Empyema thoracis

Empyema thoracis is a common benign pathology of the pleural space causing severe morbidity and mortality rates of 10-20%. Often it develops from a parapneumonic effusion over a period of 2-6 weeks. Most patients that develop an empyema are frail with significant co-morbidity, immunocompromise or have had recent thoracic instrumentation. Initial presentation often features unilateral chest pain, tachypnoea, dyspnoea, pyrexia and features of sepsis. Blood analysis reveals leucocytosis with elevated inflammatory markers (e.g. C-reactive protein). Empyema progresses through a continuum of three stages (exudative, fibrinopurulent and organized), becoming more complex and challenging to treat. Initial management includes establishing a diagnosis with imaging and pleural aspiration. A combination of physiological support, commencement of antibiotics and tube drainage is successful in most patients. Intrapleural administration of fibrinolytics (combination of DNAase and recombinant tissue plasmin activator) have been shown to reduce hospital stay and need for surgery in prospective randomized controlled trials. Surgery is reserved for refractory cases or those with delayed presentation. video-assisted thoracoscopic surgery allows debridement of the pleural cavity and accurate drain placement. More extensive decortication is often performed through thoracotomy. Options for compromised and frail patients exist but usually involve long-term drainage and the acceptance of respiratory compromise.