Empyema and restrictive pleural processes after blunt trauma: An under-recognized cause of respiratory failure

Respiratory failure is a common complication among patients sustaining majo r blunt trauma. This is usually due to the underlying pulmonary injury, pne umonia, or adult respiratory distress syndrome. However, we have frequently found these patients to actually have a pleural process as the cause of th eir respiratory failure. Our objective was to assess the frequency of empye ma and restrictive pleural processes after blunt trauma and their contribut ion to respiratory failure. We retrospectively reviewed all blunt trauma pa tients over a Ei-year period who required a thoracotomy and decortication f or empyema. Twenty-eight patients with blunt trauma required a thoracotomy and decortication for empyema. The most common finding was infected, locula ted hemothorax/effusion in 23 patients, whereas 5 had an associated pneumon ia. Chest radiographs were nondiscriminating, whereas CT scans in 25 patien ts showed previously unrecognized fluid collections, air-fluid levels, or g as bubbles. Neither thoracentesis nor placement of additional chest tubes w as helpful. Positive cultures were uncommon. Ventilator dependence was pres ent preoperatively in 13 patients who were on the ventilator an average of 13 days preoperatively and only 5.8 days postoperatively. Several patients believed to have adult respiratory distress syndrome were weaned within 72 hours of operation. All patients were ultimately cured. Empyema is an under -recognized complication of blunt trauma and may contribute to respiratory failure and ventilator dependence. Although difficult to diagnose, empyema should be considered in blunt trauma patients with respiratory failure and an abnormal chest radiograph. CT aids in the diagnosis, and the results of surgical treatment are excellent.