Surgical management of intrapleural infections

Most patients with empyema require surgical intervention. Selection of therapy is based on the patient's overall condition, on the cause of the empyema, and on the stage of empyema progression. Parapneumonic effusions in the exudative or early fibrinopurulent stage may be responsive to tube thoracostomy and may not require further intervention in 65% of patients. More complicated parapneumonic effusions require thoracoscopic or open thoracotomy for debridement or decortication and are successfully managed in over 95% of patients. Empyemas that develop postoperatively are more challenging to diagnose and treat. Open thoracotomy is usually necessary unless patients are too ill to tolerate major surgery, in which case simple open drainage is an alternative. Closure of any bronchopleural fistula is necessary before an empyema can be eradicated. In patients with empyema associated with an extrapulmonary infectious process, control of the primary source of infection is required before definitive therapy of the empyema is undertaken. The overall success rate of therapy for empyema is greater than 90% and the associated mortality rate is about 8%.