Definition

Thoracic empyema is the accumulation of pus in pockets within the chest cavity, specifically within the pleural space. The thorax encompasses the chest area formed by the sternum, ribs, and thoracic vertebrae, housing various organs and tissues such as the lungs, heart, major blood vessels, and diaphragm.

The pleura is the membrane that lines the outer surface of the lungs and the inner surface of the chest wall. Between the two layers of pleura that line these different areas, the pleural space is formed. Empyema is a condition that can lead to disability, complications, and even death if not properly managed.

Causes

The most common causes of thoracic empyema are:

• Pneumonia or lung infection (70%)
• Other causes of empyema (30%) are related to:
• Trauma
• Post-surgery involving the chest area
• Esophageal problems
• Infections in the neck
• There are also cases of empyema not caused by pneumonia or other interventions.

Lung infections leading to empyema may result from:

• Community-acquired infections, usually caused by bacteria, especially Streptococcus bacteria
• Healthcare-associated infections, in cases of trauma, surgery, and infections acquired in health facilities, are most often caused by Staphylococcus aureus, especially the type of Staphylococcus bacteria that is resistant to the antibiotic methicillin, and the Pseudomonas group of bacteria.

In Indonesia, thoracic empyema can also be a complication of tuberculosis. Empyema can also be caused by fungi, with Candida fungus being the most common cause. Empyema caused by fungi is associated with a high mortality rate. Other causes of empyema include infections in other parts of the body spreading to the lungs and lung infections caused by food particles swallowed into the lungs.

Risk Factor

The main risk factor for empyema is pneumonia. Empyema most often occurs in children and the elderly, but the number of cases is not large. Several conditions can increase the risk of empyema after pneumonia, including:

• Bronchiectasis (airway dilation resulting in mucus accumulation)
• Chronic Obstructive Pulmonary Disease (COPD)
• Rheumatoid arthritis, an autoimmune disease/body cells attack themselves
• Gastroesophageal reflux disease (GERD)
• Alcohol addiction
• Diabetes
• Weakened immune system
• History of surgical procedures
• Trauma
• Abscess or pus accumulation in the lungs

Symptoms

Symptoms of empyema may include fever, night sweats, fatigue, difficulty breathing or shortness of breath, drastic unexplained weight loss, chest pain, and a productive cough with green sputum. These symptoms are similar to pneumonia or lung inflammation but typically occur over a longer period.

Diagnosis

The diagnosis of thoracic empyema is made by considering the patient's medical history and complaints and conducting an examination. A history related to risk factors may provide clues to the presence of empyema. Moreover, individuals with a history of pneumonia who have been given antibiotics but show no improvement in symptoms may also be at risk for thoracic empyema. The doctor may perform a chest examination to listen to the patient's breath sounds and determine the possible location of the empyema. Various types of advanced examinations that can help establish the diagnosis of thoracic empyema include:

• Complete blood count, used to detect possible infections
• Imaging examinations
• Chest X-ray, which can suggest the diagnosis of thoracic empyema but cannot confirm it definitively
• Ultrasound (ultrasonography), which can be performed to clarify pleural imaging
• CT scan (computed tomography scan), which can be an alternative to ultrasound for clearer visualization of the pleura

Thoracentesis, a procedure to remove fluid from the pleural space, which will be examined in the laboratory to determine the cause of empyema and the composition of the pleural fluid

Management

Antibiotics

Thoracic empyema is essentially a disease caused by infection, so the main therapy involves antibiotics or antibacterials. The choice of antibiotic depends on the suspected bacteria causing the empyema. These antibiotics are usually given for 2-6 weeks, either as injectable antibiotics or oral medications. Generally, patients with thoracic empyema will be hospitalized for several days until their condition stabilizes.

Surgical Procedures

In addition to antibiotics, thoracic empyema requires surgical procedures. This surgery usually involves placing a tube into the pleural space. The tube is used to drain pus into a special container and is guided by X-rays or CT scans to ensure proper positioning. Typically, patients experience symptom improvement within 24 hours of tube placement. The tube remains in place until the amount of pus is minimal enough to be absorbed by the pleura. If this tube is chosen as a therapeutic option, its position and the amount of fluid collected need to be checked daily, requiring hospitalization.

Another alternative to the chest tube is a stoma, an opening in the chest wall connected to a bag to collect fluid from the pleural cavity. A stoma can be used without hospitalization.

Other surgical management can be open thoracotomy. Open thoracotomy is a procedure to open the chest wall to clean the pus directly. However, this surgery is very high risk, so it is only performed if the above therapies cannot completely treat the empyema.

Rehabilitation

After recovering from empyema, some individuals may experience lung hardening and restricted lung movement, leading to shortness of breath and fatigue. Surgery and rehabilitation can improve this condition. Decortication, a surgery involving the removal of pleural layers to provide space for lung movement, may be performed.

Complications

Thoracic empyema that is promptly and properly treated has a fairly high chance of recovery, and long-term lung damage is rare. Cooperation as a patient is crucial to take antibiotics as prescribed by the doctor and to follow up if necessary to check pleural recovery. However, the risk of death from empyema is very high in people with weakened immune systems, around 40%. If not properly managed, empyema can lead to life-threatening conditions such as sepsis.

Prevention

Prevention of thoracic empyema can be achieved by preventing pneumonia. This includes:

• Getting pneumonia vaccinations, such as Haemophilus influenzae type B, pneumococcal, and influenza vaccinations. Haemophilus influenzae type B (HiB) vaccination is already included in the child immunization program. Pneumococcal (PCV) vaccination has also been included in the government program for children, adults, and the elderly. Influenza vaccination can be done annually
• Washing hands with soap and water regularly, especially after using the toilet and before eating
• Consuming nutritious foods, especially fruits and vegetables
• Exercising regularly
• Getting enough sleep
• Quit smoking immediately if you smoke, as smoking increases the risk of lung diseases, including pneumonia and empyema
• Maintaining distance from sick people if possible

When to See a Doctor?

If you have a fever, cough, and shortness of breath, you can consult a doctor. If you have received therapy for your illness but have not recovered, you should see your doctor. The causes of fever, cough, and shortness of breath are not only bacteria that cause empyema but also other medical conditions such as tuberculosis or COVID-19. If not treated properly, these symptoms can progress to thoracic empyema, which requires quite complex therapy.