Management of Empyema
2. Class I: Failure of a community- or healthcare-associated pneumonia to respond clinically to appropriate antibiotic therapy should prompt investigations to identify the presence of a pleural effusion (LOE B). (, )
2. Class IIa: Computed tomography (CT) of the chest should be obtained when pleural space infection is suspected (LOE B). ()
LABORATORY AND PLEURAL FLUID ANALYSIS
2. Class I: A pleural pH <7.2 in a patient with suspected pleural space infection predicts a complicated clinical course, and tube thoracostomy should be performed followed by surgical intervention when appropriate (LOE B).
3. Class IIa: A pleural fluid LDH >1000 IU/L, glucose <40 mg/dL, or a loculated pleural effusion suggests that the pleural effusion is unlikely to resolve with antibiotics alone, and we recommend tube thoracostomy (LOE B).
4. Class I: Obtain pleural fluid culture specimens during aspiration or drainage procedures, not from previously inserted tubes or drains (LOE B). Inoculate freshly drained pleural fluid into aerobic and anaerobic blood culture vials in addition to sterile containers for gram stain and culture (LOE B). ()
ACUTE PLEURAL EMPYEMA: ANTIBIOTIC TREATMENT
b. Class IIa: For hospital-acquired or postprocedural empyema: include antibiotics active against methicillinresistant Staphylococcus aureus and Pseudomonas aeruginosa (eg, vancomycin, cefepime, and metronidazole or vancomycin and piperacillin/tazobactam [dosed for activity against P. aeruginosa]) (LOE C).
c. Class I: Avoid aminoglycosides in the management of empyema (LOE B).
d. Class IIa: There is no role for intrapleural administration of antibiotics (LOE C).
ACUTE PLEURAL EMPYEMA: PLEURAL DRAINAGE
Class III no benefit: Thoracentesis without pleural drain placement is not recommended for the treatment of parapenumonic effusion or empyema (LOE C).
Thoracentesis is a useful tool in the management of uncomplicated pleural effusion and a recommended step in the diagnosis of complicated effusion. In the setting of known pleural infection, however, ongoing pleural drainage is regarded as a requirement for adequate treatment and thoracentesis alone, without pleural drain placement, is not recommended.
Image-Guided Drain Placement
2. Class IIa: In septated effusions, placement of small bore catheters are recommended in patients that are not surgical candidates (LOE C).
3. Class I: Routine drain flushing is recommended to prevent occlusion (LOE B).
4. Class I: Tube thoracostomy should be combined with close CT follow-up to confirm adequacy of drainage. Persistence of any undrained fluid should prompt additional drains or more aggressive management (LOE C).
ACUTE PLEURAL EMPYEMA: INTRAPLEURAL FIBRINOLYTIC THERAPY
ACUTE PLEURAL EMPYEMA: SURGICAL MANAGEMENT
CHRONIC EMPYEMA: DECORTICATION
2. Class IIb: There is no compelling evidence that epidural catheters cannot be used safely in patients with chronic empyema if they are otherwise low risk for epidural abscess (LOE C). ()
CHRONIC EMPYEMA: SPACE FILLING OF CHRONIC EMPYEMA CAVITIES
Thoracoplasty. Class IIb: Thoracoplasty with resection of ribs may be considered in select cases to obliterate the infected pleural space where previous measures (muscle flaps, open window) have failed (LOE C). ()
CHRONIC EMPYEMA: PROLONGED TREATMENT MEASURES
Class IIa: Open thoracic window with marsupialization of the infected thoracic cavity with resection of several ribs and dressing changes is reasonable to be performed in patients with chronic empyema who are medically unfit to tolerate decortication and tissue flap placement or those patients with chronic empyema with a BPF (LOE C).
Wound Vacuum-Assisted Closure (VAC) Device
Class IIb: Wound VACs may be a reasonable alternative to daily dressing changes to debride chronic pleural cavities that are being treated with an open thoracic window. Caution should be exercised in placing VACs when there is a BPF or visceral pleural rents leading to large air leaks (LOE C).
Class IIb: An empyema tube draining a chronic empyema cavity may be considered in draining chronic infections in which there is a small persistently infected space or small BPF, especially in those patients who are medically unfit to tolerate decortication and tissue flap placement (LOE C). ()
Class I: Prompt intervention to identify or rule out the presence of a BPF and provide drainage of sepsis is recommended in patients suspected of having postpneumonectomy empyema (LOE C).
Class IIa: An aggressive surgical approach that includes antibiotics, serial debridement, closure of the BPF when present, and obliteration of the residual pleural space using vascularized tissue transposition is a reasonable strategy to manage postpneumonectomy empyema (LOE C). (, )
EMPYEMA ASSOCIATED WITH BPF
2. Class IIb: Transposition of the omentum is preferred over skeletal muscle flaps or mediastinal soft tissue, and this should be attempted after the purulent fluid has been drained completely and the pleural cavity has a surface of granulation tissue (LOE C).
Management of the residual thoracic space
1. Class IIb: Primary chest closure should be attempted with the chest cavity filled with antibiotic solution after granulation tissue has formed in the chest cavity and if the patient is medically fit to undergo another operation (LOE B).
2. Class IIa: The creation of a permanent open thoracostomy window is an acceptable treatment strategy for patients treated for an empyema with a recurrent or persistent BPF who are medically unfit for another operation or for those with recurrent cancer (LOE C). ()
2. Class IIa: Thoracoscopic debridement and drainage is recommended in pediatric patients not responding adequately to tube thoracostomy and fibrinolytic instillation (LOE B).
3. Class IIa: VATS debridement is preferred rather than open thoracotomy for the surgical management of empyema in the pediatric population (LOE C). ()
Management of Empyema
February 4, 2017
Last Updated Month/Year
August 2, 2023
Supplemental Implementation Tools
External Publication Status
Country of Publication
To establish The American Association for Thoracic Surgery (AATS) evidence-based guidelines for the management of empyema.
Female, Male, Adult, Older adult
Health Care Settings
Ambulatory, Hospital, Operating and recovery room
Nurse, nurse practitioner, physician, physician assistant
Diagnosis, Management, Treatment
D004653 - Empyema, D016724 - Empyema, Pleural, D013354 - Empyema, Subdural
empyema, thoracic surgery, lung disease, bronchopleural fistula, video-assisted thoracoscopic surgery