Pleural Empyema Surgery – Specialists and Information

A pleural empyema is a bacterial infection that causes a collection of pus in the pleural cavity. Patients admitted to the hospital with pleurisy often develop complications. Half of them develop pleural effusions. One in ten patients develops a pleural empyema. 

Patients with pleurisy experience pain when breathing @ Maksym Povozniuk /AdobeStock

Pyothorax is a serious complication of pleurisy and is often the result of bacterial pneumonia. A pleural empyema can also be caused by a lung abscess.

Other causes can also trigger a pleural empyema:

• “blood poisoning” (sepsis)
• an injury (trauma) resulting in a breach of the chest wall (= pneumothorax)
• a perforation of the esophagus. If a bacterial infection occurs as a result of these injuries, pus can accumulate in the pleura.

Which bacteria cause pyothorax?

They are often typical pathogens that cause pus and bacteria that trigger respiratory tract infections:

• Streptococcus pneumoniae
• Staphylococcus aureus
• Pseudomonas aeruginosa, a common hospital-acquired pathogen and thus a cause of so-called nosocomial infections
• Escherichia coli, an intestinal bacterium, as well as
• Klebsiella

The symptoms are usually nonspecific, as most patients have previously suffered from severe pneumonia or pleurisy. As a result, doctors often do not immediately recognize a pleural empyema.

Symptoms that may occur include: 

• Fever
• Night sweats
• Cough
• Pain behind the breastbone
• Shortness of breath (dyspnea)

• Doctors usually first suspect pleural empyema based on the patient’s medical history (anamnesis) and an abnormal chest X-ray.
• Doctors also use ultrasound and CT-based imaging of the lungs to detect smaller amounts of effusion.
• However, the actual diagnosis is made through a pleural tap.

During a pleural puncture—which can serve as preparation for pleural empyema surgery—doctors use a thin needle to extract a small amount of pleural fluid. Laboratory staff then examine the fluid for possible pathogens. Only then can doctors establish a reliable diagnosis and treatment plan. The pleural fluid typically provides evidence of severe inflammation as well as the bacterial pathogens involved:

• Inflammation causes the pH to shift toward the acidic range (pH < 7.1).
• Lactate dehydrogenase (LDH) is a cellular enzyme that can be elevated, for example, in cases of severe inflammation (LDH > 1,000 U/L).
• The number of inflammatory cells, particularly granulocytes, is elevated.

A bacterial pathogen is usually detected in cases of pyothorax.

During a pleural tap, doctors remove fluid from the pleural space (the space between the costal and pulmonary pleura) @ ellepigrafica /AdobeStock

Pleural empyema typically progresses in three stages:

1. Stage 1: Fluid accumulates in the pleural space (exudative phase).
2. Stage 2: A purulent, cloudy secretion develops (fibrinous-purulent phase).
3. Stage 3: Due to chronic inflammation, connective tissue growths form on the chest walls (scar tissue), which increasingly constrict the lung.

Once a definitive diagnosis has been made, pleural empyema is highly treatable. In Stage 1, antibiotics are usually sufficient to treat the bacterial infection.

However, it is important for doctors to identify the causative pathogen in order to prescribe the correct antibiotic.

In recent years in particular, multidrug-resistant strains of Pseudomonas, Staphylococcus, and Streptococcus have emerged. These pose a challenge for doctors in treatment.

A chest tube helps alleviate the buildup of secretions or exudate that makes breathing difficult. This involves inserting a tube into the chest cavity, allowing the secretions to drain out. This procedure relieves pressure on the lungs and improves breathing.

In cases of treatment-resistant pleural empyema, doctors treat the patient with a thoracoscopy. During this procedure, doctors perform a surgical intervention to remove the pus. This procedure is usually performed using the “keyhole method,” meaning the surgery is minimally invasive.

Thoracoscopic decortication (“unbinding” of the lung)

If the condition is not detected early, significant accumulations of pus form in Stage 2, which can be removed using a minimally invasive, video-assisted procedure (VATS). 

In stage 3, the chronic infection causes a thick membrane of connective tissue (scarring) to form on all those sections of the lung and chest wall that have already come into contact with the purulent fluid. This causes the lung to become increasingly constricted, preventing it from expanding properly during breathing. Those affected suffer from shortness of breath and become severely weakened within a very short time.

At this stage, simple chest drainage is no longer effective; instead, due to the long-term complications, the lung must be surgically exposed through a pleural empyema procedure. Today, this is already performed minimally invasively in specialized clinics as part of a thoracoscopic decortication, a procedure that frees the lung from the constraints of the connective tissue layers.

Alternatively, open decortication is performed, in which an incision approximately 5 to 7 cm long is made under the armpit to remove both the connective tissue membrane and the pus accumulations. 

The chest tube inserted during the procedure must remain in the chest for a while to continue draining the lung after surgery.

As a result of the procedure, the condition usually heals completely. However, if the pus accumulation and scar tissue are diagnosed very late, the lung may have already shrunk so much that it cannot expand back to its original size even after pleural empyema surgery. As a result, the patient’s lung capacity is permanently impaired.

As with most acute conditions, early diagnosis and treatment are crucial for the prognosis. The sooner doctors detect pleural empyema, the faster they can begin treatment.

It is often caused by pneumonia and usually presents no symptoms in young patients. As a result, doctors often diagnose pleural empyema very late in these patients. The mortality rate is therefore quite high.

In the early stages, doctors treat pleural empyema with antibiotics and drainage. If it has been present for some time, surgery is usually necessary.

The condition requires specialized tests and treatments. Therefore, hospitals that specialize in lung diseases and thoracic surgery are ideal.

Specialists who treat pleural empyema include pulmonologists, thoracic surgeons, and infectious disease specialists. Radiologists provide support for diagnostic imaging, and laboratory physicians assist with laboratory diagnostics.

Since surgery for stage 3 pleural empyema is a complex procedure, you should place yourself in the hands of proven experts. Leading Medicine Guide can help you find them.