Defining the optimal treatment for empyema

There are many ways to treat a patient with an empyema that goes from a chest tube insertion to a thoracostomy window. Different options lay in between these two extremes. For many of us a chest tube insertion is the first measure in a patient with empyema. However, I found many times, no matter how well positioned is the chest tube, that I couldn’t drain all the fluid from the pleural space. This situation leads to a discussion about what to do next, a CT guided pigtail catheter? A new chest tube? Alteplase infusion through the chest tube? VATS? Thoracotomy? If an option different than surgery is chosen, new CT scans are performed to make sure no significant amount of fluid is left and few days are lost in the process. So, what is the best first approach?

In 2009 Wozniak et al. published in the ATS a paper that shows that chest tube insertion is associated with treatment failure when it is the first intervention in patients with advanced empyema. The best results were achieved with VATS and thoracotomy. Although they address the topic in patients with advanced empyemas, I think that also in early stage empyemas the first intervention is critical. As I said, chest tubes failed many times in patients with empyemas and a quick VATS that cleans up the pleural space is many times a more wise option. After VATS you are completely sure that you drained everything, that you freed up the entire lung and the chest tube or tubes are placed where they should be. This saves time, usually offers a one-time intervention and carries a very low complication rate. There are cases that VATS is not enough and an open thoracotomy is needed, specially in those advanced empyemas, where a true and extensive decorticacion is needed.

I don’t mean with this that VATS is the treatment of choice in every patient with empyema, but I do mean that VATS should be always considered as a possible first option. If CT shows the fluid is free in the pleural space, no loculations are seen, you face a very sick patient or a patient that for some reason would no tolerate general anesthesia –and we found this last one to be a very infrequent event-, you may want to consider a chest tube insertion or a CT guided pigtail placement. A recent work by Dr. Feins’ team also published in the Annals, showed very good results with the use of intrapleural alteplase through the chest tube. This is an excellent choice, but we reserved it for those patients that wouldn’t tolerate surgery and have an empyema that didn’t resolve with just a chest tube.

The best option to treat an empyema patient is the one that you think will fix the problem with the minimum number of interventions and days of hospitalization weighted against the risks of the intervention itself, no matter which one is that procedure for you. In our hands this procedure is usually VATS.

What is the practice at your place?

Sebastian

PS: by the way the case of the picture actually needed an open thoracotomy decortication.

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