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Pleural empyema: 24-year experience
1Department of Thoracic Surgery, Tel Aviv University Sackler School of Medicine.
Background:
Despite the widespread use of antibiotics, empyema remains a common and serious problem, and its treatment is controversial.
Methods:
Our experience in 380 patients with empyema was retrospectively reviewed.
Results:
The causes of empyema were as follows: pneumonia (n = 308), late complication of tuberculosis (n = 24), trauma (n = 15), pulmonary gangrene (n = 3), retained foreign body (n = 1), and undetermined (n = 29). An exudative state was diagnosed in 273 patients, a fibrinopurulent state in 55, and an organizing state in 52. Pleuroscopy was performed in 107 patients resistant to treatment, and this revealed an expansible lung in 49 patients, a nonexpansible lung in 51, and exceptional findings (foreign body, necrotizing pneumonitis, and perforated esophageal cancer) in 7. Treatment was modified accordingly. Five patients died (mortality, 1.3%).
Conclusions:
Pleuroscopy is very helpful in disclosing factors responsible for resistance to treatment and in carrying out thorough pleural toilet. The use of talc in selected patients causes pleurodesis and prevents the reaccumulation of pus. Decortication is the ideal treatment in the organizing stage, enabling complete lung expansion. Fenestration is lifesaving in moribund patients who cannot tolerate decortication.
Insights
Empyema treatment can be guided by pleuroscopy, which helps identify causes of treatment resistance. Specific interventions like talc pleurodesis, decortication, or fenestration offer tailored solutions for better patient outcomes.
Area of Science:
- Thoracic surgery
- Pulmonology
- Infectious diseases
Background:
- Empyema remains a significant clinical challenge despite antibiotic use.
- Treatment strategies for empyema are often debated.
Purpose of the Study:
- To review the experience of managing 380 empyema patients.
- To evaluate the utility of pleuroscopy in guiding treatment decisions.
- To assess outcomes of various therapeutic interventions.
Main Methods:
- Retrospective review of 380 patients diagnosed with empyema.
- Classification of empyema stages: exudative, fibrinopurulent, and organizing.
- Performance of pleuroscopy in 107 patients with treatment-resistant empyema.
Main Results:
- Pneumonia was the most common cause (n=308).
- Pleuroscopy identified factors limiting lung expansion in 51 patients.
- Mortality rate was low at 1.3% (5 patients).
Conclusions:
- Pleuroscopy aids in identifying treatment resistance factors and facilitates pleural cleansing.
- Talc pleurodesis can prevent pus reaccumulation in selected cases.
- Decortication is optimal for organizing empyema, while fenestration is a life-saving option for critically ill patients.