When Is Surgery Required for Empyema? Treatment Options Explained

Empyema is a serious medical condition. It happens when pus builds up in the space between the lungs and the chest wall. This space is called the pleural cavity. It usually develops after a lung infection like pneumonia. If left untreated, empyema can cause major health problems. Treatment must be done quickly and correctly.

In many cases, empyema can be treated with antibiotics and drainage. But sometimes, surgery becomes necessary. In this blog, we will look at what empyema is, its causes, how it is diagnosed, and when surgery is needed. We’ll also go through different treatment options available, both non-surgical and surgical.

What is Empyema?

Empyema is a condition where infected fluid (pus) collects in the pleural space. This fluid contains bacteria, white blood cells, and debris from infected tissues. It is different from a simple pleural effusion, which is just fluid buildup. In empyema, the fluid is thick and full of infection.

There are three stages of empyema:

1. Exudative Stage – The fluid is thin and free-flowing. It mostly contains white blood cells and proteins.
2. Fibrinopurulent Stage – The fluid becomes thicker. Fibrin (a protein) forms, creating septations or pockets.
3. Organizing Stage – Fibrous tissue forms around the lung. The lung becomes trapped and cannot expand fully.

What Causes Empyema?

The most common cause is pneumonia. Other causes include:

• Lung abscess
• Tuberculosis
• Chest trauma or surgery
• Infections after medical procedures
• Bloodstream infections that spread to the lungs

When bacteria enter the pleural space, they cause inflammation and lead to the production of pus.

Symptoms of Empyema

Empyema symptoms can develop gradually or suddenly. Common signs include:

• High fever and chills
• Chest pain, especially when breathing
• Shortness of breath
• Dry or productive cough
• Fatigue and weakness
• Loss of appetite

In children, symptoms may be less specific, like irritability or poor feeding.

Diagnosing Empyema

Doctors use several tools to diagnose empyema:

• Chest X-ray: Can show fluid buildup.
• Ultrasound: Helps find the exact location and amount of fluid.
• CT scan: Gives a detailed picture of the lungs and pleural space.
• Thoracentesis: A sample of fluid is taken from the pleural space using a needle. It is sent for lab tests to check for infection.

How Is Empyema Treated?

1. Antibiotics

Antibiotics are the first line of treatment. They help fight the infection. The choice of antibiotic depends on the bacteria found in the pleural fluid. Antibiotics may be given orally or through a vein (IV).

However, antibiotics alone are not enough if there is a large amount of pus. That’s when drainage becomes necessary.

2. Chest Tube Drainage (Thoracostomy)

A chest tube is inserted through the chest wall into the pleural space. It helps remove the infected fluid. This is often guided by ultrasound or CT scan. The tube stays in place until the infection clears and the lung re-expands.

Sometimes, medications called fibrinolytics (like tPA) are added through the chest tube. They help break up thick pus and improve drainage.

When Is Surgery Required for Empyema?

Surgery is usually needed in these situations:

a. Failure of Chest Tube Drainage

If the infection does not improve with chest tube drainage and antibiotics, surgery may be the next step. This often happens when the pus is thick or trapped in multiple pockets (loculated empyema).

b. Organizing Stage of Empyema

In this stage, the lung becomes wrapped in fibrous tissue. This prevents the lung from expanding. Only surgery can remove this tissue and allow the lung to work normally again.

c. Recurrent Empyema

If a patient keeps getting empyema again and again, surgery may be required to prevent future episodes.

d. Persistent Infection

If a patient continues to have fever, pain, and high white blood cell count despite treatment, surgery is often the best option to clear the infection completely.

Surgical Options for Empyema

There are different types of surgeries used to treat empyema. The choice depends on the stage of the disease and the patient’s overall health.

1. Video-Assisted Thoracoscopic Surgery (VATS)

This is a minimally invasive surgery. Small incisions are made, and a tiny camera is inserted into the chest. The surgeon uses special tools to remove pus and fibrous tissue. VATS is commonly used for stage 2 and early stage 3 empyema.

Benefits of VATS:

• Smaller cuts
• Faster recovery
• Less pain
• Lower risk of infection

Dr. Harsh Vardhan Puri specializes in VATS and uses this method for many patients with empyema.

2. Open Thoracotomy

This is a more traditional surgery. A larger cut is made in the chest to access the lung. It is used for severe or advanced cases of empyema where VATS is not enough.

During thoracotomy, the surgeon may perform:

• Decortication: Removal of the fibrous layer around the lung to allow expansion.
• Pleurectomy: Removal of part of the pleura.

Open surgery has a longer recovery time but may be necessary for complete treatment.

3. Thoracoplasty (Rare)

In very rare cases, if the infection cannot be cleared and the lung cannot expand, thoracoplasty may be done. In this procedure, part of the rib cage is removed to close the infected space.

Recovery After Surgery

Most patients recover well after surgery if they follow proper care:

• Take prescribed antibiotics as directed
• Attend follow-up appointments
• Do breathing exercises to improve lung function
• Avoid smoking and pollutants
• Eat healthy to boost the immune system

Pain and discomfort may last for a few weeks. Physical activity can be resumed slowly, depending on how the patient feels.

Prevention of Empyema

Some steps can help reduce the risk of empyema:

• Get vaccinated against pneumonia and flu
• Treat lung infections early
• Avoid smoking
• Take proper care after lung surgery or injury
• Manage chronic diseases like diabetes and COPD properly

Final Thoughts

Empyema is a serious but treatable condition. Early diagnosis and proper treatment are key. In many cases, antibiotics and chest tube drainage can manage the infection. But when the condition becomes more severe, surgery is necessary to remove infected tissue and restore lung function.

Dr. Harsh Vardhan Puri, an expert thoracic surgeon, offers advanced treatment options, including VATS and robotic-assisted surgeries, to help patients recover faster and return to their normal lives. If you or your loved one has signs of empyema, don’t wait. Consult a lung specialist and explore all the treatment options available.

For more information, visit www.drharshvardhanpuri.com – your trusted destination for expert chest surgery and lung care in India.