Disorders of the Pleura III: Chronic Empyema
Author: Paul Schipper, MD
Institution: OHSU
Date Reviewed: June 2025
Original Case: Fawwaz Shaw, MD / University of Washington
Learning Domain: General Thoracic
Learning Objective: Management principles of Chronic Empyema
PowerPoint File: Disorders of the Pleura III: Chronic Empyema
Discussion Points
- Adequacy of Initial Therapy?
- Impact of COPD / Chronic Renal Failure
- If / When to operate?
- Operative Options?
- Pleural space management?
- Adjunctive support: nutrition / rehab
Etiologies of Empyema
- Sources contiguous with pleura (50-60%):
- Lung, mediastinum, deep cervical, chest wall, spine, and subphrenic space.
- Hematogenous spread (15%).
- Direct innoculation of pleural space (30-40%):
- Minor thoracic interventions, post-op infections, penetrating trauma.
Stages of Empyema
| Stages | Characteristics |
|---|---|
| Exudative (acute) | Pleural space is contiguous. No loculations/septations. |
| Fibrinopurulent (Transitional) | Several days-weeks. Loculations with thin fibrous septae. |
| Organizing (Chronic) | Thick fibrinous peel. Traps the lungs. |
Management Options
| Stages | Management |
|---|---|
| Exudative (acute) | Chest tube + Antibiotics. |
| Fibrinopurulent (transitional) | VATS decortication. |
| Organized (Chronic) | Thoracotomy and decortication. |
- Principle is to effectively manage the pleural space based on the stage of empyema.
- Is there a role for fibrinolytics?
- High (>45%) failure rate with fibrinolytics. May have utility in early – transitional phase of empyemas.
What if an infected pleural space remains?
- Eloesser flap
- Clagett procedure : open pleural drainage, serial debridement and irrigation with antibiotic irrigation, followed by chest closure once pleural space “sterilized”.
- Muscle transpositions / omentum to obliterate pleural space
- Thoracoplasty (mostly historical)