Optimal management of complicated empyema

BACKGROUND: Despite continued improvement in medical therapy, empyema remai ns a challenging problem for the surgeon. Multiple treatment options are av ailable; however, the optimal therapeutic management has not been elucidate d. METHODS: A retrospective review was performed of all adult patients admitte d to Denver Health Medical Center between January 1, 1993, and December 31, 1998, with the diagnosis of empyema. Data tabulated included patient demog raphics, presentation, chest computed tomography (CT) findings, treatment, and outcome. RESULTS: Empyema was diagnosed in 58 patients, 45 cases of which were multi loculated at the time of presentation. Empyema was secondary to pneumonia i s 41 patients and posttraumatic in 15. In addition to antibiotic therapy, i nitial treatment included chest tube drainage alone (n = 6), chest tube dra inage with primary operation (n = 19), and chest tube drainage with intrapl eural fibrinolytic therapy (n = 33). In 15 patients (45%), fibrinolytic the rapy failed. Initial chest CT revealed a pleural peel in 5 patients treated with fibrinolytics and all failed. Multiloculation, however, was not a fac tor in failure of fibrinolysis. Moreover, chest CT missed the presence of a pleural peel in 17 of 31 patients documented to have a significant peel at the time of thoracotomy. CONCLUSION: Multiple therapeutic options are available for the management o f empyema. Multiloculation is not a contraindication to an initial trial of chest tube drainage or fibrinolytic therapy. In contrast, CT evidence of a pleural peel uniformly predicted failure of nonoperative treatment, (C) 20 01 by Excerpta Medica, Inc.