History and exam
Key diagnostic factors
common
presence of risk factors
Risk factors for empyema include immunocompromise, comorbidities predisposing to the development of pneumonia, pre-existing lung disease, iatrogenic interventions in the pleural space, male sex, and young or old age.
recent pneumonia
Failure of patients with pneumonia to respond to antibiotics, or a deterioration in clinical condition, suggests the development of a complicated parapneumonic effusion or empyema.
constitutional symptoms
Malaise, anorexia, weight loss, or fatigue may occur.
pyrexia and rigors
Signs of pneumonia, empyema, and systemic infection.
dullness to percussion
Dullness occurs at the lung base in pleural effusions and pneumonia, but that associated with an effusion is classically described as 'stony' in quality.
reduced breath sounds and reduced vocal resonance
Decreased air entry is found in pleural effusions and pneumonia.
signs of sepsis
Evidence of sepsis includes pyrexia, tachypnoea, tachycardia, and hypotension (BP <90/60). Such patients require urgent resuscitation.
Other diagnostic factors
common
subacute presentation
Patients usually present with a 1 to 2 week history of symptoms.
productive cough
A cough productive of green or rust-coloured sputum may be present in pneumonia.
pleuritic chest pain
Chest pain on inspiration results from inflammation of the parietal pleura (the visceral pleura is not innervated).
dyspnoea
Presence of a large pleural effusion can cause breathlessness.
The patient may also be breathless if there is associated pneumonia.
recent instrumentation of the pleural space
Patients who have had recent surgery, tunnelled pleural catheter placement, or other manipulation or trauma of their pleural space are considered high risk.
Risk factors
strong
pneumonia
The majority of empyemas develop following bacterial pneumonia.[8] Pleural inflammation leads to the development of a parapneumonic effusion and invasion of the pleural space by bacteria.
Therefore, risk factors for pneumonia, including aspiration (e.g., following a stroke, in the presence of a nasogastric or endotracheal tube), immunocompromise, alcohol abuse, and drug addiction are also risk factors for empyema.
Patients who fail to respond to antibiotic treatment for pneumonia should be reassessed for development of an empyema.
iatrogenic interventions in the pleural space
Iatrogenic empyemas can occur following intervention in the pleural space such as thoracic surgery or medical procedures such as chest drain insertion, thoracentesis (pleural aspiration), tube thoracostomy (chest drain insertion), and aspiration of pneumothoraces or pleural effusions.[22]
thoracic trauma
Blunt or penetrating chest trauma can lead to empyema.[22]
Undrained haemothoraces can become secondarily infected, resulting in empyema.
immunocompromised state
Patients immunocompromised due to haematological disease, chemotherapy, HIV, or malnutrition are at increased risk of developing empyema.
The lack of characteristic clinical signs can delay diagnosis.
comorbid lung disease
Pre-existing lung diseases, such bronchiectasis, COPD, and lung cancer increase the risk of developing empyema by contributing to reduced lung clearance.
Patients with comorbidities are also at increased risk of dying from an empyema.[3]
weak
male sex
The male to female ratio of patients with empyema is approximately 2:1.[23]
older or young age
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