Successful two-port video-assisted thoracoscopic surgery for acute empyema in a high-risk patient with a high RAPID...

Acute empyema presents a significant mortality risk in advanced-age populations, with rates reaching up to 20% in patients over 80 years of age. While initial treatment typically involves antibiotics and thoracic drainage, surgical intervention is often necessary in stage II empyema due to multiloculation and inadequate drainage. The renal (urea), age, fluid purulence, infection source, dietary (albumin) (RAPID) score has been proposed as both a prognostic tool and a potential surgical indicator, but its role in high-risk patients remains uncertain.

An 85-year-old male nursing home resident with an Eastern Cooperative Oncology Group performance status of 3 and comorbidities including type 2 diabetes, chronic kidney disease stage 3b, and cardiovascular history presented with fever and cough. Chest computed tomography revealed encapsulated pleural effusion with multiloculation, consistent with acute stage II empyema secondary to aspiration pneumonia. Initial antibiotic therapy and thoracic drainage were ineffective. Despite high-risk conditions and a RAPID score of 6, semi-elective two-port video-assisted thoracoscopic surgery (VATS) decortication was performed. Postoperative recovery was uneventful, and the patient was discharged on day 13 without complications.

This case highlights that VATS can be a viable and safe treatment option for acute empyema, even in high-risk older adults with a high RAPID score, provided clinical stability and appropriate disease staging.