Loculated Empyema After Failed Chest Tube Drainage
A 56-year-old man with poorly controlled type 2 diabetes presents 3 weeks after a right lower lobe pneumonia with fever, dyspnea, and weight loss. CT shows a loculated right pleural collection with a thick pleural peel and underlying consolidated lung. A chest tube placed 4 days ago drained 200 mL of frank pus, but he remains febrile with WBC 18,000/µL, albumin 2.2 g/dL, and creatinine 1.6 mg/dL. Tube output is now minimal, and an ultrasound shows persistent loculations. He is hemodynamically stable but has lost 6 kg. The team asks whether to give fibrinolytics, place another drain, or operate.
1. What is the next step, and why?
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This is a fibrinopurulent or organizing empyema with failed tube drainage, persistent sepsis, and a thick peel. The most reliable next step is VATS decortication, ideally within 24–48 hours, because fibrinolytics are less effective when a thick peel and loculations are already present. A second drain is unlikely to resolve the underlying trapped lung. I would obtain CT angiography only if vascular involvement is suspected. Preoperatively, I would optimize glucose, correct dehydration and electrolytes, transfuse if indicated, and start broad antibiotics with anaerobic coverage based on culture data. If the patient were too unstable for general anesthesia, image-guided drainage plus fibrinolytics would be a temporizing option, but here he is stable enough for surgery.
2. How would you optimize this patient before and after decortication?
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Before surgery, I would control hyperglycemia, restore volume, correct renal dysfunction, and provide nutrition-preferably enteral if tolerated-because hypoalbuminemia and weight loss impair healing and increase infection risk. I would review cultures and tailor antibiotics, ensure adequate analgesia, and arrange chest physiotherapy. After VATS decortication, I would leave a chest drain, aim for full lung re-expansion, continue antibiotics until clinical and radiographic improvement, and monitor for persistent air leak or trapped lung. Early mobilization and nutrition are important. If he remains febrile with a residual collection, I would reimage rather than simply escalate antibiotics.
3. During VATS, the lung fails to re-expand after decortication. What are your options and how do you decide?
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A trapped lung may reflect a thick visceral peel, underlying parenchymal destruction, or a persistent bronchopleural fistula. I would complete the decortication, remove all organized peel, and test for air leak. If the lung still does not expand because of a stiff visceral peel, I would avoid excessive pressure and consider a limited thoracotomy for better exposure. If there is a large bronchopleural fistula or destroyed lobe, resection may be required. Postoperatively, a prolonged air leak can be managed with a pleural drain and, in selected cases, a Heimlich valve or pleurodesis; however, pleurodesis will not work if the lung cannot contact the chest wall. The decision depends on the cause of non-expansion and the patient’s ability to tolerate further surgery.