Empyema Empyema is defined by its appearance in the pleural cavity; it is defined as a pus pocket that forms in the pleural cavity. It is an opaque, whitish-yellow, viscous fluid that is the result of serum coagulation proteins, cellular debris, and fibrin deposition. Empyemas develop primarily because of delayed presentation by the patient with advanced pneumonia and progressive pleural infection.(Sahn 2007) Patients with empyema always require pleural space drainage for adequate resolution of pleural sepsis and often require decortication. Decortication is a surgical procedure performed under general anesthesia in which the surgeon manually breaks up the adhesions and drains the pleural space. The surgeon puts a chest tube into place so the pleural space continues to drain (postsurgically) until fluid ceases to be produced and drainage resolves, typically a few days.
Demographics: Empyema is less come occurring in approximately 5-10% of patients who present with parapneumonic effusion and pneumonia. In review of 14 studies of empyema, which involved a total of 1383 patients, 70% of the cases were secondary to pneumonia(Sahn 2007). Empyema usually present within 4-6 weeks following onset of pneumonia that goes untreated or unresponsive to treatment(Sahn 2007).
Clinical Presentation: Most cases of empyema will present with similar symptoms of pneumonia (i.e., fever, malaise, cough, dyspnea, and pleuritic chest pain) are similar to those of pneumonia without a PPE. Elderly patients may be relatively asymptomatic, presenting only with fatigue or altered mental status. A patient may present with scapular or shoulder pain, and the pain may refer to the lower quadrant.
Differential Diagnosis: It is important to remember that a through subjective exam is imperative. Pulmonary disease is rarely manifested as a pain syndrome without associated symptoms of disease being present. Common symptoms accompanying the pain complaints include sore throat, fever, hoarseness, cough, dyspnea, stridor, and wheezing. Smoking increases the risk for the most common conditions of the respiratory system including cancer and infection. Patients with who present with a history or pneumonia, or recent respiratory tract infection should be referred to a physician for chest imaging.
It is important to note that gastrointestinal disorders such as biliary colic and acute appendicitis have similar pain referral patterns.
Physical Examination:Should include percussion and auscultation of the chest, which may reveal signs of dullness, inspiratory crackles, or bronchial sounds. The presence of constitutional signs and symptoms indicate systemic illness.
Bottom Line: Refer Out A patient that presents to physical therapy with the fore-mentioned presentation should be referred to their primary physician for further testing. Patients with empyema always require pleural space drainage for adequate resolution of pleural sepsis and often require decortication.
Please refer to the "Empyema" section of the reference list.