Thoracic empyema: current opinions in medical and surgical management.
OBJECTIVE
Empyema is defined as pus in the thoracic cavity due to pleural space infection and has a multifactorial underlying cause, although a majority of them are post-bacterial pneumonia caused by tuberculosis or by infection following penetrating chest injuries or surgical procedures. It is still associated with significant morbidity and mortality in adults and children despite optimal management according to current guidelines. Historically, empyema management has been empirical, but more recent data are leading to more focused management guidelines.


RESULTS
The number of therapeutic agents licensed for intrapleural use or undergoing clinical trials in the management of empyema continues to expand, although their use is currently controversial and probably best limited to trials and specialist centers. Although their use is limited by availability, ultrasound and guided aspiration is the investigation of choice in suspected empyema. It is safer, more sensitive, provides more information, and, in the case of guided-drainage, is more likely to be effective. Finally, there is a growing body of literature that supports very early involvement of thoracic surgeons in empyema management. An emerging question for the future is whether some or indeed all patients with empyema should now bypass medical thoracostomy and proceed directly to video-assisted thoracoscopic surgery for both acute and chronic empyemas.


CONCLUSIONS
A summary of the most recent opinions and results in thoracic empyema management is outlined. Treatment of empyema can be summarized as appropriate antibiotic therapy combined with medical or surgical pleural space drainage, management of any underlying factors, with further surgery indicated for chronic disease.
Department of Medical Microbiology, University College London Hospital NHS Foundation Trust, London, UK. sflee@ibmc.up.pt
Simon F
SF
Lee
David
D
Lawrence
Helen
H
Booth
Stephen
S
Morris-Jones
Bruce
B
Macrae
Alimuddin
A
Zumla
D000328:Adult; D000368:Aged; D000900:Anti-Bacterial Agents / Q000627:therapeutic use*; D003131:Combined Modality Therapy; D004322:Drainage / Q000379:methods; D016724:Empyema, Pleural / Q000175:diagnosis / Q000188:drug therapy* / Q000601:surgery*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D016032:Randomized Controlled Trials as Topic; D018570:Risk Assessment; D012720:Severity of Illness Index; D020775:Thoracic Surgery, Video-Assisted / Q000379:methods*; D016896:Treatment Outcome
D000900:Anti-Bacterial Agents