Surgical Science, 2011, 2, 446-450
doi:10.4236/ss.2011.29097 Published Online November 2011 (
Copyright © 2011 SciRes. SS
Chronic Empyema: Aetiopathology and Management
Challenges in the Developing World
Martins Oluwafemi Thomas1,2*, Ezekiel Olla Ogunleye1,2
1Lagos University Teaching Hospital, Suru lere, Lagos, Nigeria
2College of Medicine, University of Lagos, Surulere, Lagos, Nigeria
E-mail: *
Received July 4, 2011; revised Septembe r 21, 2011; accepted October 13, 2011
Objectives: Chronic empyema thoracis (CET) is common worldwide despite widespread use of highly ef-
fective antibiotics. Also, newer technological armamentaria are available for its diagnosis and treatment. This
research was performed to study the aetiopathological profile and the management challenges of CET in
view of the background information stated above. Methods: It is a prospective study spanning a period of 62
months in Lagos, Nigeria. Patients’ bio-data, aetiological factors, salient clinical features, management mo-
dalities and complications of care were documented and analysed. We excluded patients who were not fit for
surgery and those who could not afford surgery. Patients that were initially registered as chronic empyema
patients but who later became positive for malignancy were also excluded. Results: There were 93 patients
(61 males and 31 females). Age range was 4 - 72 years but the range 20 - 49 years constituted 71.0% of the
studied population. Poorly treated acute chest infections was the aetiological factor in 49.5% of patients. Tu-
berculosis was established in 37 patients (39.8%) who were especially in social classes I and II. Decortica-
tion and pneumonectomy were done for 52.7% and 16.1% of the patients respectively. Average hospitalisa-
tion was prolonged for pneumonectomy because some patients had pneumonectomy space infections. Dis-
cusion: CET remains a worldwide problem despite widespread use of potent antibiotics. There are newer
diagnostic and therapeutic armamentaria that are not readily available in developing world thereby posing
major challenges to practicing surgeons.
Keywords: Chronic Empyema Aetiopathology Management
1. Introduction
Empyema thoracis (ET) is collection of pus in pleural
cavity and it is common worldwide. Despite availability
and widespread use of highly effective antibiotics, em-
pyema thoracis occurs and is associated with significant
morbidity and occasional mortality [1]. Globally, respi-
ratory diseases are a leading cause of morbidity and
mortality among both children and adults.
ET affects both sexes and no age is exempted. The
clinical and pathological features vary with duration of
ailment. In the early phase, the features are those of acute
respiratory infection, characterised by cough, fever and
ipsilateral chest pain. In the late phase, fever, is less
pronounced. Features like worsening dyspnoea, weight
loss and cough supe rvene.
Various aetiological factors of empyema thoracis have
been identified. Parapneumonic empyema continues to
be a disease of significant morbidity and mortality among
children despite recent advances in medical management
Streptococcus pneumonia is a major respiratory patho-
gen and the spectrum of clinical presentations highly
associated with this pathogen include bacteraemic and
non-bacteraemic presentations of pneumonia as well as
parapneumonic effusions or empyema [2].
In developing countries, antecedent conditions such as
malnutrition, measles or infection with antibiotic-resis-
tant organisms may increase the risk of severe pneumo-
nia accompanied by empyema. Other co-morbid condi-
tions may include diabetes mellitus and HIV/AIDS.
Many countries of the world have adopted the use of
pneumococcal vaccine in children. This has been found
effective in reducing the risk of pneumococcal infec-
Trauma is another important cause of empyema thoracis.
Haemothorax, pneumothorax or haemo-pneumothorax can
be secondarily infected leading to ET. Attempt at treat-
ment, if not handled professionally, can also lead to ET.
Pleural effusions (exudative or transudativ e) can proceed
to frank empyema thoracis if not properly managed. In
all the conditions mentioned above, early institution of
definitive care will stop the progression of acute ET to
chronic empyema. However, delay in termination of the
progression often leads to formation of fibrinous strands
thereby laying the foundation for fibrous adhesions, lo-
culation of empyma and formation of a thick fibrous
cortex as in the complex of chronic empyema thoracis
CET is therefore an important sequela of untreated or
poorly treated empyema thoracis. The bacteriology of
chronic empyema is fairly diverse [1,3-5]. A study of
empyema thoracis in India revealed that aetiology was
tubercular in 42% of patients whereas, the rest were bac-
terial. Among the bacterial cases, they found Staphylo-
coccus aureus as the commonest organism implicated [1].
In the same study, the rest of the patients had gram nega-
tive infection by Pseudomonas aerugenosa, Klebsiella
pneumoniae and Escherichia coli. While these organisms
can occur singly, mixed infections are possible and a
good number may be culture negative. Outside the regu-
lar causes of chronic empyema stated (vide supra), it is
important to note the rare causes of chronic empyema
like achalasia [6].
The spectrum of ensuing pathology of chronic em-
pyema is fairly wide. It may range from small encysted
empyema (which may occur singly or in multiples),
through varying degrees of encasement of lobes or whole
lung, and up to varying degrees of parenchymal destruc-
tions involving lung segments, lobes or whole lung.
Destroyed lung is now accepted to designate the large
destructions of the lung, secondary to pulmonary and
essentially infectious diseases, the cure of which is ob-
tainable but with possible important sequelae [7].
This spectrum of pathological entities constitute the
indications for surgical intervention in chronic empyema.
It is also important to know that failure of prolonged
medical treatment, multi-drug resistance of tubercle ba-
cilli and continuing haemoptysis constitute important
indications for surgery. Eith er of the lungs or both can be
affected. There is no agreement on the dominance of one
lung over the other when it comes to frequency of oc-
currence [1,8].
The diagnostic armamentarium is fairly diverse. Chest
radiographs complimented with computerised tomogra-
phic scan of the chest are often sufficient to study anat-
omic details of chronic empyema. Microbiology is of
essence in determining the organisms present in the em-
pyema and their sensitivity to known antimicrobials.
The surgical treatment mod alities of chronic empyema
are dependent on the targeted pathologic entity. Rib re-
section and open drainage had been in use for a long time.
Decortication is done to peel the fibrous cortex that en-
cases the lung. When there is parenchymal damage,
varying degrees of lung resection are indicated depend-
ing on the extent of the damage. Rarely, this may be
multi-segmentectomy, but more commonly lobectomies,
bi-lobectomies or pneumonectomies are often necessary.
All these are now being done by Video Assisted Thora-
coscopic Surgery (VATS). Elective postoperative venti-
lation is often indicated. Common complications of lung
resections include cardiac arrest, pneumonectomy space
infection, bronchopleural fistula formation amongst oth-
This study was conducted to determine the aetiopa-
thology and management challenges of chronic em-
pyema in a developing world. It is actually a research to
see the aetiopathological profile and management chal-
lenges of CET in view of widespread use of antibiotics
and available modern armamentaria for its management.
It is expected to further improve the current knowledge
and understanding of the various aspects of chronic em-
2. Methods
The study was conducted at the Lagos University Teach-
ing Hospital in southwest Nigeria from October 1999 to
December 2005.
In a prospective setting, data sheets were designed to
accommodate the needed parameters. The parameters
were recorded for patients who were referred to our team
in Lagos metropolis with diagnosis of chronic empyema
thoracis. We recorded their bio-data with a particular
note of ages, sexes and social classes.
We noted the followings:
Duration of their ailment;
Clinical evidence of cardiac involvement;
The lung or lungs affected;
Aetiological factors that were found in them;
Method(s) of diagnosis implored.
Diagnoses were premised on clinical features and
laboratory re po r ts.
We specifically sought the follo wing features:
History of trauma;
Previous di ag n osi s of p ul monary tuberculosis;
Previous diagnosis of acute chest infection;
History of any chest procedures like needle asp iration;
Previous chest operation like tube thoracostomy and
Copyright © 2011 SciRes. SS
We also noted the outcomes of laboratory diagnoses
Radiographs and computerised axial tomograph of
Microbiology including mantoux test, bacteriology,
and mycology of aspirates;
cytology of chest aspirates.
The final treatment modalities were recorded for each
of them. Specifically, we recorded the definite operations
performed like decortication, lobectomy, pneumonec-
tomy. Postoperative complications were also noted for
each patient when they occurred. The data sheets were
studied and analysed manually. We calculated measure-
ments for disp ersi on of the distri bution.
We excluded patients who were not fit for surgery and
those who could not afford surgery because we thought
they would not be available to complete the research.
Patients that were initially registered as chronic em-
pyema patients but who later became positive for malig-
nancy were ex cl uded.
We also excluded rib resection drainage because the
few patients involved eventually underwent definitive
operations. The main issue here was that it became in-
creasingly difficult to manage their effluents because of
the rising cost of drainage bags.
We noted th e duration of ho spitalisation and operation
related deaths.
3. Results
The study period lasted 62 months and 93 patients were
involved. They were 61 males and 32 females giving an
M:F ratio of 1:1.9 (Table 1). The age range was 4 - 72
years but age range 20 - 49 constituted 71.0% of all the
patients. Within the latter age range, 46 patients (69.7%)
were males. Further analysis showed no significant dif-
ferences in sex distribution at the extremes of age.
Poorly treated acute chest infection was the aetiologi-
cal factor in 49.5% of patients. (Table 2) Tuberculous
aetiology was established in 37 patients (39.8%) and
83.8% of them occurred in patients of social classes I and
II (Table 2). In all patients in social classes I and II con-
stituted 79.6% of the studied population, none of the pa-
tients was in social class V.
Decortication was done for 49 patients constituting
52.7% while pneumonectomy was done for 16.1% of the
patients. (Table 3) Average hospitalisation for d ecortica-
tion was 16.7 days while lobectomy and pneumonectomy
patients spent 18.2 and 24.1 respectively. Average hos-
pitalisation was prolonged for pneumonectomy because
of the weight effect of 3 patients who had pneumonec-
tomy space infections and they all had prolonged hospi-
Table 1. Age and sex distribution of patients.
Age (yr) M F Total
<10 1 - 1 (1.1%)
10 - 19 1 1 2 (2.2%)
20 - 29 13 8 21 (22.6%)
30 - 39 16 8 24 (25.8%)
40 - 49 17 4 21 (22.6%)
50 - 59 8 5 13 (13.9%)
60 and above5 6 11 (11.8%)
61 (65.6%) 32 (34.4%) 93 (100.0%)
Table 2 . Aetiological factors and social classes.
AetiologicalSocial class
Factors I II III IV V Total
Chest trauma1 2 - - - 3
Tuberculosis18 13 6 - - 37
Poorly treated14 19 8 5 - 46
Iatrogenic5 2 - - - 7
Pneumonia38 36 14 5 - 93
Table 3. Treatment modalities.
Modality No of patients
Decortication 49 (52.7%)
Lobectomy 29 (31.2%)
Pneumonectomy 15 (16.1%)
Total 93 (100.0%)
There were three operative deaths. One death followed
decortication while the other 2 were for lobectomies.
Therefore operative mortalities were 0.0% for pneu-
monectomy, 2.0% for decortications and 3.4% for lobec-
Based on the exclusion criteria stated (vide supra), 28
other patients who got enlisted initially were dropped
from the study.
4. Discussion
Empyema thoracis remains a common problem world-
Copyright © 2011 SciRes. SS
wide. Its pathological spectrum range from acute, through
the sub-acute to chronic states. These three phases are
also described as types I, II and III respectively. The
acute and sub-acute forms are easily managed with chest
tube insertion and antibiotics most of the times. Man-
agement of the chronic form is more challenging both
technically and in terms of costs to the patients esp ecially
in a developing world. Technological advancement has
improved the diagnostic and therapeutic armamentaria of
chronic empyema but these have not lessened the finan-
cial burden. In our study, we chose to look at the ae-
tiopathological profile and the technical challenges of
managing empyema thoracis with particular interest in
the developing world.
Using our study criteria which are fairly strict, 93 pa-
tients in the chronic empyema bracket a in a 62-month
period is a major haul and this exposes the burden of the
disease in the developing world. It therefore comes to
reason that this is a major problem with its attendant
technical and financial challenges. The 65.6% prepon-
derance of males over females as in this study, is fairly
consistent with earlier researches in Taiwan, China,
South Korea Vietnam, India and Nigeria [1,2,4-6]. We
believe that this is the cumulative effect of the fact that
men are generally more predisposed to the aetiological
factors of chronic empyema. The predominant age range
of 20 - 49 (71.0%) is also consistent with earlier Asian
and African studies [1,2,4-6].
The aetiology of chronic empyema as found from this
study, though fairly diverse, is largely dominated by
poorly treated pneumonias (49.5%) and pulmonary tu-
berculosis (39.8%). This is of major concern in view of
the growing influence of HIV/AIDS on the epidemiology
and pathology of tuberculous infections. Another point
of concern in the distribution of the studied population is
the occurrence of 79.6% of patients in social classes I
and II. This constitutes a major financial burden for this
group of people especially where there is no health in-
surance programme.
From our study, decortication was more commonly
indicated than pneumonectomy. As demonstrated in Ta-
ble 3, 52.7% of our patients had decortication while
16.1% underwent pneumonectomy. We had our chal-
lenges in the postoperative care of patients who had rib
resection drainage procedures because of the rising cost
and relative non-availability of drainage bags. This lim-
ited the number of such proce du res i n ou r st udy .
Average hospitalisation for decortication was 16.7 days
while lobectomy and pneumonectomy patients spent 18.2
and 24.1 respectively. These hospitalisation figures are
generally shorter when compared with the patients
treated with fibrinolytic agent in India [1]. We also noted
the role of pneumonectomy space infection in prolonging
hospitalisation. This can be reduced with more strict pre-
operative and intra-operative care.
Another challenge is that Video Assisted Thoraco-
scopic surgery (VATS) which is a proven method of re-
ducing hospitalisation is not readily available in the de-
veloping world. Therefore patients who ordinarily should
benefit from this technology are deprived of such benefit
on the basis of non-availability.
The overall operative mortality was 3.2%. A break-
down revealed zero mortality for pneumonectomy, 2.0%
for decortications and 3.4% for lobectomies. This is the
trend in many of the previous studies in Asia and Africa
We concluded that there is no significant change in
aetiology of chronic empyema over the years and that the
spectrum of its pathology is also constant. However, the
developing world is not catching up with the evolving
technological advancement in the management of chronic
empyema. This, therefore, is a major challenge for tho-
racic surgeons and their patients.
We therefore recommend that practitioners in the de-
veloping world should acquire the needed expertise and
procure VATS equipment to reduce postoperative mor-
bidity of empyema surgery and halt the progression to
chronic empyema.
5. Acknowledgements
I wish to acknowledge the secretarial support of my dear
daughter Oyindamola THOMAS. She assisted greatly in
typing the manuscript.
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