Empyema | White Plains Hospital

Empyema

An Empyema is a collection of pus which accumulates in the space between the outer surface of the lung and the inner surface of the chest wall, referred to as the pleural space.

Causes

  • Bacterial pneumonia - a pneumonia may, literally, breakout of the lung allowing infected fluid to accumulate in the pleural space. While the pneumonia located inside of the lung is treated with antibiotics, the pleural space does not have its own blood supply making it difficult for even intravenous antibiotics to reach this area. As such, the pleural space can provide an excellent medium for the bacterial infection to proliferate.
  • Lung abscess - an abscess, similar to a pneumonia, and breakout of the lung and drainage fluid into the pleural space.
  • Chest surgery - postoperative infections of the pleural space which go untreated can progress to an empyema.
  • Trauma - penetrating trauma such as gunshot wounds or stab wounds can directly infect the pleural space. Blunt trauma which results in multiple rib fractures can lead to pneumonia was which secondarily can infect the pleural space and lead to an empyema.

Symptoms

  • Chest pain which is usually worse when you take a deep breath - this is referred to as pleuritic chest pain or pleurisy. This is a result of the inflamed lining of the lung and the inflamed lining of the chest wall being irritated.
  • Shortness of breath - the body's response to protect the lung from the infected fluid is floating in is to form what is referred to as a peel around the lung. This is designed to separate the lung from the infected fluid and you can think of it as the orange rind protecting the orange. Unfortunately, what this actually does is prevents the lung from fully expanding. This interferes with the lung's ability to expand and allow oxygen to enter the bloodstream and can give rise to the sensation of shortness of breath.
  • This is a CXR depicting a large right pleural effusion secondary to an infection.
    This is a CXR depicting a large left pleural effusion secondary to an infection.

    Fever and chills
  • Malaise
  • Cough
  • Sweating
  • Fatigue
  • Shaking chills or rigors
  • Weight loss

Diagnostic Tests

Treatment

  • The overall goal of treatment is to cure the infection, remove the collection of pus, and allow the lung to fully reexpand
  • The infection is treated with antibiotics or appropriate agents depending on the results of the analysis of the fluid withdrawn
  • Removal of pus
    • Thoracentesis - occasionally, if the empyema is diagnosed in its early phase before the fluid has been allowed to thicken and a peel to form around the lung, the infected fluid can simply be withdrawn through a needle
    • Tube thoracostomy - once the fluid has been present for a short period, it frequently thickens and becomes too thick to be withdrawn through a needle. In those instances, a tube can be placed into the chest to allow the fluid to be withdrawn.
    • VATS procedure - a video assisted thoroscopic surgery may be necessary if the fluid cannot be withdrawn through a tube. An empyema left untreated frequently becomes more dense and solid. In these cases, a more extensive procedure may be required to fully remove all the infected material.
    • Open thoracotomy - if the material is too thick to be removed through the small incisions used in a minimally invasive thoroscopic procedure, then a larger incision is required to allow complete cleaning of the pleural space.
  • Reexpansion of the lung
    • Minimally Invasive Thoroscopic Surgery (VATS)- if a peel or rind has formed around the lung, this will need to be removed to allow the lung to fully expand. This is necessary to regain full lung function. If the appeal has not been present for too long, then this may be removed thoroscopically.
    • Open Thoracotomy and Decortication- if the peel has been present for a long period of time, and usually it is begun growing in to the lung itself and may not be able to be removed in a minimally invasive fashion. In order to reestablish lung function, a open thoracotomy would be performed and the peel physically dissected off of the lung itself. This procedure is referred to as a Decortication and allows for reexpansion of the lung and reestablishes lung function.

Here at White Plains Hospital, we have a fully staffed thoracic surgery service that includes board certified thoracic surgeons, anesthesiologists, pulmonologist, and critical care intensivists. We also have a staff of highly trained nurses, respiratory therapists, nutritionists, physical therapist, case managers, and social workers that work in sync with your surgeon to provide great care for you when you are recovering from your surgery.