Pleural Empyema

Pleural empyema is a collection of pus in the area between the lungs and the inner surface of the chest wall (pleural space). It is caused by microorganisms, usually bacteria. Empyema can develop after pneumonia (infection of the lung tissue), injury, or chest surgery. Pus in the pleural space can’t be coughed out. Instead, it needs to be drained by a needle or surgery.

The pleural space naturally has some fluid, but infection can cause fluid to build up faster than it can be absorbed. The infected fluid thickens. It can cause the lining of your lungs and chest cavity to stick together and form pockets. This is called an empyema. Your lungs may not be able to inflate completely, which can lead to breathing difficulties.

If left untreated, the inflammation gets more severe. This may result in Loculation under which Scar tissue may form that divide the chest cavity into smaller multiloculated cavities. This makes it even more difficult to treat. If the infection continues to get worse, it can lead to the formation of a thick peel over the pleura, called a pleural peel. This peel prevents the lung from expanding. Surgery is required to fix it.

In rare instances, empyema can lead to severe complications like sepsis.

The chances of developing empyema increase if the patient has one or more of the following conditions:

• Tuberculosis
• Bronchiectasis
• Chronic obstructive pulmonary disease (COPD)
• Rheumatoid arthritis
• History of Alcoholism
• Diabetes
• Weak immune system (post-transplant)
• Lung abscess.

Symptoms of empyema include:

• shortness of breath
• dry cough
• Chest pain, which worsens when you breathe in deeply (pleurisy)
• Excessive sweating, especially night sweats.
• Fever and chills.
• General discomfort, uneasiness, or ill feeling (malaise)
• Headache
• Confusion
• loss of appetite, Weight loss (unintentional)

Empyema is suspected for pneumonia that is not responding to treatment. Tests or procedures to confirm the diagnosis:

• Chest X-rays and CT scans – To detect fluid in the pleural space; and whether its uni or multiloculated.
• Blood tests – To check the white blood cell count, look for the C-reactive protein. White cell count can be elevated when you have an infection.

Treatment involves a multidisciplinary approach by pulmonologist, thoracic surgeon and physiotherapist.

For treatment, in early stages, antibiotics are used to treat the underlying infection. Antibiotics prescribed would depend on the type of bacteria, causing the infection. Percutaneous thoracentesis (drain the pus through a needle inserted in the pleural space) can also be done.

Surgical treatment includes:

• Video-assisted thoracic surgery: Surgeon will remove the affected tissue around your lung and then insert a drainage tube. They will create three small incisions and use a tiny camera called a thoracoscope for this process.
• Open decortication: In this surgery, your surgeon will peel away the pleural peel.

Dr. Narendra Agarwal

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