison with the typical protracted preoperative hospital course.
PMCID: PMC3692661  PMID: 11504262
9.  Empyema thoracis: a role for open thoracotomy and decortication 
Archives of Disease in Childhood  1998;79(6):510-513.
BACKGROUND—Thoracentesis and antibiotics remain the cornerstones of treatment in stage I empyema. The management of disease progression or late presentation is controversial. Open thoracotomy and decortication is perceived to be synonymous with protracted recovery and prolonged hospitalisation. Advocates of thoracoscopic adhesiolysis cite earlier chest drain removal and hospital discharge. This paper challenges traditional prejudice towards open surgery.
METHODS—A five year audit of empyema cases referred to a regional cardiothoracic surgical unit analysing previous clinical course, surgical management, and outcome.
RESULTS—Between February 1992 and February 1997, the number of referrals to this centre increased dramatically. Twenty two children were referred for surgery (15 boys, seven girls; age range, 0.5-16 years). Before referral, patients had been unwell for 6-50 days (median, 15), had been treated with several antibiotics, and had undergone chest ultrasound (15 patients), computed tomography (five patients), pleural aspiration attempts (13 patients), and intercostal drainage (seven patients). The organism responsible was identified in only two cases (Streptococcus pneumoniae). Three patients had intraparenchymal abscess formation. Eighteen patients underwent open thoracotomy and decortication. Drain removal was performed on the first or second day. Fever resolved within 48hours. Median hospital stay was four days. All patients had complete clinical and radiological resolution.
CONCLUSIONS—Treatment must be tailored to the disease stage. In stage II and III diseases, open decortication followed by early drain removal results in rapid symptomatic recovery, early hospital discharge, and complete resolution. In the early fibrinopurulent phase, alternative strategies should be considered. However, even in ideal cases, neither fibrinolysis nor thoracoscopic adhesiolysis can achieve more rapid resolution at lower risk.

PMCID: PMC1717767  PMID: 10210997
10.  Non surgical treatment of empyema thoracis with intrapleural streptokinase in a patient with AIDS. 
Genitourinary Medicine  1995;71(4):259-261.
After unsuccessful treatment with intercostal tube drainage and antibiotics intrapleural streptokinase was used to treat successfully an empyema in a man with AIDS and advanced cutaneous Kaposi's sarcoma who was unfit for surgical decortication. The role of this technique in the management of HIV positive patients with empyema is discussed.
PMCID: PMC1195527  PMID: 7590722
11.  Surgical management and outcome analysis of stage III pediatric empyema thoracis 
Report of 125 pediatric patients of empyema thoracis treated by open decortication, highlighting the presentation, delay in referral, operative findings, the response to surgical intervention and follow-up.
Materials and Methods:
All the children who underwent open decortication for stage III empyema thoracis during the study period were included. Preoperative workup included hemogram, serum protein, chest radiographs and contrast-enhanced computed tomographic (CECT) scan of the chest.
One hundred and twenty-five patients (81 males, 44 females) (age 3 months–12 years, mean 4.9 years) were operated during a 4.5-year period. Among them, two children underwent bilateral thoracotomies. Also, 81.6% patients were referred 3 weeks after the onset of disease (mean duration 9 weeks). Intercostal chest drainage (ICD) had been inserted in (119) 95% cases. Thickened pleura, multiloculated pus and lung involvement were invariably seen on CECT scan. Bronchopleural fistula was present in 10 patients and empyema necessitatis in 2. Decortication, removal of necrotic tissue and closure of air leaks was performed in all the patients. Necrotizing pneumonia was seen in (35) 27.5% cases. Mean duration of postoperative ICD was 7 days. Follow-up ranged from 3 months to 4 years (mean 12 months). There was no mortality. Six patients had proven tuberculosis.
The duration of the disease had a direct relationship with the thickness of the pleura and injury to the underlying lung. Delayed referral causes irreversible changes in the lung prolonging recovery. Only 18% presented within the early period of the disease. Meticulous open surgical debridement gives gratifying results. The status of the lung at the end of surgery is a major prognostic factor.
PMCID: PMC2998674  PMID: 21180497
Contrast-enhanced computed tomographic chest scan; decortication; empyema thoracis; pediatric
12.  A colonic splenic flexure tumour presenting as an empyema thoracis: a case report 
The case report describes the rare presentation of a 79-year-old patient with a locally perforated splenic flexure tumour of the colon presenting with an apparent empyema thoracis in the absence of abdominal signs or symptoms.
Case presentation
Initial presentation was with a non-productive cough, anorexia and general malaise. An admission chest X-ray and subsequent computed tomographic image of the thorax showed a loculated pleural effusion consistent with an empyema. The computed tomography also showed a thickened splenic flexure. Thoracotomy was performed and a defect in the diaphragm was revealed after the abscess had been evacuated. A laparotomy was carried out at which point a tumour of the splenic flexure of the colon was found to be invading the spleen and locally perforated with subsequent collection in communication with the thorax. The tumour and spleen were resected and a transverse end colostomy was fashioned.
One must consider the diagnosis of pathology inferior to the diaphragm when an apparent empyema thoracis is encountered even in the absence of clinical signs or symptoms.
PMCID: PMC2629468  PMID: 19144103
13.  Empyema thoracis: a 10-year comparative review of hospitalised children from south Asia 
Archives of Disease in Childhood  2003;88(11):1009-1014.
Aims: To study the clinical and microbial profile of childhood empyema in South Asia and to identify the changes over the past three decades.
Methods: A total of 265 children (aged 1 month to 12 years) with empyema admitted to the Advanced Pediatric Center, PGIMER, Chandigarh, India in 1989–98, were reviewed retrospectively.
Results and Conclusions: One third of children were under 5. Culture positivity had decreased significantly (48% v 75%) over the years. Staphylococcus aureus continues to be the commonest (77%) aetiological agent; clustering was seen during hot and humid months (46%). Culture positive Streptococcus pneumoniae cases also decreased (9% v 27%); all were seen during the winter and spring season. Gram negative rods grew in more patients (11% v 7%). Community acquired methicillin resistant S aureus (MRSA) was isolated in three patients. Most children (93%) were treated with parenteral cloxacillin and an aminoglycoside. Tube drainage (TD) was used in 92% of fibropurulent cases, and was successful in 79%. Of 48 patients with failed TD, 12 needed decortication; limited thoracotomy was sufficient in the remaining 36. Surgery was mainly required by children with persistent pleural sepsis after 10 days of TD. Delaying surgery until 14 days had a significantly higher potential of requiring decortication. Early change to oral antibiotics (after 1–2 weeks of parenteral therapy) reduced the hospital stay significantly (17+7 v 23+7 days) without compromising long term outcome. Twenty two patients presenting late in the chronic stage underwent decortication at admission.
PMCID: PMC1719356  PMID: 14612371
14.  A study of empyema thoracis and role of intrapleural streptokinase in its management 
Clinical spectrum, microbiology and outcome of empyema thoracis are changing. Intrapleural instillation of fibrinolytic agents is being increasingly used for management of empyema thoracis. The present study was carried out to describe the clinical profile and outcome of patients with empyema thoracis including those with chronic empyema and to study the efficacy and safety of intrapleural streptokinase in its management.
Clinical profile, etiological agents, hospital course and outcome of 31 patients (mean age 40 ± 16 years, M: F 25: 6) with empyema thoracis treated from 1998 to 2003 was analyzed. All patients were diagnosed on the basis of aspiration of frank pus from pleural cavity. Clinical profile, response to therapy and outcome were compared between the patients who received intrapleural streptokinase (n = 12) and those who did not (n = 19).
Etiology was tubercular in 42% of the patients (n = 13) whereas the rest were bacterial. Amongst the patients in which organisms could be isolated (n = 13, 42%) Staphylococcus aureus was the commonest (n = 5). Intrapleural streptokinase was instilled in 12 patients. This procedure resulted in increase of drainage of pleural fluid in all patients. Mean daily pleural fluid drainage after streptokinase instillation was significantly higher for patients who received intrapleural streptokinase than those who did not (213 ml vs 57 ml, p = 0.006). Only one patient who was instilled streptokinase eventually required decortication, which had to be done in five patients (16.1%). Mean hospital stay was 30.2 ± 17.6 days whereas two patients died.
Tubercular empyema is common in Indian patients. Intrapleural streptokinase appears to be a useful strategy to preserve lung function and reduce need for surgery in patients with late stage of empyema thoracis.
PMCID: PMC459221  PMID: 15222893
15.  Self-insertion of needles: An unusual cause of empyema thoracis and its thoracoscopic management 
Intrapulmonary aberrant needles are rare in clinical practice. Most common cause till date is the intra-thoracic migration of pins and wires commonly used in treatment of fractures and dislocations of upper extremity. Some cases of traumatic intra-thoracic insertion of needles have also been reported. We report a patient of empyema thoracis due to unusual habit of self-insertion of needles in his body because of some myth. The patient was successfully managed by video-assisted thoracoscopic surgery.
PMCID: PMC2843125  PMID: 20407570
Empyema thoracic; intra-thoracic needles; video assisted thoracoscopic surgery
16.  Thoracoscopic management of empyema thoracis 
Appropriate management of empyema thoracis is dependent upon a secure diagnosis of the etiology of empyema and the phase of development. Minimal access surgery using video-assisted thoracoscopy (VATS) is one of many useful techniques in treating empyema. Complex empyema requires adjunctive treatment in addition to VATS.
PMCID: PMC2749197  PMID: 19789675
Empyema; video-assisted thoracoscopy
17.  Adult thoracic empyema: A comparative analysis of tuberculous and nontuberculous etiology in 75 patients 
Thoracic empyema is a disease of significant morbidity and mortality, especially in the developing world where tuberculosis remains a common cause. Clinical outcomes in tuberculous empyema are complicated by the presence of concomitant fibrocavitary parenchymal disease and frequent bronchopleural fistulae. We performed a prospective study over a one-and-a-half-year period with the objective of comparing the clinical profiles and outcomes of patients with tuberculous and nontuberculous empyema.
Materials and Methods:
A prospective study of adult cases of nonsurgical thoracic empyema admitted in a tertiary care hospital in eastern India was performed over a period of 18 months. A comparative analysis of clinical characteristics, treatment modalities, and outcomes of patients with tuberculous and nontuberculous empyema was carried out.
Seventy-five cases of empyema were seen during the study period, of which 46 (61.3%) were of nontuberculous etiology while tuberculosis constituted 29 (38.7%) cases. Among the nontuberculous empyema patients, Staphylococcus aureus (11, 23.93%) was the most frequent pathogen isolated, followed by Gram-negative bacilli. Tuberculous empyema was more frequent in younger population compared to nontuberculous empyema (mean age of 32.7 years vs. 46.5 years). Duration of illness and mean duration of chest tube drainage were longer (48.7 vs. 23.2 days) in patients with tuberculous empyema. Also the presence of parenchymal lesions and bronchopleural fistula often requiring surgical drainage procedures was more in tuberculous empyema patients.
Tuberculous empyema remains a common cause of empyema thoracis in a country like India. Tuberculous empyema differs from nontuberculous empyema in the age profile, clinical presentation, management issues, and has a significantly poorer outcome.
PMCID: PMC2988167  PMID: 21139713
Bronchopleural fistula; empyema; parapneumonic effusion; tuberculous empyema
18.  Intrapleural therapy in management of complicated parapneumonic effusions and empyema 
Empyema thoracis causes high mortality, and its incidence is increasing in both children and adults. Parapneumonic effusions (PPEs) develop in about one-half of patients hospitalized with pneumonia, and their presence increases mortality by about four-fold. PPEs can be divided into simple PPEs, complicated PPEs, and frank empyema. Two guideline statements on the management of PPEs in adults have been published by the British Thoracic Society (BTS) and the American College of Chest Physicians; a third guideline statement published by the BTS focused on management of PPEs in children. The two adult guideline statements recommend drainage of the pleural space in complicated PPEs and frank empyema. They also recommend the use of intrapleural fibrinolysis in those who do not show improvement. The pediatric guideline statement recommends adding intrapleural fibrinolysis to those treated by tube thoracostomy if they have loculated pleural space or thick pus. Published guideline statements on the management of complicated PPEs and empyema in adults and children recommend the use of intrapleural fibrinolysis in those who do not show improvement after pleural space drainage. However, published clinical trial reports on the use of intrapleural fibrinolysis for the treatment of pleural space sepsis suffer from major design and methodologic limitations. Nevertheless, published reports have shown that the use of intrapleural fibrinolysis does not reduce mortality in adults with parapneumonic effusions and empyema. However, intrapleural fibrinolysis enhances drainage of infected pleural fluid and may be used in patients with large collections of infected pleural fluid causing breathlessness or respiratory failure, but a proportion of these patients will ultimately need surgery for definite cure. Intrapleural streptokinase and urokinase seem to be equally efficacious in enhancing infected pleural fluid drainage in adults. In most of the published studies in adults, the use of intrapleural fibrinolysis was not associated with serious side effects. There is emerging evidence that the combination of intrapleural tissue plasminogen activator (tPA) and deoxyribonuclease (DNase) is significantly superior to tPA or DNase alone or placebo in improving pleural fluid drainage in patients with pleural space infection. In children, intrapleural fibrinolysis has not been shown to reduce mortality, but has been shown to enhance drainage of the pleural space and was safe. In addition, two prospective, randomized trials have shown that intrapleural fibrinolysis is as effective as video-assisted thoracoscopic surgery for the treatment of childhood empyema and is a more cost-effective treatment and therefore should be the primary treatment of choice.
PMCID: PMC3262383  PMID: 22291507
parapneumonic effusions; empyema; intrapleural fibrinolysis; intrapleural DNase
19.  Esophgeal Perforation and Bilateral Empyema Following Endoscopic EsophyX Transoral Incisionless Fundoplication 
Clinical Endoscopy  2014;47(6):560-563.
Transoral incisionless fundoplication (TIF) has been used for endoscopic treatment of gastroesophageal reflux disease (GERD). TIF using the EsophyX device system (EndoGastric Solutions) was designed to create a full-thickness valve at the gastroesophageal junction through the insertion of multiple fasteners; it improves GERD, reduces proton pump inhibitor use, and improves quality of life. Although TIF is effective in select patients, a significant subset of patients undergoing TIF develop persistent or recurrent GERD symptoms and may need antireflux surgery to control the GERD symptoms. We now report a 48-year-old man with chronic GERD unresponsive to medical management. He underwent TIF complicated by esophageal perforation and developed mediastinitis, left pneumothorax, bilateral pleural effusions, and acute respiratory failure. He required chest tube placement and bilateral decortication for treatment of nonresolving empyemas. Additional postmarketing studies are required to assess the safety, efficacy, and clinical outcomes of this novel procedure, and patients undergoing this procedure need close postprocedural follow-up.
PMCID: PMC4260105  PMID: 25505723
Gastroesophageal reflux; Transoral incisionless fundoplication; Esophageal perforation; Empyema; Pneumothorax
20.  Paediatric complicated pneumonia: Diagnosis and management of empyema 
Paediatrics & Child Health  2011;16(7):425-427.
Pneumonia can be complicated by an empyema, progressing from an exudative effusion, to a fibrinopurulent stage with loculations, and then organized with a thick fibrinous peel. The predominant causative organisms are Streptococcus pneumoniae, Staphyloccocus aureus (including methicillin-resistant S aureus) and Streptococcus pyogenes. Recently, an increased incidence of paediatric complicated pneumonia has been reported. For diagnostic imaging, a chest radiograph followed by a chest ultrasound is preferred. Computed tomography chest scans, with associated radiation, should not be routinely used. Antibiotic coverage should treat the most common causative organisms. Additional invasive or surgical management is recommended to reduce the duration of illness in cases not promptly responding to antibiotics or with significant respiratory compromise. Choice of management should be guided by best evidence and local expertise. Video-assisted thorascopic surgery or insertion of a small-bore percutaneous chest tube with instillation of fibrinolytics are the best current options.
PMCID: PMC3200394  PMID: 22851899
Chest tube; Complicated pneumonia; Empyema; Fibrinolytics; Paediatric
21.  Treatment of a tuberculous empyema with simultaneous oral and intrapleural antituberculosis drugs 
A 71-year-old man was diagnosed with an uncomplicated tuberculous (TB) empyema. Differential penetration of anti-TB drugs, believed to explain the phenomenon of acquired drug resistance in TB empyema, was confirmed by measurement of serum and pleural fluid anti-TB drug concentrations. Simultaneous oral and intrapleural anti-TB drugs were administered and a cure was achieved. The present case is discussed in the context of the literature on acquired drug resistance in TB empyema. It is argued that high-end doses of oral drugs or combined oral plus intrapleural drugs, along with tube thoracostomy or intermittent thoracentesis, will cure uncomplicated TB empyema without threatening to induce drug resistance or having to resort to surgery.
PMCID: PMC2679544  PMID: 18716684
Acquired drug resistance; Tuberculous empyema
22.  Residual hemothorax after chest tube placement correlates with increased risk of empyema following traumatic injury 
Empyema complicates tube thoracostomy following trauma in up to 10% of cases. Studies of potential risk factors of empyema have included use of antibiotics, site of injury and technique of chest tube placement. Residual fluid has also been cited as a risk factor for empyema, although the imaging technique to identify this varies.
To determine whether residual hemothorax detected by chest x-ray (CXR) after one or more initial chest tubes predicts an increased risk of empyema.
A study of patients admitted to two level I trauma centres between January 7, 2004, and December 31, 2004, was conducted. All patients who received a chest tube in the emergency department, did not undergo thoracotomy within 24 h, and survived more than two days were followed. Empyema was defined as a pleural effusion with positive cultures, and a ratio of pleural fluid lactate dehydrogenase to serum lactate dehydrogenase greater than 0.6 in the setting of elevated leukocyte count and fever. Factors analyzed included the presence of retained hemothorax on CXR after the most recent tube placement in the emergency room, age, mechanism of injury and injury severity score.
A total of 102 patients met the criteria. Nine patients (9%) developed empyema: seven of 21 patients (33%) with residual hemothorax developed empyema versus two of 81 patients (2%) without residual hemothorax developed empyema (P=0.001). Injury severity score was significantly higher in those who developed empyema (31.4±26) versus those who did not (22.6±13; P=0.03).
The presence of residual hemothorax detected by CXR after tube thoracostomy should prompt further efforts, including thoracoscopy, to drain it. With increasing injury severity, there may be increased benefit in terms of reducing empyema with this approach.
PMCID: PMC2679547  PMID: 18716687
Empyema; Residual hemothorax; Tube thoracostomy
23.  VATS: first step in the parapneumonic empyema* 
Il Giornale di Chirurgia  2014;35(5-6):146-148.
Pneumonia is a common cause of pediatric hospitalization and almost 50% of children hospitalized for pneumonia develops meta pneumonic pleural effusion, most of which resolve spontaneously (1). The meta pneumonic effusion remains a major source of morbidity and mortality in the pediatric population and is a complication on the rise in both the U.S. (2) and Europe (3–6).
There is no uniformity of treatment of the meta pneumonic effusion in its early stages and are still questioning some aspects of proper management, remains uncertain and not always shared the operative timing (7). The treatment options are represented, in combination with antibiotic therapy, the thoracentesis (8), the positioning of one or more pleural drainage (9), fibrinolytic therapy (10), the toilet of the pleural cavity by means of video-assisted thoracoscopic surgery (VATS) (11) or “open” with thoracotomy (12) or traditional mini thoracotomy. We report our experience concerning the processing of meta pneumonic effusion, suggesting how the video thoracoscopy may be the treatment of choice in the early stages of the disease.
PMCID: PMC4321519  PMID: 24979108
VATS; Meta pneumonic effusion; Empyema
24.  Esophagopleural Fistula: A Complication of Chest Intubation for Empyema 
This report documents the first recorded patient in the recent literature with an esophageal perforation and an esophagopleural fistula following chest intubation for empyema. It was treated successfully by conservative method with feeding gastrostomy. It is important to realize that tube thoracostomy drainage is not an innocuous procedure and to be alert to this complication, especially in the presence of empyema.
PMCID: PMC2552417  PMID: 7365819
25.  Empyema thoracis in AIDS. 
PMCID: PMC1294316  PMID: 8196030

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