Skip to Main Content


  • Pyothorax: Pus within pleural cavity, usually thick, creamy, malodorous

    • Etiology includes:

    • -In setting of pneumonia, lung abscess, bronchiectasis, it is referred to as parapneumonic (60%)

      -Postsurgical (20%)

      -Post-traumatic (10%)

      -Less common causes include esophageal rupture and other chest wall or mediastinal infections

    • 3 temporal phases:

    • 1. Acute exudative

      -Sterile low viscosity pleural fluid

      -Low WBC count and lactic dehydrogenase (LDH)

      -Normal glucose

      -Normal pH

      2. Transitional (fibrinopurulent)

      -Increase in turbidity, WBC, and LDH

      -Low glucose and pH

      -Fibrin deposited thereby fixing the lung

      3. Chronic organizing

      -Occurs 7-28 days after disease onset

      -Exudates thickens, causing further fixation of lung

      -pH < 7.0

      -Glucose < 40 mg/dL




  • • Most organisms are anaerobic bacteria: bacteroides, fusobacterium, peptococcus

    Staphylococcus is cause in > 90% of children under 2 years; common cause in adults also

    E coli, Pseudomonas cause 66% of aerobic, gram-negative empyemas

    • Rarely fungi and Entamoeba histolytica can cause empyemas

    • Average number of bacterial species isolated: 3.2 per patient

    Incidence of complications with Staph pneumonias in adults:

    • -Abscess (25%)

      -Empyema (15%)

      -Effusion (30%)

    Incidence of complications with Staph pneumonias in kids:

    • -Abscess (50%)

      -Empyema (15%)

      -Pneumatocele (35%)

      -Effusion (55%)


Symptoms and Signs


  • • Rarely asymptomatic

    • Fever, pleuritic chest pain, dyspnea, hemoptysis, cough

    • Tachycardia, anemia, tachypnea, diminished breath sounds, clubbing


Imaging Findings


  • Chest film and chest CT:

    • -Pneumonia

      -Lung abscess

      -Pleural effusion

      -Mediastinal shift away if large empyema


  • • Thoracentesis is diagnostic

    • -In early empyema, pleural fluid may not be purulent

      -pH < 7.0

      -Glucose < 40 mg/dL

      -LDH > 1000 U/L

      -Suggests evolving empyema despite negative Gram stain and culture

      -Frank pus usually develops later in empyema development


  • Chest CT: May be necessary if loculated

    Bronchoscopy: Performed to exclude presence of endobronchial obstruction

    Thoracentesis: Diagnostic


  • • Goals:

    • -Control infection

      -Remove purulent material with lung reexpansion

      -Eliminate underlying disease process

    • Options:

    • -Repeated thoracentesis

      -Chest tube drainage

      -Rib resection with open drainage

      -Decortication and empyemectomy


      -Muscle flap closure


Treatment Algorithm: Empyema


  • • Clear thoracentesis

    • -Check Gram stain and culture

      -If positive, thoracentesis/chest tube

      -If negative, check pH, glucose, LDH; chest tube if indicated

    • Pus on thoracentesis

    • -Place chest tube

      -Convert to open drainage

      -Perform sinogram: No cavity, then withdraw tube; small cavity, evaluate how well drained—if well drained, then slowly advance tube—if not well drained, then consider rib resection, thoracoscopy, or new chest tube; large cavity, if well drained, slowly advance tube—if no reexpansion, consider decortication—if not well drained, consider early decortication, rib resection, or Eloesser procedure

    • Residual spaces, continued sepsis: Consider open drainage procedures 10-14 days after chest tube (allows time for pleural fusion

    • Rib resection: Of short segments of 1-3 ribs in dependent portion

    • Eloesser procedure: Simple rib resection and open flap drainage

    • Creation of U-shape flap: Chest wall sewn to parietal pleura with rib resection

    • ...

Want remote access to your institution's subscription?

Sign in to your MyAccess profile while you are actively authenticated on this site via your institution (you will be able to verify this by looking at the top right corner of the screen - if you see your institution's name, you are authenticated). Once logged in to your MyAccess profile, you will be able to access your institution's subscription for 90 days from any location. You must be logged in while authenticated at least once every 90 days to maintain this remote access.


About MyAccess

If your institution subscribes to this resource, and you don't have a MyAccess profile, please contact your library's reference desk for information on how to gain access to this resource from off-campus.

Subscription Options

AccessSurgery Full Site: One-Year Subscription

Connect to the full suite of AccessSurgery content and resources including more than 160 instructional videos, 16,000+ high-quality images, interactive board review, 20+ textbooks, and more.

$995 USD
Buy Now

Pay Per View: Timed Access to all of AccessSurgery

24 Hour Subscription $34.95

Buy Now

48 Hour Subscription $54.95

Buy Now

Pop-up div Successfully Displayed

This div only appears when the trigger link is hovered over. Otherwise it is hidden from view.