Decortication for chronic postpneumonic empyema

Thoracic empyema after pneumonia continues to be a source of morbidity and mortality. Despite the widespread use of antibiotics, more than 50 percent of empyemas are secondary to a primary pulmonary process. An empyema present for four to six weeks is considered chronic and can severely restrict the movement of the entire hemithorax.

Twenty-five adult patients with chronic, postpneumonic empyema required decortication at the Bronx Municipal Hospital Center between 1988 and 1990. Only patients with chronic postpneumonic empyema were included. All patients failed conservative treatment with antibiotics and tube drainage. Decortication was required to control infection and release the pulmonary entrapment.

Patients were often debilitated from alcoholism (52 percent), drug addiction (32 percent), and chronic disease. Ten patients (40 percent) required additional operative procedures to control infection: two pneumonectomies, three lobectomies, three wedge resections, and two debridements of pulmonary abscess were performed. Preoperative plain roentgenographs and computed tomographic scans diagnosed the empyema in all cases; however, they were frequently unable to predict the operative findings. There was one recurrence and one mortality (4 percent). The average postoperative period of hospitalization was 18 days (seven to 30 days).

Decortication remains a highly effective treatment for chronic postpneumonic empyema and may identify underlying complications that could account for a patient's poor response to conservative treatment. Pulmonary abscess and parenchymal necrosis may not be detected during preoperative evaluation.