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302 Pleural Effusion and Empyema

imaging during the tube placement. Finally, interventional radiologists, • Persistence and chronicity (from inadequate drainage due to
using fibrinolytics, have further improved the care of complicated the premature removal of the drainage tube or failure to estab-
empyema by improved management of loculations and amelioration lish drainage at the dependent position of the empyema cavity).
of fibrous peel formation and fibrin deposition. Numerous studies Management may involve open drainage by rib resection, pneumo-
have documented the effectiveness of intrapleural fibrinolytics (e.g., nectomy (if there is associated lung disease, such as bronchopleu-
urokinase or tissue plasminogen activator (TPA)) to treat obstructed ral fistula), or obliteration of the pleural space by collapsing the
thoracostomy tubes, increase drainage in multiloculated effusions, and chest wall to meet the lung by performing thoracoplasty.
lyse adhesions. Cost may limit its more widespread use. Prognosis and Outcomes
Open Drainage Mortality-related prognostic factors of empyema thoracis in children
Thoracotomy or minithoracotomy (with decortications) to remove include age, causative bacteriological agents such as Streptococcus mil-
the pleural peel and lyse the adhesions (in advanced empyema) if the leri, concomitant disease, and history of operation. 25,26 Morbidity and
patient does not respond promptly to treatment is very effective, with a mortality may be reduced through early diagnosis and therapy. 23,24,27,28
reported 95% success rate for patients with fibrinopurulent empyema. A significant proportion of children with chronic disease develop
Customarily, rib resection has been required to manage the a thoracic scoliosis, which is always directed towards the side of the
organised empyemas. Empyemas that have reached the organised effusion. This is thought to be due to pleuritic pain from the infection/
phase are characterised by the presence of thick pleural peel, causing inflammation and discomfort from the chest drainage tube.
varying degree of pulmonary parenchymal entrapment. Limited Empyema necessitans is another long-term complication of poorly
thoracoplasty and muscle flap rotation are also needed in some or uncontrolled empyema thoracis. The pus collection bursts and
instances to obliterate the pleural space problem. communicates with the exterior, forming a fistula between the pleural
Video-Assisted Thoracoscopic Surgery cavity and the skin.
Video-assisted thoracoscopic surgery (VATS) has proven to be an The main determinants of outcome of empyema thoracis are early
effective and less-invasive replacement for the limited decortica- and adequate treatment, access to proper care, nutritional status of the
tion procedure. Thoracoscopic debridement closely imitates open patient, and the causative agent (tuberculous empyema).
thoracotomy and drainage. Mechanical removal of purulent material Prevention
and the breakdown of adhesions can be easily accomplished via this
Early, aggressive, and adequate treatment of pneumonia; good hygiene;
route. VATS results in more rapid relief of symptoms, earlier hospital
and adequate nutrition are imperative to preventing empyema thoracis in
discharge, and significantly less discomfort and morbidity. For the
children in Africa. Public education and management of patients at risk
paediatric population of many developed centres, VATS is the pre-
by medical experts and specialists will play a crucial role in this regard.
ferred method to alternative procedures such as rib resection and open
drainage or pleural obliteration. Evidence-Based Research
The Eloesser Procedure In the literature of the last 10 years, only two reports are available in
The Eloesser procedure and its modification are important options in English from Africa on the treatment of postpneumonic pleural space
the surgical treatment of chronic, complicated ET. infection. 29,30 Both reports are of descriptive studies. The mean age at
presentation of the patients is 5 years. Fever, cough, and dyspnoea are
Postoperative Complications the standard presentations, together with radiologic evidence of pleu-
To encourage lung re-expansion, adequate analgesics are adminis- ral effusion. Pneumococci and staphylococci were the most common
tered, and the patient is encouraged to take deep breaths and undergo organisms isolated. In the Ethiopian study, no patient required thora-
basic chest physiotherapy including, where possible, blowing up cotomy and decortication, and in the Nigerian study, only one patient
(inflating) balloons. did. Mortality ranged from 7% to 16%.
Specific postoperative complications include:
• Air leak (bronchpleural fistula). This may spontaneously or it may
require pneumonectomy (lung resection).

Key Summary Points

1. Pleural effusion is aspirated and protein content is measured; 5. If an empyema does not resolve promptly with tube drainage, an
exudates are cultured, and have cell count, gram staining, and ultrasound examination should be done and a new drain inserted
acid-fast staining evaluated. if necessary.
2. Streptococcus pneumonia and Staphylococcus aureus are the 6. In children, thoracotomy is rarely necessary and is a last resort.
major pathogens in children; antibiotic treatment should be 7. The failure of an empyema to resolve is a good indication for
started before culture results are available. VATS.
3. Tuberculous pleurisy needs to be distinguished from TB 8. In areas with high HIV prevalence, a bloodstained pleural
empyema.
effusion is usually caused by Kaposi sarcoma.
4. Tube thoracostomy (with antibiotics) is the treatment of choice
for empyema; and it must be carried out as soon as the
diagnosis is made.