Ten-year exploratory retrospective study on empyema

Introduction

Thoracic empyema remains a serious illness that usually represents a complication of pneumonia in susceptible patients. Our exploratory study aims to describe this potentially fatal disease and identify clinically useful correlations that would lead to more effective management and treatment.

Methods

We performed a retrospective review of patients hospitalized between the years 1996 and 2006 at Forum Health – WRCS. Demographics, initial symptoms and signs, underlying diseases, pleural fluid analysis and cultures, chest CT reports, length of stay and outcome were reviewed.

Results

The charts of 104 patients who filled the above criteria were reviewed. Their age ranged from 10 months to 87 years; 52% were nonsmokers. The main presenting symptoms were dyspnea (65%), fever (60%), cough (60%), chest pain (45%) weight loss (14%) and hemoptysis (9%). Approximately 22% of the patients had an underlying malignancy. Other underlying chronic illnesses included chronic obstructive pulmonary disease (27%), congestive heart failure (24%), and diabetes (21%). Pleural fluid Gram stain was positive in 25% of the patients and pleural fluid cultures in 49%. Of those with positive cultures, Gram(+) aerobes were found in 60%, Gram(-) in 24% and anaerobes in only 12%. Treatment of the patients included: repeat thoracentesis (effective in only two patients); intrapleural thrombolysis performed in five patients, effective in four; and chest tube drainage (performed in 80% of the patients). Approximately one-half of them required further procedures: video-assisted thoracoscopic surgery was performed in 10 patients (10%), six of whom required subsequent thoracotomy; and thoracotomy and decortication (performed in 46% of the patients). Overall mortality was 9% and surgical mortality was 2.1%.

Conclusion

Clinical suggestions arising from our study are as follows. Empyema is a fatal complication of pneumonia and should always be suspected in patients with nonimproving pneumonia. Early aggressive antibiotic therapy targeting Gram-positive aerobes should be initiated. An underlying malignancy should be always considered in the differential diagnosis. Cardiothoracic surgeons should always be consulted early in the clinical course for evaluation of a possible video-assisted thoracoscopic surgery or thoracotomy.