Pleural empyema

What exactly is a pleural empyema?

Pleural empyema, also known as pyothorax, is an accumulation of pus in the pleural cavity because of an inflammation.

The pleura is made up of two thin membranes. The pulmonary pleura, or visceral pleura is what covers the lungs, while the parietal pleura lines the inside of the chest. Between the two membranes, we find the pleural cavity, which is usually very small and contains only a few milliliters of fluid that helps the pleural sheets attach to each other. If a large amount of fluid accumulates, such as in pleural empyema, the pleural gap expands, and lung tissue is displaced.

What are the causes of a pleural empyema?  

Pus consists of proteins and other remnants of dead cells. It forms when there is local tissue destruction caused by protein-degrading enzymes, which can be released by bacteria or immune cells as part of the defense response.

Pleural empyema occurs when bacteria invade the pleural space. This leads to inflammation of the pleura and the accumulation of granulocytes, a type of white blood cell that destroys bacteria. The death of tissue, triggered by bacteria and granulocytes, results in pus formation.

The most common cause is pneumonia, but bacterial infections of nearby organs, such as the heart or upper abdomen, can also lead to pleural empyema. In the case of sepsis, bacteria can spread through the bloodstream from other infection sites, such as the bladder. The pathogens can also enter the pleural space from the outside, for example, through an accident involving chest trauma or surgery.

The following factors increase the risk of pleural empyema:

• Immunosuppression (e.g., corticosteroid therapy or AIDS)
• Alcohol abuse or intravenous drug use
• Diabetes mellitus
• Gastroesophageal reflux disease (acid from the stomach rising into the esophagus, which may reach the lungs)

Which symptoms occur with pleural empyema? 

Small and encapsulated pleural empyemas may be asymptomatic. More frequently, however, patients experience a reduced general condition, severe illness, fever, and often shortness of breath.

How does the specialist diagnose a pleural empyema?

During the medical history interview, symptoms and risk factors are asked about. This is followed by a physical examination. In larger cases, a weakened breath sound over the empyema may already be noticeable when auscultating with a stethoscope.

A blood test can reveal elevated levels of various inflammation markers (leukocytes, CRP, PCT, sedimentation rate), indicating an ongoing inflammation.

Imaging tests, such as ultrasound, X-rays, or CT scans, can help identify fluid in the pleural space. The images may also show if the fluid is divided by tissue septa. However, it may be hard to tell whether the fluid is an empyema just from imaging, since other types of fluid, like serous fluid or blood, look similar.

Therefore, the definitive diagnosis is made with a pleural puncture. During this procedure, the doctor will insert a needle between two ribs to drain the fluid. If the fluid is pus, it confirms the presence of a pleural empyema. The pus is then sent for lab testing to identify the bacteria causing the infection.

What treatment options are there?

Antibiotic therapy must always be administered for pleural empyema. Initially, broad-spectrum antibiotics are used to cover the most likely pathogens. Once the causative bacteria are identified, the antibiotic treatment may be adjusted accordingly.

Additionally, a pleural drain must always be placed, ideally a suction drain. This plastic tube is inserted between two ribs to allow the pus to drain and the pleural cavity to be flushed. There is currently no clear evidence regarding the use of fibrinolytic drugs via the drain. However, it may help prevent significant compartmentalization and organization of the empyema, potentially avoiding the need for surgery.

If the treatment is unsuccessful, which is more likely with compartmentalized empyemas, damaged tissue may need to be removed through surgery.

After the acute inflammation subsides, pleural empyemas can lead to significant scarring that can severely impair lung function. In such cases, surgery is also required to remove the pleura, as well as fibrous tissue and scar tissue.

When is a surgery necessary and how does it work?

An operation may be necessary if treatment with antibiotics and drainage is unsuccessful or if the lung is restricted by scar tissue after the acute inflammatory phase has subsided.

Surgical treatment of pleural empyema usually involves video-assisted thoracoscopic surgery (VATS).

This minimally invasive procedure is performed under general anesthesia, using small incisions between the ribs. With the help of a camera and surgical instruments, the damaged tissue is removed, and a chest drain is inserted for a few days. Finally, the incisions are closed again.

Which doctors & clinics specialize in pleural empyema?

Patients with pleural empyema receive interdisciplinary care. It is primarily a condition of internal medicine. However, patients require intensive care and possibly mechanical ventilation, which is often provided by the anesthesiology department in many hospitals. If surgical intervention is necessary, it is performed by thoracic surgeons.

Anyone in need of a doctor would expect the best possible medical care for themselves. Therefore, patients are looking for the most suitable clinic for their needs. Since this is not an objective decision and a respectable doctor would refrain from claiming to be the best, patients must trust the experience of a doctor.

We can help you find an appropriate expert for your condition. All the doctors and clinics listed have undergone extensive review and have been verified by us for their outstanding expertise in the field of pleural empyema. They are looking forward to and are ready to address your questions and treatment requests.