Empyema Symptoms, Causes, and Treatment

female doctor talking with patient and pointing at a chest x-ray

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An empyema is a collection of pus in the pleural space, the area between the membranes lining the lungs (pleura). It often occurs as a complication of pneumonia but can occur after a thoracentesis, lung surgery, with a lung abscess, or following chest trauma. It is most commonly caused by infections with Streptoccocus or Staphylococcus bacteria. Symptoms may include a fever and chills, chest pain, a cough, and/or shortness of breath. The diagnosis may be made with a chest X-ray or chest CT scan, and a thoracentesis (lung tap) may be done to determine the type of bacteria causing the infection. Treatment includes a combination of antibiotic therapy to treat the infection and chest tube placement to drain the fluid, though surgery may be needed to remove scar tissue and parts of the pleura involved in the infection.

Anatomy

The pleural space or cavity is a region in the chest cavity that lies between the visceral pleura (the membrane on the outside of the lungs) and the parietal pleura (the membrane lining the inside of the chest wall. Ordinarily, this area contains just a few teaspoons of pleural fluid. With an empyema, this area may instead contain a pint or more of infected, pus-like (purulent) pleural fluid. (When there is extra fluid in the pleural space it is referred to as a pleural effusion.)

Empyema Fluid

The fluid contained in an empyema is referred to as pus and contains a combination of bacteria, dead cells, and white blood cells. The most common bacteria causing an empyema are Streptococcus pneumoniae (the "pneumonia" bacteria) and Staphylococcus aureus.

When a sample of pleural fluid is drained, the cloudy and thick appearance of an empyema is usually quite obvious in how it contrasts with normal pleural fluid which is thin and translucent.

Signs and Symptoms

Signs and symptoms of an empyema can be caused both by the presence of the infection and by pressure on the lungs and chest from the increase of fluid in the pleural space. Common signs and symptoms include:

  • Fever and chills
  • Night sweats: These can be very significant with drenching sweats at night requiring a changing of night clothes, sometimes several times
  • Chest pain, often sharp and worsening with inspiration
  • Shortness of breath: Difficulty breathing can come on slowly or rapidly depending on the size of the effusion and the severity of the underlying process
  • A dry cough: A cough may also be productive due to associated pneumonia
  • Hiccups: Irritation of the diaphragm and nerves (phrenic nerves) in this region due the build-up of fluid can result in hiccups 
  • Weight loss (unintentional weight loss defined as a loss of 5 percent of body weight over a period of 6 months or less without trying)
  • Fatigue: Fatigue can sometimes be profound and differs from ordinary tiredness
  • A general sense of not being well

Causes

There are a number of different conditions which may result in an empyema. Some of these include:

  • Pneumonia (This is the most common cause of an empyema)
  • Chest trauma, from a fall, motor vehicle accident, or other injury
  • Chest surgery, such as surgery for lung cancer or heart disease
  • A thoracentesis: Sometimes an infection may be caused inadvertently when a thoracentesis (needle "tap" of the pleural space) is done to diagnose disease or when a chest tube is placed to drain air (as in a pneumothorax) or fluid (as in a pleural effusion)
  • A bronchopleural fistula: A bronchopleural fistula is a fistula or canal that may develop between the pleural space and bronchi during lung surgery, allowing bacteria to pass from the bronchi to the pleural space)
  • An extension of infection: An infection in the abdomen (peritonitis) or area between the lungs (mediastinum) may spread into the pleural space
  • A lung abscess may rupture into the pleural space

Risk Factors

An empyema is more likely to occur in someone with:

  • Diabetes
  • A history of alcoholism
  • Autoimmune diseases such as rheumatoid arthritis
  • A suppressed immune system, such as with chemotherapy
  • Lung diseases such as COPD and chronic bronchitis
  • Gastroesophageal reflux disease

That said, these risk factors do not need to be present for an empyema to form.

Diagnosis

To diagnose an empyema, doctors first take a careful history and perform a physical exam. A history can help determine if there are any risk factors, and a physical exam may reveal diminished breath sounds.

Imaging

A chest x-ray or chest CT scan may help suggest the diagnosis, though sometimes an ultrasound examination may be done as well.

Thoracentesis

Though imaging studies may suggest the diagnosis, a sample of the fluid present in the pleural space is needed to confirm the diagnosis, and if present, to select the proper treatment.

In a thoracentesis, a long thin needle is inserted through the chest wall and into the pleural space. A sample of the fluid is taken, and usually the excess fluid is drained off. If a significant amount of fluid is present, draining the fluid can often reduce symptoms greatly.

The fluid obtained is then sent to the lab for analysis. A culture is done if an infection is suspected to isolate the specific bacteria involved, and to determine the best choice of antibiotics to treat the infection.

Treatment Options 

The treatment of an empyema entails both removing the fluid and treating the underlying process.

Fluid Removal

The fluid is removed via a thoracentesis, usually in the process of diagnosing the empyema. Sometimes this is fairly simple, especially if the empyema has not been present for long. A chest tube may then be placed in order to continue draining the fluid.

When an empyema has been present for some time, it may become loculated. This occurs when scar tissue forms and separates the fluid into separate cavities.This makes draining the fluid much more difficult, and sometimes several attempts at thoracentesis are needed to remove the fluid from the different "compartments."

Treating the Infection

Doctors will usually start antibiotics as soon as a sample suggests the possibility of an infection. Some people wonder why these aren't given right away, but the start of antibiotics is often delayed to give the lab the best chance of determining exactly which bacteria are causing the infection. (If antibiotics are started before the thoracentesis, it can be difficult to identify which bacteria are responsible for the infection.) After you are started on antibiotics the lab will do further tests to check on which antibiotics the bacteria are most sensitive to—and the antibiotics you are given may be changed after a few days.

Treatment of the Underlying Problem

The process which caused the empyema in the first place must also be addressed. This may include draining of a lung abscess, repair of a bronchopleural fistula, and more.

Complications/Surgery

With an empyema, especially one that has been present for awhile, scar tissue may build up. It may be necessary for a surgeon to remove some of the scar tissue and portions of the pleura in order to resolve the infection. This can be done either through a thoracotomy (open lung surgery) or thoracoscopic surgery (minimally invasive lung surgery) with video-assisted thoracoscopic decortication being an effective and less invasive option for many people.

A 2018 study suggests that video-assisted thoracoscopic surgery may be significantly more effective than thoracoscopy for those who develop an empyema after lung surgery. In addition, recent studies have found that non-surgical methods are often as effective as surgical methods for the treatment of empyema.

Other complications may include sepsis—an overwhelming infection throughout the body, and scarring and thickening of the pleural membranes.

Prognosis

The prognosis of an empyema depends largely on the underlying cause. Due to the severity of many of the conditions that precede an empyema, the mortality rate following an empyema can be as high as 30 percent. The incidence of empyema has been increasing in recent years, as has the most common types of bacteria responsible for the condition.

A Word From Verywell

An empyema is a term used to describe the presence of infected pleural fluid surrounding the lungs. The most common cause is pneumonia, but other conditions, as well as surgery and trauma, may be responsible. Treatment consists of taking a sample of the fluid to send to the lab and removing excess fluid which may result in shortness of breath and other symptoms. Antibiotics are then given to treat the infection.

Pronunciation: em-pie-ee-ma

Also called: pylothorax, pleural infection, purulent pleuritis, empyema thoracis

Examples: Jerry developed an empyema after his lung cancer surgery, and his doctor did a procedure to remove the infected fluid.

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Article Sources

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  • Spaggiari, L., and D. Galetta. Video-Thoracoscopic Management of Postpneumonectomy Empyema. The Thoracic and Cardiovascular Surgeon. 2018 Aug 7. (Epub ahead of print).