Modern management of adult thoracic empyema

Seventy adult patients with thoracic empyema were treated at the University of Michigan Medical Center between 1978 and 1982. Twenty-two (31%) of the empyemas were associated with pneumonia, 23 (33%) occurred as postoperative complications, and seven (10%) were iatrogenic. When used as the initial mode of drainage, repeat thoracentesis was successful in only four of 11 cases (36%). Similarly, closed tube thoracostomy, as initial treatment, was successful in only 14 of 40 cases (35%). Rib resection, however, provided cure or control in 10 of 11 patients (91%) when employed as the first treatment method. Eight of 12 patients (67%) with parapneumonic empyemas were treated successfully with closed tube thoracostomy, in contrast to only two of 17 patients (12%) with postoperative empyemas so treated. Eventual control or cure of empyema was achieved in 57 patients (81%), whereas 13 (19%) died (five from their empyema and eight with empyema as an active problem at the time of death). All of the five empyema-caused deaths occurred in patients who underwent chest tube drainage as the most invasive treatment modality. The mortality rate for immunosuppressed patients was 40% (four of 10 patients). This analysis of a large recent series of adult empyemas suggests that chest tube drainage is often inadequate and more aggressive management is likely to result in fewer treatment failures and fewer total procedures. Early rib resection, especially for postoperative empyemas and those in immunocompromised patients, is recommended.