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Empyema is an accumulation of pus in the space between the lung and the membrane that surrounds it (pleural space) that occurs when an infection spreads from the lungs. This pus contains white blood cells that fight infection (polymorphonuclear leukocytes) and blood proteins involved in clotting (fibrin). When pus builds up in the pleural space, it puts pressure on the lungs and results in shortness of breath and pain. As fibrin is laid down, it separates the pleural fluid into tiny pockets (loculation). Formation of scar tissue can entrap sections of lung and cause permanent lung damage.
Empyema is usually a complication of a lung infection (pneumonia) or a localized pocket of pus (abscess) in the lung. It may also result from an infection after chest surgery (postoperative infection), a traumatic penetrating chest injury, or a medical procedure that invades the chest such as thoracentesis or insertion of a chest tube. Pus from an abscess in the abdomen just beneath the lungs (subphrenic abscess) may also spread to the pleural space and result in empyema. Empyema can occur as a complication of many other conditions, including septicemia, septic thrombophlebitis, spontaneous pneumothorax, mediastinitis, or esophageal rupture.
Risk: Men are at a slightly higher risk for empyema than women (Tobler). Incidence and Prevalence: There are approximately 1 million cases of empyema in the US each year (Tobler). |
Source: Medical Disability Advisor
| History: In most cases, the individual reports a current or recent bout with pneumonia or a lung abscess. Often, symptoms are present for days before the diagnosis of empyema is made. Chest pain is often reported and may be described as sharp pain that worsens when inhaling, coughing, or sneezing. Other common symptoms include dry cough, difficulty breathing (dyspnea), chills, night sweats, a general feeling of illness (malaise), loss of appetite (anorexia), and unintended weight loss. Physical exam: The individual usually has a mild to moderate fever, rarely in excess of 102° F (38.9° C). Rapid, shallow breathing may be noted when the individual tries to avoid deep breaths. Listening to the chest with a stethoscope reveals decreased breath sounds, wheezing, and a creaky sound in the chest. Asking the individual to speak while listening to the lungs may reveal a characteristic sound called egophony. Tenderness to pressure may occur over the chest wall adjoining the empyema. The breath may have a foul odor. Tests: A standard chest x-ray may or may not be helpful and can appear normal if only a small volume of pus is present. X-ray taken with the individual lying on the side can detect a smaller effusion. Extensive pneumonia can obscure the empyema. It may be difficult to recognize a localized empyema.
A blood test often reveals an abnormally high level of white blood cells.
A definite diagnosis of empyema can only be made by obtaining a sample of pleural fluid, examining it microscopically, and culturing it. The fluid can be drawn out through a needle (thoracentesis) or during the insertion of a chest tube for drainage (thoracostomy). Ultrasonography and/or CT can also play a role in monitoring and treating empyema. If the amount of fluid seen on x-ray is small and the patient is clinically improving, the physician may elect to monitor the accumulation over time before undertaking an invasive diagnostic procedure. |
Source: Medical Disability Advisor
| Empyema is usually treated on an inpatient basis with intravenous antibiotics for the underlying infection. Prompt drainage of the accumulated pus is important. Although removal of pus with a needle (thoracentesis) can provide immediate relief, fluid usually reaccumulates quickly. Insertion of a chest tube (thoracostomy) allows continuous drainage of fluid. The individual's breathing (respiratory) status is monitored closely so respiratory assistance can be provided, as needed. Pain medication (analgesics) may be prescribed, if needed. If the pleural fluid collections are separated into smaller areas because of fibrin deposition (loculated), a medication to break up the fibrin, such as urokinase, may be instilled into the chest cavity. A surgeon may need to manually open and drain the fluid pockets (decortication) if the lung does not expand properly.
An empyema may require many weeks to resolve. Once the underlying infection is controlled and the respiratory status is stable, individuals can be discharged from the hospital with a chest tube and drainage bag in place. |
Source: Medical Disability Advisor
| The outcome for empyema varies significantly, depending on the underlying cause, promptness of treatment, and severity of individual's symptoms. In most cases, antibiotic therapy and prompt, continuous drainage of fluid provide complete recovery without permanent damage to the lungs. However, full recovery may require several days of hospitalization and several weeks of at-home recovery. |
Source: Medical Disability Advisor
| If pneumonia is associated with empyema, respiratory therapy may be helpful to loosen secretions and promote deeper breathing. |
Source: Medical Disability Advisor
| Pus can become walled off into pockets (loculated), making it harder to treat. The empyema may be resistant to multiple antibiotics that make treatment more difficult and prolonged. Air can enter into the pleural space (pneumothorax), and scarring of the lungs (pulmonary fibrosis) can occur. Pleural thickening may also occur.
If left untreated, an erosion can occur between the breathing passages (bronchial tree) and the pleural space (bronchopleural fistula) or between the pleural space and the skin (empyema necessitatis). Respiratory failure and septic shock are extreme complications that can result in death. |
Source: Medical Disability Advisor
| Work restrictions are affected by the individual's course of recovery and any complications. Prolonged sick leave is necessary for recovery. Upon return to work, flexibility in the work schedule may be needed to accommodate frequent checkup visits to the physician or rest breaks, as needed. Heavy lifting and physically demanding jobs may need to be limited. |
Source: Medical Disability Advisor
| If an individual fails to recover within the expected maximum duration period, the reader may wish to consider the following questions to better understand the specifics of an individual's medical case. Regarding diagnosis:
- Has individual recently had pneumonia or a lung abscess?
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Has individual undergone recent chest surgery, insertion of a chest tube, or thoracentesis?
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Has individual experienced recent trauma to the chest from a penetrating injury?
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Has individual had septicemia, mediastinitis, or esophageal rupture?
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Does individual report sharp chest pain that worsens on inhaling, coughing, or sneezing? Does individual have difficulty breathing (dyspnea), chills, night sweats, a general feeling of illness (malaise), loss of appetite (anorexia), and unintended weight loss?
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Was a sample of pleural fluid taken for exam and culture and for definitive diagnosis?
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Was a chest x-ray, ultrasound, and/or CT required?
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Was the diagnosis of empyema confirmed?
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What is the underlying cause of the infection?
Regarding treatment:
- Was individual hospitalized to receive intravenous antibiotics and for drainage of the accumulated pus?
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Was insertion of a chest tube (thoracostomy) done to allow for continuous drainage?
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If fibrin deposits are involved, did individual receive medication to dissolve the fibrin deposits (thrombolytics)?
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Did individual receive pain medication (analgesics)?
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Were chest tubes and drainage bags left in place when individual was discharged from the hospital?
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Was individual compliant with the treatment regimen, including medications, at-home care, and follow-up examinations?
Regarding prognosis:
- Was the underlying cause promptly identified and treated?
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Was antibiotic therapy specific for the organism causing the infection?
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Was individual allowed several weeks of at-home recovery?
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Has individual complied with all medical instructions?
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Did individual develop a pneumothorax?
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Has lung scarring (pulmonary fibrosis) occurred?
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Have complications that could lengthen disability developed, such as loculation, bronchopleural fistula, or sepsis?
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Does individual have underlying illnesses, such as immune system disorders or chronic lung disease, that may affect recovery?
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Source: Medical Disability Advisor
| Tobler, Marc, and Michael J. Holbert. "Empyema." eMedicine. Eds. Judith K. Amorosa, et al. 26 Jul. 2004. Medscape. 16 Dec. 2004 <http://emedicine.com/radio/topic245.htm>. |
Source: Medical Disability Advisor
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