League of Arab States

Council of Arab Health Ministers

Arab Board of Health Specialization
Scientific Council of Surgery

Republic of Yemen
Council of Arab Health Ministers
Arab Board of Health Specialization
Ministry of Public Health and Population
The Yemeni Board for Medical Specialization
Scientific Council of Surgery – Training Committee

Outcomes of First Intervention in Management of Empyema

Republican Teaching Hospital Authority
(Al Jumhouri & typical police hospital)
Sana'a _Yemen
1st 2022 – 2024.
A thesis Submitted for Partial Fulfillment of the Requirements for Obtaining the Arab Board
Certificate in General Surgery
Prepared by
Dr. Khaled Sultan Ali Galeb
MBBS – Sana'a University
Supervisors
Dr. Mohammed Issa
Prof. of General and Laparoscopic Surgery, Faculty of Medicine, Sana'a University
Consultant of Surgery department, Sana'a University.
Trainer of the Arab Board of Surgery in Yemen
Direct General Coordinator
Dr. Yasser Abdurabo Obaidel
Assist. Prof. of General and Laparoscopic Surgery, Endocrine Surgeon
Faculty of Medicine Sana'a University.
Head of General Surgery Dept., Al-Thawra Modern General Hospital.
General Coordinator of the Arab Board of Surgery in Yemen

2022 - 2024
 CERTIFICATE

CERTIFICATE

This research was fully prepared under the supervision and direction of Prof. Dr.
Mohammed Issa and Assist. Prof. Dr. Yasser Abdurabo Obaidel for the award of the Arab
Board Certificate in General Surgery.

Supervisor
Dr. Mohammed Issa
Prof. of General and Laparoscopic Surgery, Faculty of Medicine,
Sana'a University
Consultant of Surgery department, Sana'a University.
Trainer of the Arab Board of Surgery in Yemen

I
 DECLARATION

DECLARATION

I declare that the work entitled “Outcomes of First Intervention In Management of

Empyema” submitted by me for the award of the Arab Board Certificate in General Surgery is
my own original work and carried out by me under the supervision and direction of Dr.
Mohammed Issa and has not formed the basis for award of any degree, diploma, associate ship,
fellowship, titles in this or any other university or institution. I further declare that the material
obtained from other sources has been duly acknowledged in this work.

I
 DEDICATION

DEDICATION

Most respectfully dedicated to my father, and mother

and all my family
also my all our doctors.
.

II
 ACKNOWLEDGEMENTS

ACKNOWLEDGEMENTS

Firstly and lastly, my great gratitude to ALLAH. The most gracious, the most
merciful.

I would like to express my deepest respect and my greatest indebtedness to: Dr.
Mohammed Issa Assist. Prof. of General and Laparoscopic Surgery, for his keen advices,
continuous support and contact observations throughout the work were readily given.

I thank all those who have made substantial contributions to the help and their assistance
in this study. also It is my pleasure to introduce my great thanks and appreciation to Assistant
Professor of General and Laparoscopic Surgery, Dr. Yasser Abdurabu Obadiel, General
Coordinator of the Arab Board of Surgery in Yemen for his constant encouragement and support
in the scientific and academic field.

III
 ABSTRACT

ABSTRACT
INTRODUCTION:

Empyema is an infectious process characterized by the accumulation of pus in the pleural

space, leading to high mortality rates, can result from various conditions. This study aims to
evaluate how the choice of initial intervention impacts patient outcomes in empyema
management.

METHODS:

A Prospective cohort study at tow teaching hospitals located in Sana'a governorate the
Tertiary Republican Teaching Hospital Authority and General Police Hospital. The data was
collected over a period between 2022 and 2024 was cover all patients presenting to the
hospitals with empyema who underwent different first interventions, such as surgical
decortication, tube thoracostomy, pig-tail catheter, VATS, or thoracotomy.

RESULTS:
Total number of patients involved in this study were 40 patients a higher percentage of
males (67.5%) compared to females. The age of the patients ranged from 19 to 75 years. The
majority of patients (58%) Mean Age: 47.1 years, Median Age: 50 years, St. deviation: 12.85
years. The study included a total of 40 patients, out of which 22 were classified as successful
and 18 as unsuccessful. the association between the side of empyema and success rate was
not statistically significant The laboratory characteristics of pleural fluid, several parameters
were measured. The mean pH values were 7.28 (SD=0.28) for all cases, 7.38 (SD=0.33) for
successful cases, and 7.17 (SD=0.15) for unsuccessful cases.

CONCLUSION:

Most common redeomenet in this study are male in middle to old age, Smoking history is
a significant negative predictor of success. Early and appropriate intervention, particularly in
later stages, is crucial for better outcomes The data indicates a clear correlation between the
stage of empyema and the required intervention for successful outcomes. Early stages are
more successfully managed with less invasive procedures, while advanced stages necessitate
more aggressive surgical approaches. Mortality rates also increase with the severity of
empyema, highlighting the importance of early diagnosis and intervention.

IV
 LIST OF CONTENTS

LIST OF CONTENTS
CERTIFICATE..................................................................................................................I
DECLARATION..............................................................................................................II
DEDICATION.................................................................................................................III
ACKNOWLEDGEMENTS............................................................................................IV
ABSTRACT.......................................................................................................................V
LIST OF CONTENTS....................................................................................................VI
LIST OT TABLES.......................................................................................................VIII
CHAPTER I
INTRODUCTION
1.1. Introduction................................................................................................................1
1.2. Justification of Study.................................................................................................2
BACKGROUND LITERATURE REVIEW
Overview:............................................................................................................................................3
Anatomy and Physiology:...................................................................................................................3
Epidemiology......................................................................................................................................3
Pathogenesis and Causes:....................................................................................................................4
Stages of Empyema.............................................................................................................................4
History and Physical Examination Findings:.......................................................................................5
Diagnostic Workup:.............................................................................................................................5
Evaluation of Empyema:.....................................................................................................................5
Initial Interventions:............................................................................................................................7
Surgical Interventions:.........................................................................................................................8
Complications:...................................................................................................................................11
1.3 Previous Study
CHAPTER II
OBJECTIVE
General Objective............................................................................................................15
Specific Objectives...........................................................................................................15
CHAPTER III
METHODOLGY
3.1 Study Design.............................................................................................................17
3.2 Study Setting.............................................................................................................17
3.3 Period of Study.........................................................................................................17
3.4 Sample of Study........................................................................................................17
3.5 Study Population......................................................................................................17
3.6 Inclusion Criteria.....................................................................................................17
3.7 Exclusion Criteria....................................................................................................18
3.8 Data Collection.........................................................................................................18
3.9 Outcome Measures...................................................................................................19
3.10 Statistical Analysis....................................................................................................19
3.11 Patient Group Categorization.................................................................................20
3.12 Data Analysis:...........................................................................................................20

V
 LIST OF CONTENTS

3.13 Ethical consideration................................................................................................20

CHAPTER IV
THE RESULTS
4.1 The Results................................................................................................................21
4.1.1 Gender and Age Distribution...............................................................................21
4.1.2 Demographic Characteristics and the Success Rate:.........................................21
4.1.3 Characteristics of Empyema and the Success Rate:..........................................23
4.1.4 Laboratory Characteristics:.................................................................................23
4.1.5 Radiological Findings:..........................................................................................24
4.1.6 Association Between the First Intervention Performed and the Success Rate:24
4.1.7 Complications:.......................................................................................................25
4.1.8 Correlations B/W Stage with 1st Intervention and Outcome & Mortality......26
CHAPTER V
DISSCUSSIONS
5.1 Discussions..................................................................................................................27
4.1 Limitation of Study..................................................................................................30
CHAPTER VI
CONCLUSIONS
6.1 Conclusions...............................................................................................................31
CHAPTER VII
RECOMMENDATIONS
7.1 Recommendations....................................................................................................32
CHAPTER VIII
REFERENCES
8.1 REFERENCES.........................................................................................................34
QUESTIONER.................................................................................................................37

VI
 LIST OF TABLES

LIST OT TABLES

Table 1 Evaluation of Pleural Infection [10].................................................................................................6

Table 4- 1demographic characteristics and the success rate....................................................................22

Table 4- 2 Empyema Characteristics and Successful Rate.........................................................................23
Table 4- 3 Association between characteristics of pleural fluid& Successful Rate....................................24
Table 4- 4 Radiological findings.................................................................................................................24
Table 4- 5 Association between first intervention and Successful Rate....................................................25

Figure 4- 1 A simple study according to gender....................................................................................21

Figure 4- 2 The correlation between the stage of empyema, the first intervention performed, the
outcomes, and mortality rates among the study's 40 patients...............................................................27

VII
CHAPTER I

INTRODUCTION
 CHAPTER I:
INTRODUCTION

CHAPTER I
INTRODUCTION
1.1. Introduction

Empyema is an infectious process characterized by the accumulation of pus in the pleural

space, leading to high mortality rates. The multifactorial pathogenesis and different stages of
empyema necessitate rapid diagnosis and prompt treatment to enhance patient survival.
Treatment typically involves a combination of medical and surgical interventions aimed at
eradicating the infection. Advances in therapy have provided clinicians with various
therapeutic options, including thoracocentesis, chest tube drainage (with or without
intrapleural fibrinolytic therapies), video-assisted thoracic surgery (VATS), and thoracotomy.
[1] Around 20% of patients with pneumonia will develop a parapneumonic effusion that may
lead to empyema. Seventy percent of patients with empyema have parapneumonic effusion,
the other 30% of cases are related to trauma, post-thoracic surgery, esophageal ruptures, or
cervical infections, and a small number are not related to previous pneumonia or intervention,
this is known as primary empyema[1],[2]. Empyema can result from various conditions,
including community- or hospital-acquired pneumonia, penetrating chest trauma, thoracic
surgery, esophageal rupture, pulmonary tuberculosis, lung abscess, bronchiectasis, subphrenic
abscess, and osteomyelitis of ribs. Independent risk factors for empyema development include
age under 60, poor oral hygiene, disorders with a predisposition to aspiration (e.g., seizures,
alcohol use disorder, central nervous system disease), IV drug misuse, diabetes,
cardiovascular disease, liver cirrhosis, and other immunocompromised states (e.g., HIV
infection, malignancy)[3]. Rapid and appropriate intervention is essential in managing
empyema effectively. This study seeks to provide insights into how the initial choice of
intervention influences patient outcomes, with the goal of informing clinical decision-making
and improving management strategies for empyema. The choice of the first intervention in the
management of empyema is crucial in determining treatment outcomes. Several studies have
explored the relationship between the initial procedure and treatment success rates, additional
procedures, and mortality rates. Several studies have investigated the impact of the initial
intervention on the outcome of empyema treatment. A systematic review and meta-analysis
by huang et al. (2020) [4] compared the efficacy and safety of VATS versus chest tube
drainage (CTD) in the treatment of empyema. The analysis included 16 randomized

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INTRODUCTION

controlled trials and found that VATS was associated with a significantly higher clinical
success rate, shorter hospital stay, and lower recurrence rate compared to CTD. Another
retrospectively study analyzed the outcomes of 120 patients with empyema who underwent
either VATS or CTD. The results showed that VATS was associated with a higher success
rate, lower complication rate, and shorter hospital stay compared to CTD. The authors
suggested that VATS should be considered the preferred initial intervention for empyema[5].

Understanding the impact of the initial intervention on treatment outcomes in empyema

management is critical for developing optimal treatment protocols. This research aims to
provide comprehensive data to guide clinical decisions, ultimately improving patient care and
outcomes in the management of empyema.

1.2. Justification of Study

 Limitations of studies in Yemen of existing use and effectiveness of Initial

treatment choice in empyema.

 To improved understanding of the effectiveness and limitations of the Initial

treatment choice in empyema can help optimize the treatment strategies for
empyema also can inform healthcare professionals in their clinical decision-
making process.

 The significance of the Initial intervention choice lies In its potential impact on
patient outcomes, such as mortality rates, quality of life, and recovery time.

 Research in this area can shed light on which the interventions are associated
with better outcomes, ultimately leading to improved patient experiences and
long-term health outcomes..

 To provide evidence-based recommendations that can enhance surgical planning

and patient outcomes.

 This study aims to conduct further research on the topic to provide more Insights
into the optimal first Intervention for empyema management.

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INTRODUCTION

BACKGROUND LITERATURE REVIEW

Overview:

Empyema, an infectious process defined by the presence of frank pus in the pleural space,
has been recognized since the time of Hippocrates and historically carries a high mortality
rate. Empyema is a complex entity with multifactorial pathogenesis and etiology, requiring
clinicians to recognize different stages of the disease. Rapid diagnosis is essential for
successful treatment and patient survival. The treatment aims to combine medical and surgical
interventions targeting the infection source and ensuring adequate lung re-expansion[6].

Anatomy and Physiology:

The pleural space is bounded externally and internally by parietal and visceral layers of
pleura, respectively. The normal pleural space accommodates 0.26 mL/kg of pleural fluid,
which is kept in balance through a process of parietal pleura formation and resorption. The
unique anatomy and physiology of the pleural space provides tight regulation of liquid within
the space under normal physiologic conditions. When this balance is disrupted and pleural
effusions develop, there can be significant impacts on the respiratory system. The rising
incidence and high morbidity of pleural infection remain a significant challenge to health care
systems worldwide. With distinct microbiology and treatment paradigms from pneumonia,
pleural infection is an area in which the evidence base has been rapidly evolving (DeBiasi et,
al. 2021). Empyema is characterized by purulent fluid (pus) in the pleural space following
pulmonary infections. In advanced stages, fibrin deposits around the lung parenchyma,
leading to lung entrapment and preventing adequate lung expansion. This results in
ventilation-perfusion mismatch.[7]
Epidemiology
A recent systematic review pointed out a discrepancy in the age bracket of adult patients
with pleural infection between high-income and low income countries, where patients in the
latter group tended to be 15 years younger on average. The same systematic review found
high prevalence of comorbidity in patients with pleural infection (median prevalence 72%),
with no difference in prevalence between patients from high-income and lower-income
countries[8],[9],[10] Empyema is often a complication of bacterial pneumonia, affecting up to
65,000 patients annually in the U.S. in Europe, the US, Canada, and Australia the average age
of patients diagnosed with pleural infection is 58–63 years.[11]

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INTRODUCTION

Pathogenesis and Causes:

Empyema, defined as a collection of pus in the thoracic cavity due to infection in the
pleural space, is often a complication of bacterial pneumonia, affecting up to 65,000 patients
annually in the U.S. Other causes include thoracic surgery, chest trauma, lung abscess, and
bronchogenic carcinoma. Patients with diabetes, immunosuppression, and cardiovascular
disease are at higher risk[1]. Pleural empyema is a serious condition with a considerable
mortality rate and morbidity. Chronic pleural empyema is usually a consequence of in
adequate treatment of acute pleural empyema[12].
Independent risk factors for empyema include:[13],[14]
 Age under 60 years old.  Diabetes.
 Poor oral hygiene.  Cardiovascular disease.
 Disorders predisposing to aspiration (e.g., seizure, alcohol  Immunocompromised states (e.g., HIV
use disorder, CNS disease). infection, malignancy).
 IV drug misuse.  Liver cirrhosis.
Study 2021 by Hassan, M. et, al. they evaluated the correlations between several potential
prognostic factors (age, predisposing diseases, early drainage, insufficient initial antimicrobial
therapy, thoracic surgical treatment, intrapleural fibrinolysis, and nosocomial status) and
outcome[10]. Also reported the incidence of pleural infection in adults has been continuously
increasing over the past two decades, particularly in older adults, and most of such patients
have comorbidities, Management of pleural infection requires prolonged duration of
hospitalization (average 14 days). There are recognized differences in microbial etiology of
pleural infection depending on whether the infection was acquired in the community or in a
health-care setting. Anaerobic bacteria are acknowledged as a major cause of pleural
infection, and thus anaerobic coverage in antibiotic regimens for pleural infection is
mandatory.
Stages of Empyema
The American Thoracic Society describes empyema's evolution as a continuous process
subdivided into three stages:[15]
 Exudative Stage: Initial bacterial infection causes an acute inflammatory response
between the pulmonary parenchyma and visceral pleura. Increased capillary
permeability leads to an influx of neutrophil-rich fluid into the pleural space. This
exudative fluid is usually free-flowing and resolves with appropriate antibiotic
treatment.
 Fibrinopurulent and Loculated Stage: In the absence of appropriate treatment,
fibrin clots and membranes form, resulting in isolated fluid collections in the
pleural space. This stage typically requires antimicrobials and drainage.

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INTRODUCTION

 Chronic Organizational Stage: If not drained, fibroblasts form a thick pleural peel
between the visceral and parietal pleura, encasing the underlying lung
parenchyma and inhibiting adequate gas exchange, leading to a trapped lung or
chronic empyema.

History and Physical Examination Findings:

Clinical presentation can be multifactorial and varies based on underlying comorbidities,
the timing of clinical presentation, and the causative microorganism. Patients with empyema
generally present late in the clinical course with untreated pneumonia or mismanaged
complicated pleural effusions. Common clinical features of empyema are nonspecific and
similar to bacterial pneumonia. Symptoms include cough, dyspnea, fever, and/or pleuritic
chest pain. On physical exam, dullness to percussion and decreased breath sounds can be
appreciated but are not particularly diagnostic of empyema. Therefore, imaging may be
necessary in any patient with suspected parapneumonic effusion.
Diagnostic Workup:
The American Association for Thoracic Surgery (AATS) guidelines recommend a
combination of chest imaging studies, laboratory tests, and pleural fluid analysis to diagnose
empyema. Pleural fluid analysis, including culture, cell count, pH, and chemistry, is critical in
predicting clinical outcomes.

Evaluation of Empyema:
Chest Radiography: is essential in diagnosing and managing empyema. While advanced
imaging modalities are available, plain radiographs remain useful for screening pleural
effusions in pneumonia patients. Typically, A unilateral, markedly asymmetric pleural
effusion with blunting of the costophrenic angle is seen. Smaller effusions can be detected
with lateral view X-rays, and decubitus views. Ultrasonography and computed tomography
(CT) scans offer greater sensitivity for fluid detection and additional information on the extent
and nature of pleural infection. Ultrasound, being radiation-free, is effective in distinguishing
free from loculated pleural effusions. A study published in Thorax (2017) demonstrated
ultrasound's superior sensitivity compared to plain radiographs for diagnosing pleural
effusion. CT scans with intravenous contrast provide high diagnostic yield for empyema, with
the "split pleura" sign being highly indicative of a complicated parapneumonic effusion
requiring drainage[16].
Table 1 Evaluation of Pleural Infection [10]

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INTRODUCTION

Chest Radiography: Thoracic Ultrasound: Computed Tomography (CT):

 Initial investigation for  Considered essential for  Offers detailed pleural anatomy
suspected pleural infection in managing pleural infection. and extent of infection.
patients with respiratory  Cost-effective, radiation-  Uses intravenous contrast to
symptoms. free, and available at the delineate pleural and mediastinal
 Modest sensitivity but bedside. pathologies.
appropriate for screening.  Higher sensitivity than  Signs like the split-pleura sign,
 Identifies non-free-flowing chest radiography, contrast enhancement, and air
effusions and features like the detecting >50% of foci are indicative of empyema
"D sign." effusions. and complicated effusions.
 Can miss significant  Identifies fluid  Essential for guiding
parapneumonic effusions, characteristics, predicts pus interventions, though ultrasound
especially with lower-lobe presence, and guides drain is better for detecting pleural
consolidation. insertion. septations.
Pleural Fluid Analysis
Diagnostic Aspiration:
 Confirming infection by aspirating pus.
 Nonpurulent effusions: pH <7.2 indicates infection and need for chest-tube drainage.
 Glucose <40 mg/dL and LDH >1,000 IU/L suggest infection.
Biochemical Markers:
 Pleural fluid CRP >100 mg/L may indicate complicated effusions.
 Routine microbiological analysis enhances diagnostic yield.
Nucleic Acid Tests:
 More sensitive than cultures for identifying microbial causes.
 High-throughput DNA sequencing offers a single assay for detection.
 Multiplex PCR assays are promising for clinical use due to sensitivity and cost-effectiveness.
 Challenges include antibiotic sensitivity patterns and contamination differentiation.
Thoracocentesis: is recommended for diagnostic fluid sampling in patients with pleural
effusions greater than 2 cm depth on lateral decubitus film or CT, especially when associated
with pneumonia, chest trauma, surgery, or ongoing sepsis. Frank pus in the pleural space
necessitates surgical drainage. If the fluid's infection status is uncertain, a pH below 7.2
measured via a blood gas analyzer indicates the need for drainage. Empyema diagnosis is
supported by polymorphonuclear cell predominance, low glucose, and high LDH (>1000) in
pleural fluid. Fluid cultures guide appropriate antimicrobial therapy, with research showing
increased culture yield when pleural fluid is injected into blood culture bottles immediately
after aspiration[17].[18]
Other Tests: Blood cultures are necessary for all empyema patients. Although generally
non-diagnostic, positive results can identify causative pathogens and bacteremia.
The RAPID score is a clinical tool used to predict the mortality risk in patients with
pleural infections, such as empyema. It stands for Renal function, Age, Purulence, Infection
source, and Dietary factors. The RAPID score helps clinicians make informed decisions
regarding the management and treatment of pleural infections. Each component of the RAPID
score is given a certain number of points based on clinical parameters, and the total score

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INTRODUCTION

categorizes patients into different risk levels. Each parameter in the RAPID score is assigned
points based on specific thresholds. The total score is then calculated by summing the points
from each parameter. The total RAPID score stratifies patients into different risk categories
for mortality: (Ashley A. Liou et, al. 2023). Journal of thoracic diseases[19]
 Low Risk: Total RAPID score 0-2.
 Moderate Risk: Total RAPID score 3-4.
 High Risk: Total RAPID score 5-7.

Differential Diagnosis: Determining the cause of pleural effusion is imperative to

determine the proper treatment and prognosis for the patient’s condition. The most common
causes are congestive heart failure; cancer; and pulmonary embolism; Pneumonia
(community, healthcare-acquired, aspiration); Hemothorax; and Chylothorax.

Initial Interventions:
Antibiotic Treatment: The first line of treatment for early-stage empyema involves
appropriate antibiotic therapy. Community-acquired empyema is treated with second- or
third-generation cephalosporins with metronidazole, or parenteral aminopenicillin with β-
lactamase inhibitors. For hospital-acquired or post-procedural empyema, antibiotics targeting
methicillin-resistant Staphylococcus aureus (MRSA) and Pseudomonas aeruginosa are
recommended. Antibiotic therapy alone may be curative in stage I empyema but is often
insufficient for stages II and III, necessitating additional drainage or surgical intervention[20].

Community-acquired empyema—The antibiotic Caution should be taken with the use of

regimen should target common pathogens of the aminoglycosides due to poor pleural penetration
oropharynx, including aerobic Staphylococcus and, therefore, are not the recommendation in the
and Streptococcus species and anaerobes. treatment of empyema. Duration of antibiotics is
Appropriate antibiotics include third-generation generally recommended for 2 to 6 weeks
cephalosporins, metronidazole, or a beta- (intravenous followed by oral), depending on the
lactam/beta-lactamase inhibitor combination. degree of infection and clinical response to therapy.
Hospital-acquired empyema - As well as covering typical organisms and anaerobes, antimicrobial
therapy should be directed at providing coverage for MRSA and Pseudomonas. Reasonable options
include Vancomycin plus metronidazole and an antipseudomonal cephalosporin. Vancomycin plus
piperacillin/tazobactam, a broad spectrum beta-lactam/beta-lactamase inhibitor, provides both
anaerobic and antipseudomonal activity.

- Pleural Drainage

Prompt drainage is essential for effective management. The initial procedure typically
involves tube thoracostomy, especially for patients with loculated pleural effusion or large

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INTRODUCTION

free-flowing effusions. Discontinuation of drainage is considered when the effusion volume

falls below 50 to 100 mL/day over two to three days. Successful pleural drainage leads to a
significant reduction in symptoms and prevents progression to more severe stages. However,
treatment failure, indicated by persistent infection or effusion, may necessitate additional
drainage or surgical intervention.

- Intrapleural Fibrinolytic Therapy (IPFT)

In cases where tube thoracostomy is inadequate, IPFT with tissue plasminogen activator
(tPA) and deoxyribonuclease (DNase) can be used to enhance drainage. This approach has
shown reduced need for surgical intervention by 30 to 80%. IPFT is effective in many patients
but may require surgical evaluation if there is no response. New study 2024 puplished in
European Journal of Cardio-Thoracic Surgery (Hiroyuki Tamiya et,al. 2024).[21] The early
administration of fibrinolytics may reduce the need for surgery and death in adult patients
with empyema.

- Intrapleural Irrigation for Empyema

A new intrapleural irrigation approach using saline lavage has recently demonstrated
benefits for patients with empyema. The Pleural Irrigation Trial (PIT) found that empyema
patients receiving saline irrigation via tube thoracostomy showed radiographic improvement
after three days compared to those receiving standard care. Additionally, a smaller
retrospective study comparing saline flushes plus urokinase versus saline alone reported
decreased chest tube duration and reduced use of fibrinolytics. Although no mortality benefit
was observed, larger randomized studies are needed to confirm the advantages of this cost-
effective and well-tolerated therapy.[22]

Surgical Interventions:

Video-Assisted Thoracic Surgery (VATS): has become the standard for lung cancer
diagnosis and treatment. However, this surgical technique requires specific and dedicated
training. Over the past 20 years, several simulation systems have been developed to promote
VATS training. Advances in virtual reality may facilitate its integration into the VATS
training curriculum. A comprehensive overview of simulators for thoracoscopic surgery,
especially for lung lobectomy, is provided, highlighting their role and possible efficacy in the

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INTRODUCTION

surgical trainee curriculum. It is less invasive than open thoracotomy and associated with
shorter hospital stays and lower morbidity. VATS is effective in achieving complete drainage
and resolving empyema in many cases. It is especially preferred in stage II empyema for
reducing postoperative complications. VATS is often indicated in symptomatic patients with
parapneumonic effusion or empyema that fails to resolve with antibiotics, tube thoracostomy,
and a course of tPA/DNase. VATS is preferred over open thoracotomy since outcomes are
similar and morbidity and hospital length of stay is lower. While some surgeons prefer to
proceed directly with open thoracotomy in some cases (eg, patients with significant
adhesions, greater visceral pleural thickness, or larger empyema cavity size), others prefer to
start with VATS and convert intraoperatively to open thoracotomy for example, some patients
in whom stage 2 disease is suspected (fibropurulent stage) who turn out to have components
of stage 3 (chronic organization) may need an open procedure for complete decortication;
conversion is also appropriate in those with intolerance of single lung ventilation,
uncontrollable bleeding, or needing access to structures not amenable to VATS repair.
Conversion to thoracotomy was more common in patients with delayed referral (>2 weeks)
for VATS and those who had gram-negative bacteria causing empyema. In some decortication
cases, underlying necrotic lung is discovered, prompting parenchymal resection[23].
Decortication

For advanced-stage empyema, decortication is performed to remove the thick fibrous peel
and restore lung function. While effective, it is generally reserved for patients with chronic
empyema due to its invasive nature. Decortication improves lung volume and function but
carries risks such as bleeding, infection, and recurrence. A decortication is an option for lung
re-expansion if symptoms persist 6 months after empyema resolution.
Indications: Decortication is primarily indicated for pleural empyema, which can be
either pyogenic or tubercular in nature. Pyogenic empyema is often caused by pathogens such
as Streptococcus pneumoniae, Staphylococcus aureus, and Klebsiella pneumoniae. Other
indications for lung decortication include hemothorax, pleural thickening due to inflammatory
conditions such as rheumatoid arthritis, and tumors like malignant mesothelioma.
Preparation: Preoperative patient selection and proper surgical planning are crucial for
optimal outcomes. Essential preoperative imaging includes a chest radiograph and contrast-
enhanced computed tomography (CECT) to assess the pleural peel thickness, lung trapping,
lung parenchyma condition, and mediastinal shift. In some cases, bronchoscopy is also

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INTRODUCTION

performed. Routine blood tests are necessary before surgery.

Pre-procedure Positioning: The patient is placed in the lateral decubitus position with the
diseased side up, and a folded towel or roll is positioned beneath the dependent side. The
down leg is flexed to 90 degrees, with a pillow placed between the legs. All pressure points
are cushioned. An esophageal dilator or wide-bore nasogastric tube may be inserted to
identify the esophagus during left-sided decortication to prevent injury. The chest wall is then
prepped and draped.

Technique Posterolateral Thoracotomy: [24]

 Begins midway between the spinous process and the scapula, extending to the mid-
axillary or anterior axillary line and approximately 2 inches below the scapula tip. The
incision is deepened using electrocautery, dividing the latissimus dorsi and serratus
anterior muscles. The tip of the scapula is grasped with Allis forceps, and the ribs are
counted in the subscapular space.
 The thoracic cavity is accessed via the fifth or sixth interspace, ensuring the
electrocautery divides the intercostal muscles at the upper border of the lower rib to
avoid the neurovascular bundle. Rib resection might be needed if the ribs are crowded.
 The extrapleural space is carefully entered to avoid the empyema cavity and
mediastinal structures. The apex of the lung is freed carefully to prevent injury to the
subclavian vessels. During medial dissection, care is taken to avoid injuring the
esophagus (left-side decortication) or vena cava (right-side decortication), and the
diaphragm during inferior dissection. The pleural peel is removed from the lung
parenchyma, including the fissures.
 Air Leak Management: The anesthesiologist inflates the lung to locate air leaks, which
are sutured closed. Adequate hemostasis is ensured using diathermy or bipolar forceps.
 Drainage: An intercostal drain is inserted into the thoracic interspace, with some
surgeons using two drains—one in the base (posterior) and one in the apex (anterior).
These tubes remain until clinical and radiological signs indicate lung expansion.
 Closure: The chest wall is closed in layers.

Postoperative Care Includes: adequate analgesia, antibiotic therapy, hydration, and

nutritional support. Intensive monitoring and mechanical ventilation may be required for
sicker patients. Proper management of chest tubes and periodic chest radiographs and arterial

10
 CHAPTER I:
INTRODUCTION

blood gas analysis are essential.

Complications:

Complications from empyema or its treatment can include fibrothorax, pleural

thickening, sepsis, pneumothorax, and bronchopleural fistulas. Treatment modalities like
thoracentesis, IPFT, VATS, and decortication also have associated risks including bleeding,
pain, and infection. Complications of empyema can also arise from different treatment
modalities. Thoracentesis can lead to complications, including pneumothorax and bleeding.
Furthermore, IPFT has been shown to be associated with bleeding, pain, shortness of breath,
and fever. Complications associated with VATS include air leak, bleeding, wound infections,
and pain. Decortication can result In bleeding, air leak, Infection, pain, and recurrence

11
 ITERATURE REVIEW

1.3 Previous Study

Japan, Hiroyuki Tamiya 2024.

Title: Reduction in the need for surgery and mortality after early administration of fibrinolytics
following empyema drainage. Among the 16,265 eligible patients, 3,082&13,183 patients were
categorized into early and control group, respectively. It Conclude early administration of
fibrinolytics significantly reduced needed for surgical intervention& improved survival rates.[21]

Jolliffe, J., Dunne, B., (2024). ANZ Journal of Surgery.

Title: Long term outcomes in surgically intervened empyema patients: a systematic review.
Summary: This systematic review analyzed long-term outcomes in patients who underwent
surgical intervention for empyema. It found that early and appropriate surgical management led
to improved long-term survival and reduced recurrence rates[25].

Pérez, P., & Bello, A. (2024).

Title: Management of chronic pleural tuberculosis and non-TB empyema in the 21st century.
Summary: This review discussed contemporary approaches to managing chronic pleural
tuberculosis and non-tuberculous empyema. It emphasized the importance of early diagnosis and
intervention, including surgical options, to achieve optimal outcomes[26].

Di Mitri, M., Thomas, E., Capano, E., et al. (2024).

Findings: Early VATS in children with pleural empyema led to faster recovery, fewer
complications, and shorter hospital stays. Conclusion: Early VATS is beneficial for pediatric
patients with pleural empyema.[27]

USA, Ashley A. Liouet, al.2023

Title: The role of the RAPID score in surgical planning for empyema
Results: The RAPID score effectively guides surgical planning for empyema by
predicting disease severity and informing intervention strategies. Patients with higher RAPID
scores benefit from early and aggressive surgical approaches, such as VATS or open
thoracotomy, which help reduce complications and improve outcomes. In contrast, patients
with lower RAPID scores can often be managed with less invasive procedures. The study
supports incorporating the RAPID score into clinical practice to enhance decision-making
and patient care in empyema management[19].

12
 CHAPTER I:
ITERATURE REVIEW

Tong, S. S., Wang, B. Y., et al. (2023).

Title: Comparison of outcome between sole operation and operation after tube thoracostomy in
late phase empyema.
Summary: included 1,042 patients with phase II or III empyema underwent surgical
decortication; Primary outcomes were peri-operative and in-hospital characteristics. Secondary
outcomes analyzed 1-year overall survival rate and 1-year event free survival. The study
compared outcomes of sole operation versus operation following tube thoracostomy in late-phase
empyema patients. It concluded that immediate surgical intervention without prior tube
thoracostomy was associated with better outcomes and shorter hospital stays[28].

Santana-Rodríguez, Albalkhi, I., et al. (2022).

Title: Surgical management of parapneumonic empyema.
Summary: This review explored the surgical management of parapneumonic empyema,
emphasizing the effectiveness of early surgical intervention, particularly video-assisted
thoracoscopic surgery (VATS), in improving patient outcomes and reducing complications[29].

Hassan, M., et al. (2021).

Title: Recent Insights into the Management of Pleural Infection.
Findings: Early and appropriate management, including combined tPA and DNase therapy, early
surgical intervention, and timely treatment initiation, significantly improve outcomes in pleural
infections. Standardized treatment protocols based on early and appropriate interventions are
essential for optimizing patient outcomes in pleural infections.[10]

Godfrey, M. S., Bramley, K. T., & Detterbeck, F. (2019).

Findings: Combined medical and surgical management approaches are necessary for treating
empyema effectively. It concluded that An integrated approach involving both medical and
surgical interventions provides the best outcomes for empyema patients[30].

Goldin, A. B., Parimi, et al. (2012). (The American Journal of Surgery)

Title: Outcomes associated with type of intervention and timing in complex pediatric empyema
Summary: The study examined the outcomes of different interventions and their timing in
managing complex pediatric empyema. Findings suggested that early surgical intervention,
particularly VATS, resulted in better outcomes and reduced hospital stays compared to delayed
or non-surgical treatments[31].

13
 CHAPTER I:
ITERATURE REVIEW

Rahman, Maskell, et al. (2011). New England Journal of Medicine.

Title: Intrapleural use of tissue plasminogen activator and DNase in pleural infection.
Abstract: This randomized trial assessed the combination of tissue plasminogen activator (tPA)
and DNase versus placebo in patients with pleural infection. 210 patients were randomized, and
the combination therapy showed improved drainage of pleural fluid, reduced hospital stay, and
fewer surgical referrals, supporting its use in pleural infection management[18].

Wozniak et, al. 2009 (The Annals of Thoracic Surgery)

Title: Choice of First Intervention is Related to Outcomes in the Management of Empyema
Summary: This study analyzed the impact of the initial intervention on the outcomes of
empyema management. It found that the choice of first intervention significantly influences
patient outcomes, with early surgical intervention leading to better results compared to initial
non-surgical approaches[32].

Khalil, B. A., et al. (2007).

Title: Less is best? The impact of urokinase as the first line management of empyema thoracis.
Summary: The study evaluated the efficacy of urokinase as the first-line treatment for pediatric
empyema thoracis. Results indicated that urokinase significantly improved outcomes by reducing
the need for surgical intervention and shortening hospital stays[33].

Mandal, A. K., (1998).

Title: Outcome of primary empyema thoracis: therapeutic and microbiologic aspects.
Summary: This research focused on the therapeutic and microbiologic aspects of primary
empyema thoracis. The study concluded that timely surgical intervention and appropriate
antibiotic therapy, based on microbiological findings, are crucial for favorable outcomes[34].

14
 CHAPTER II: OBJECTIVE

CHAPTER II

OBJECTIVE
 CHAPTER II: OBJECTIVE

CHAPTER II

OBJECTIVE

General Objective

To determine the impact of the first intervention choice on treatment success rates in
empyema management.

Specific Objectives

 To assess the association between the initial procedure and the need for additional
interventions.
 To investigate the relationship between the first intervention and mortality rates in
patients with empyema.

 To identify any confounding variables that may influence the outcomes of

different first interventions

15
 CHAPTER III PATIENT AND METHODOLGY

CHAPTER III

PATIENT AND METHODOLGY

16
 CHAPTER III PATIENT AND METHODOLGY

CHAPTER III

METHODOLGY

3.1 Study Design

A Prospective cohort study.

3.2 Study Setting

The research was conducted at tow teaching hospitals located in Sana'a governorate the
Tertiary Republican Teaching Hospital Authority and General Police Hospital. They are
considered as main references teaching hospital in Yemen. They provided services basically
for Sana'a governorate area residency, and also for the general population from all over the
country.

3.3 Period of Study

Data was collected over a period between 2022 and 2024.

3.4 Sample of Study

The study was including 40 patients diagnosed with empyema who underwent different
first interventions, such as surgical decortication, tube thoracostomy, pig-tail catheter, VATS, or
thoracotomy.

3.5 Study Population

This study was cover all patients presenting to the hospitals with empyema who
underwent different first interventions, such as surgical decortication, tube thoracostomy, pig-
tail catheter, VATS, or thoracotomy.

3.6 Inclusion Criteria

 Patients aged 18 years and older.

 Confirmed diagnosis of empyema, verified through clinical, radiological, and

laboratory findings.

17
 CHAPTER III PATIENT AND METHODOLGY

 Patients who have undergone one of the initial interventions for empyema,
including:

- Thoracentesis
- Tube thoracostomy
- Pigtail catheter insertion
- Video-assisted thoracic surgery (VATS)
- Open thoracotomy
- Patients who have provided informed consent for the use of their medical
records for research purposes.
- Availability for regular follow-up visits

3.7 Exclusion Criteria

 Patients under 18 years of age.

 Patients with unconfirmed or suspected empyema without definitive diagnostic
confirmation.
 Patients with incomplete medical records, lacking critical information required for
the study, such as details of initial intervention or outcomes.
 Patients who had prior surgical interventions for empyema before the study
period.
 Patients with comorbid conditions that could significantly confound the study
outcomes, such as:
- Advanced malignancies with limited life expectancy.
- End-stage organ failure (e.g., heart, liver, kidney)
- Severe immune-compromised states
 Patients (or their legal representatives) who have declined to consent to the use of
their medical records for research purposes.
3.8 Data Collection

The data were collecting from patients and medical records. The data incudng:
 Demographic information (Name, Age, Gender, Race/Ethnicity).
 Empyema stage
 Comorbidities ( chronic disease’s- )
 Laboratory results ( CBC, CRP, Pleural fluid test)

18
 CHAPTER III PATIENT AND METHODOLGY

 Imaging findings (X-Ray/ CT/ results).

 Choice of first intervention
 Treatment outcomes
 Any additional procedures performed
 Chest Radiography: is essential in diagnosing and managing empyema. While
advanced imaging modalities are available, plain radiographs remain useful for
screening pleural effusions in pneumonia patients. The American Thoracic
Society describes empyema's evolution as a continuous process subdivided into
three stages:[15] So we classify as:
Stage Define stage according to ATS Laboratory Chest finding on
Finding CT-Scan
Exudative Stage: Initial bacterial infection causes an acute
inflammatory response between the pulmonary
PH = > 7.3
parenchyma and visceral pleura. Increased capillary
LDH <1000 Free Flawing
Stage I permeability leads to an influx of neutrophil-rich fluid into
WBC= Low Fluid
the pleural space. This exudative fluid is usually free-
RBS= > 50mg
flowing and resolves with appropriate antibiotic
treatment.
Fibrinopurulent and Loculated Stage: In the absence of PH = < 7.2
appropriate treatment, fibrin clots and membranes form, LDH >1000 Loculations
Stage
resulting in isolated fluid collections in the pleural space. WBC= High &
II
This stage typically requires antimicrobials and drainage. (>3000) Septation
RBS= < 50mg
Chronic Organizational Stage: If not drained, fibroblasts Large Loculated
form a thick pleural peel between the visceral and parietal With pleural
Stage Difficulty to
pleura, encasing the underlying lung parenchyma and thickening +
III Drained
inhibiting adequate gas exchange, leading to a trapped pleural
lung or chronic empyema. calcification
3.9 Outcome Measures

The primary outcome measures will include:

 Treatment success rates:

- Clinically improvement.
- Full lung expansion on radiography.
- No additional drain.

 The need for additional interventions.

 Mortality rates.

3.10 Statistical Analysis

Data was collected, tabulated, analyzed by a computer software SPSS version 22.0. Data

19
 CHAPTER III PATIENT AND METHODOLGY

was expressed as mean (±standard deviation) or median (interquartile range), whenever

appropriate. Between groups, comparison of numerical variables were performed by paired T
test, unpaired t test (student's test) between groups; comparison of categorical variables were
performed by Chi-Square test. A difference in variables were expressed by P value (< 0.05 is
considered significant, and < 0.01 is highly significant). Kaplan-Meier survival analysis was
performed.

3.11 Patient Group Categorization

Patients will be categorized into three groups based on the definitive treatment during
their initial hospitalization:

 Chest tube drainage

 VATS decortication and drainage
 Open decortication and drainage

3.12 Data Analysis:

 Treatment outcomes, including success rates, readmission, re-intervention, and

mortality, will be compared between the groups
 Statistical analysis will be performed using appropriate software. The data will be
checked for completeness, cleaned, coded, entered, and analyzed with SPSS 25.
 Comparative analysis will be performed using Chi-square tests for categorical
data and t-tests for continuous data.
 A p-value <0.05 will be considered statistically significant.
 Descriptive statistics for demographic and clinical variables.
 Identification and analysis of any complications.

3.13 Ethical consideration

 Patient anonymity had ensured throughout the study.

 Informed consent of Patient.
 Institutional Review Board approval obtained before data collection.

20
CHAPTER IV

THE RESULTS
 CHAPTER IV:
RESULTS

CHAPTER IV
THE RESULTS
4.1 The Results
4.1.1 Gender and Age Distribution

Total number of patients involved in this study were 40 patients, from the table below the
gender showed a higher percentage of males (67.5%) compared to females (32.5).

Table 4- 1 A simple study according to gender

Gender Frequency Percent

Male 27 67.5%
Female 13 32.5
Total 40 100.0

Male
67.5
Female %
32.5%

Figure 4- 1 A simple study according to gender

Age Distribution: The age of the patients ranged from 19 to 75 years. The majority of
patients (58%) were middle-aged to older adults (56-75 years) represented 26% of the cohort,
and young adults (19-35 years) accounted for 16%. Mean Age: 47.1 years, Median Age: 50
years, Standard Deviation: 12.85 years. The most common age group is (36-55) years with 22
patients. The distribution is as follows:

Age Distribution Frequency Percent

Mean : 47.1 years
Young Adults (19-35 years) 6 patients (16% of total)
Median : 50 years
Middle-Aged Adults (36-55 22 patients (58% of total)
ST. Deviation: 12.85years
years)
Older Adults (56-75 years) 10 patients (26% of total)

4.1.2 Demographic Characteristics and the Success Rate:

This table shown the association between demographic characteristics and the success
rate of the patients. A total of 40 patients were included in the study, out of which 22 were
classified as successful, while 18 were classified as unsuccessful. The analysis revealed that
21
 CHAPTER IV:
RESULTS

age did not have a significant association with the success rate (p-value = 0.248). In terms of
gender, 67.5% of males (N=27) were successful compared to 77.3% (N=17) of unsuccessful
males, while 32.5% of females (N=13) were successful compared to 22.7% (N=5) of
unsuccessful females. Although there was a difference in success rates between genders, it
was not statistically significant (p-value = 0.152). A notable finding was the strong
association between a history of smoking and success rate. Among patients with a history of
smoking (40.0%, N=16), only 18.2% (N=4) achieved success, while 81.8% (N=18) were
unsuccessful. This association was statistically significant (p-value = 0.001*). When
examining comorbidities, there were no significant associations with success rate for diabetes
mellitus (15.0%, N=6), hypertension (32.5%, N=13), ischemic heart diseases (2.5%, N=1),
cardiovascular diseases (5.0%, N=2), renal impairment (5.0%, N=2), or other comorbidities
(2.5%, N=1).

Table 4- 1demographic characteristics and the success rate

4.1.3 Total Successful Unsuccessful C

P-
Category N=40 N=22 N=18 h
value
N % N % N %
ar
1. Age (Mean/SD) 47.1 12.8 49.2 10.8 44.4 14.7 0.248
2. Gender ac
a) Male 27 67.5 17 77.3 10 55.6 0.152 te
b) Female 13 32.5 5 22.7 8 44.4
ri
3. Occupation
a) Farmer 14 35.0 9 40.9 5 27.8 sti
b) Student 10 25.0 6 27.3 4 22.2
cs
c) Worker 4 10.0 1 4.5 3 16.7 0.259
d) Housewife 10 25.0 6 27.3 22.2 10.0 of
e) Teacher 2 5.0 0 0.0 2 11.1
4. Hx of smoking 16 40.0 4 18.2 12 66.7 0.001*
5. Comorbidities
a) DM 6 15.0 3 13.6 3 16.7 0.796
b) HTN 13 32.5 7 31.8 6 33.3 0.921
c) IHD 1 2.5 1 4.5 0 0.0 0.373
d) CVD 2 5.0 0 0 2 11.1 0.114
e) Renal
2 5.0 0 0 2 11.1 0.114
impairment
f) Others 1 2.5 1 4.5 0 0 0.373
Empyema and the Success Rate:

22
 CHAPTER IV:
RESULTS

In this table presents the association between characteristics of empyema and the success
rate of the patients. The study included a total of 40 patients, out of which 22 were classified
as successful and 18 as unsuccessful. Regarding the side of the empyema, 80.0% (N=32) were
on the right side, 15.0% (N=6) on the left side, and 5.0% (N=2) were bilateral. The success
rates for each side were 81.8% (N=18) for the right side, 18.2% (N=4) for the left side, and
0.0% (N=0) for bilateral cases. However, the association between the side of empyema and
success rate was not statistically significant (p-value = 0.136). In terms of the stage of
empyema, 12.5% (N=5) were classified as Stage I, 60.0% (N=24) as Stage II, and 27.5%
(N=11) as Stage III. The success rates for each stage were 22.7% (N=5) for Stage I, 50.0%
(N=11) for Stage II, and 27.3% (N=6) for Stage III. The association between the stage of
empyema and success rate was statistically significant, with Stage I cases showing a
significantly lower success rate compared to the other stages (p-value = 0.034*)

Table 4- 2 Empyema Characteristics and Successful Rate

4.1.4 Laboratory Characteristics:

Total Successful Unsuccessful p-value
Category N=40 N=22 N=18
N % N % N %
1. Side
a) Right 32 80.0 18 81.8 14 77.8 0.136
b) Left 6 15.0 4 18.2 2 11.1
c) Bilateral 2 5.0 0 0.0 2 11.1
2. Stage 0.034*
a) Stage I 5 12.5 5 22.7 0 0.0
b) Stage II 24 60.0 11 50.0 18 72.2
c) Stage III 11 27.5 6 27.3 5 27.8

The laboratory characteristics of pleural fluid, several parameters were measured. The
mean pH values were 7.28 (SD=0.28) for all cases, 7.38 (SD=0.33) for successful cases, and
7.17 (SD=0.15) for unsuccessful cases. The association between pH and success rate was
statistically significant (p-value = 0.015*). Other laboratory measurements, including white
blood cell count (WBC), glucose level, and lactate dehydrogenase (LDH) levels, did not show
significant associations with the success rate. The presence of positive or negative cultures in
the pleural fluid also did not demonstrate a significant association with the success rate of the

23
 CHAPTER IV:
RESULTS

patients.

Table 4- 3 Association between characteristics of pleural fluid& Successful Rate

4.1.5 Radiological Findings:

Table 4 provides an overview of the radiological findings observed in the patients. Among
the 40 cases included in the study, several findings were identified. Encysted empyema was
Total Successful Unsuccessful
P-
Category N=40 N=22 N=18
value
N % N % N %
3. Lab. of Pleural fluid
a) pH (mean+SD) 7.28 0.28 7.38 0.33 7.17 0.15 0.015*
b) WBC(mean+SD) 3.48 1.60 3.48 1.69 3.47 1.54 0.992
c) Glucose (mean+SD) 46.45 5.86 47.32 6.16 45.39 5.46 0.306
d) LDH (mean+SD) 1410 667.8 1359 761.4 1472 547.5 0.601
e) Culture
- Positive 10 25.0 4 18.2 6 33.3 0.283
- Negative 30 75.0 18 81.8 12 66.7
observed in 9 cases, accounting for 22.5% of the patients. Pleural effusion was present in 5
cases, representing 12.5% of the sample. The most prevalent finding was loculation/septation,
which was identified in 29 cases, amounting to 72.5% of the patients. Pleural thickening was
noted in 7 cases, corresponding to 17.5% of the sample

Table 4- 4 Radiological findings

4.1.6 FINDINGS Frequency Percentage Associ

1. Encysted empyema 9 22.5 ation
2. Pleural effusion 5 12.5
3. Loculation/septation 29 72.5
4. Pleural thickening 7 17.5
5. Cavitation 1 2.5
Between the First Intervention Performed and the Success Rate:

In this table presents the association between the first intervention performed and the
success rate of the patients. The study included a total of 40 patients, out of which 22 were
classified as successful and 18 as unsuccessful. The first intervention options and their

24
 CHAPTER IV:
RESULTS

respective frequencies and percentages are as follows:

 Video-assisted thoracoscopic surgery (VAST): 3 cases (7.5%)

 Thoracotomy + drainage tube: 23 cases (57.5%)
 Thoracotomy + decortication: 14 cases (35.0%)

Among the successful cases, 9.0% (N=2) underwent VAST, 45.5% (N=10) underwent
thoracotomy + drainage tube, and 45.5% (N=10) underwent thoracotomy + decortication.
Among the unsuccessful cases, 5.6% (N=1) underwent VAST, 72.2% (N=13) underwent
thoracotomy + drainage tube, and 22.2% (N=4) underwent thoracotomy + decortication

Table 4- 5 Association between first intervention and Successful Rate

Total Successful Unsuccessful

Category N=40 N=22 N=18 P-value
N % N % N %
1. VAST 3 7.5 2 9.0 1 5.6
2. Thoracostomy
23 57.5 10 45.5 13 72.2
Drainage tube 0.307
3. Thoracotomy
14 35.0 10 45.5 4 22.2
+decortication
Total 40 100.0 22 100.0 18 100.0

4.1.7 Complications:

the complications and mortality observed in the patients. Among the postoperative
complications, the most common was chest infection, which occurred in 40% of the cases.
Bronchopleural fistula, anemia, surgical site infection, and bleeding were also reported, with
frequencies of 20%, 15%, and 10%, respectively. Other complications such as residual
effusion, residual cavity, pneumothorax, and sepsis were less frequently observed, each
accounting for 5% of the cases. In regarding to the mortality, 3 cases (7.5 %) resulted in
death.

25
 CHAPTER IV:
RESULTS

Complications and mortality Frequenc Percentage

y
1. Postoperative Bronchopleural Fistula 4 10
complications Chest infection 8 20
Thoracotomy site pain 6 15
Bleeding 3 7.5%
Air leak 3 7.5
Pneumothorax 1 2.5
Surgical site infection 5 12.5
2. Mortality 3 7.5

4.1.8 Correlations B/W Stage with 1st Intervention and Outcome & Mortality

This table presents the correlation between the stage of empyema, the first intervention
performed, the outcomes, and mortality rates among the study's 40 patients.

Table 4- 6 1st Intervention and Outcome & Mortality

Empy F 1st intervention F Outcome
ema
stage
Stage Success Un-success Mortality / Mortality/

Thoracostomy Drainage tube according stage 1st intervention

I 5 4
VAST 1 4 (80%) - - -
1( 20%) - - -

Stage 24 Thoracostomy Drainage tube 14 3 (12%) 9 (37.5%) 2 (8.3%) 14.3%

II Thoracotomy +decortication 8 7(29.2% 1(4.2%) -
VAST 2 1 (50%) 1(4.2%) -
Stage 11 Thoracostomy Drainage tube 5 1(9.1%) 4(36.4%) - 16.7%
III Thoracotomy +decorticatio 6 5/45.4% - 1(9.1%)

The analysis indicates a clear correlation between the stage of empyema, the type of first
intervention performed, outcomes, and mortality rates. The data suggests that less invasive
interventions, such as thoracostomy drainage tube, tend to have higher success rates and lower

26
 CHAPTER IV:
RESULTS

mortality in early-stage empyema. As the disease progresses, more aggressive treatments like
thoracotomy + decortication are required, but these come with higher risks and varied
outcomes.

Drainage tube Thoracotomy +decortication VAST

80%

50%

20% 45.40%
29.20%

12%
9%

Stage I
Stage II
Stage III

Figure 4- 2 The correlation between the stage of empyema, the first intervention
performed, the outcomes, and mortality rates among the study's 40 patients

27
 CHAPTER V:
DISCUSSION

CHAPTER V

DISSCUSSION
 CHAPTER VI:
DISSCUSIONS

CHAPTER V

DISSCUSSIONS

5.1 Discussions

The management of empyema is controversial, The outcomes significantly influence by

the choice of the first intervention especially when determine choice management according
to empyema stage. This study evaluates the effectiveness of initial interventions, including
thoracostomy drain tubes, open thoracotomy with decortication, and VATS (Video-Assisted
Thoracoscopic Surgery) thoracoscopy. The results of our study showed difference in success
depending on the empyema stage, comorbidity, and the first initial interventions types.
although complications were common and varied by procedure and patient condition. The
demographic characteristics of the patients included in the study, focusing on age, sex, and
comorbidities. Total number of patients involved in this study were 40 patients, with higher
percentage of males compared to females, majority of patients (58%) were middle-aged adults
between 36-55 years. The gender distribution is consistent with several studies R. Gupta et al.
(2022) which indicate a higher prevalence of empyema in 24 males and 15 females but
different in age group, another study align with our results by S.-S. Tong et al. (2023) this
study included 620 247(79.7%) male Female 63(20.3%). Also A. A. Liou et al. (2023) Sixty-
nine percent of patients were male with mean age of 58 years old. Possible explanations could
include higher rates of smoking and occupational exposure to respiratory irritants among
males and pleural infection is roughly twice as prevalent in men (Godfrey et al. 2019). The
Our results not conducted with M. Di Mitri et al. (2024) which they enrolled 66 patients who
underwent a surgical treatment for PE, of whom 40.9% (n = 27) were female, and 59.1% (n =
39) were male. The mean age of patients was 47.1 years and median age 50 year. The age
distribution in aligns with literature indicating that empyema is more common in older
patients, likely due to the increased prevalence of comorbid conditions and decreased
immune function with age.

The our data shown the association between demographic characteristics and the success
rate of the patients. A total of 40 patients were included in the study, out of which 22 were
classified as successful. Age did not significantly affect the success rate of empyema
treatment (p-value = 0.248). Males had a higher success rate compared to females, but this

27
 CHAPTER VI:
DISSCUSIONS

difference was not statistically significant (p-value = 0.152). this align with S.-S. Tong et al.
(2023) which they noted There was no statistically significant difference noted in age, sex,
Comorbidity Index score, empyema phase, location, pathogen, and laboratory data between
groups.

Smoking is a known risk factor for adverse respiratory outcomes, which can negatively
impact empyema treatment success. This is supported by our research and Argento, A. C., &
Wahidi, M. M. (2016) indicating that smokers have a higher risk of complications and poorer
recovery rates. C. J. Wozniak et al. (2009) have published, the Smoking, alcohol abuse,
multiple medical problems, poor performance status, and impaired nutrition characterized
many of the patients.

In terms of the stage of empyema, 12.5% (N=5) were classified as Stage I, 60.0% (N=24)
as Stage II, and 27.5% (N=11) as Stage III. The success rates for each stage were 22.7%
(N=5) for Stage I, 50.0% (N=11) for Stage II, and 27.3% (N=6) for Stage III. The stage of
empyema significantly impacted the success rate, with Stage I showing the highest success
rate (p-value = 0.034*). Early-stage empyema is typically more amenable to less invasive
treatments, leading to better outcomes. Advanced stages often require more invasive
procedures and are associated with higher complication rates, which supports findings from
other studies. Early surgical intervention correlates with better outcomes and reduced
morbidity (N. Santana-Rodríguez et al. 2022)

The laboratory characteristics of pleural fluid, several parameters were measured. The
mean pH values were 7.28 (SD=0.28) for all cases, 7.38 (SD=0.33) for successful cases, and
7.17 (SD=0.15) for unsuccessful cases. The association between pH and success rate was
statistically significant (p-value = 0.015*). This finding is consistent with research indicating
that low pH in pleural fluid is a predictor of poor prognosis

Other laboratory measurements, including white blood cell count (WBC), glucose level,
and lactate dehydrogenase (LDH) levels, did not show significant associations with the
success rate. The presence of positive or negative cultures in the pleural fluid also did not
demonstrate a significant association with the success rate of the patients. These results
suggest that while these parameters are useful for diagnosing empyema, they may not be
strong predictors of treatment outcomes on their own

28
 CHAPTER VI:
DISSCUSIONS

Meta-analysis by Godfrey et al. (2019), which noted on Classification schemas for

pleural infection differ regarding pleural fluid glucose thresholds (60 vs. 40 mg/dL) and
inclusion or not of pleural fluid lactate dehydrogenase measurement. All classifications
include pH measurement, but pH can be affected by residual air, heparin, or lidocaine in the
sample, can significantly vary between individual locules, or be elevated by urease-producing
organisms such as Proteus. Therefore, a pleural effusion should not be classified and managed
as uncomplicated solely by biochemical features; for borderline laboratory results the clinical
context of the patient must be considered. Escalating therapy empirically or resampling the
effusion is indicated whenever clinical questions linger

The challenge in management of thoracic empyema lies in the fact that the “outcome” of
the empyema in a given patient represents the interaction of three highly variable domains:

 Host/pathogen factors (patient comorbid diseases, physiologic reserves, and host

immune responses).
 Pleural space factors (the degree of macroscopic organization and loculation,
pleural fluid biochemistry, and fibrinolytic inhibitor levels).
 Therapeutic interventions (antimicrobials, drainage, IPFT, surgery, and the
timeliness of therapy or lack thereof).

The most common complications were chest infections (20%) and bronchopleural fistulas
(10%). SSI 12 and Thoracotomy site pain 15%. These complications are well-documented in
literature as significant concerns post-empyema treatment. mosty of these compication
improved with Effective management strategies, including appropriate antibiotic use, careful
surgical technique, post-operative follow-up to short and long time that have minimizing
these risks. Postoperative intravenous analgesia requirement was <48 h in all 40
thoracotomies. Oral analgesics were started on the second postoperative day. One patients
were given anti-tubercular treatment on the basis of histopathological confirmation of biopsy
of pleural peel. Most of the patients achieved satisfactory chest (Lung) expansion at 3, 6
months and at 1-year.

The mortality rate was 7.5%. This rate is within the expected range for empyema,
considering the severity and complexity of the cases. Advanced age, comorbidities, and
delayed intervention are common factors contributing to mortality.

29
 CHAPTER VI:
DISSCUSIONS

Among the successful cases, 2 cases (9.0%) underwent VAST, 10 cases (45.5%)
underwent thorastomy + drainage tube, and 10 cases (45.5%) underwent thoracotomy +
decortication. Among the unsuccessful cases, 5.6% (N=1) underwent VAST, 72.2% (N=13)
underwent thoracotomy + drainage tube, and 22.2% (N=4) underwent thoracotomy +
decortication. The majority of patients in Stage I received thoracostomy drainage tubes and
VAST associated with antibiotic have a high success rate of 80% and 20% respectively. This
suggests that early-stage empyema can often be successfully managed with less invasive
procedures such as thoracostomy. Minimally invasive techniques, such as VATS, are
effective in treating complicated parapneumonic effusions and empyemas (Porcel et, al.
2018). These results align with M. Di Mitri et al. (2024) which they published the early
VATS is highly effective in managing pleural empyema in children. It leads to quicker
recovery, shorter hospital stays, and fewer complications. There was no mortality in this
group, indicating favorable outcomes for early-stage empyema when promptly treated.

Stage II patients had a varied distribution of first interventions. Thoracostomy drainage

tube was the most common, but it had a lower success rate (12%) compared to thoracotomy +
decortication (29.2%) and VATS (50%). This suggests that as the empyema progresses, more
invasive procedures might be necessary for successful outcomes. Mortality in Stage II was
8.3%, with thoracotomy + decortication showing a mortality rate of 14.3%. This indicates that
while thoracotomy + decortication is more effective in achieving success, it also comes with
higher risks. In Stage III, thoracotomy + decortication had a higher success rate (45.4%)
compared to thoracostomy drainage tube (9.1%). This underscores the need for more
aggressive surgical interventions in advanced stages of empyema. The mortality rate in Stage
III was 9.1%, with thoracotomy + decortication associated with a mortality rate of 16.7%.
This reflects the increased complexity and risk associated with treating advanced empyema.

Our findings are consistent with those of previous studies that demonstrated the
necessity of more invasive surgical interventions in the advanced stages of
empyema. For example, a study by Karaman et al. (2004) found that closed-tube
thoracostomy was less effective in managing advanced empyema than open
thoracotomy and decortication, particularly in more severe cases. 15
Similarly, Wozniak et al. (2009) reported that thoracotomy and VATS were more
successful initial procedures for managing Stage II empyema than tube
thoracostomy, which often failed and required subsequent surgical intervention. 11
This finding supports our observation that more invasive procedures, such as

30
 CHAPTER VI:
DISSCUSIONS

thoracotomy, decortication, and VATS, are necessary to achieve better outcomes

in advanced stages.
A meta-analysis by Pan et al. (2017) highlighted that while thoracotomy and
decortication had higher success rates in advanced empyema, they were also
associated with higher morbidity and mortality compared with VATS. 16 This is
consistent with our findings indicating higher mortality rates associated with
thoracotomy and decortication, particularly in Stage III empyema.
Furthermore, a study by Chan et al. (2007) comparing VATS and thoracotomy
found that both approaches were equally effective in treating empyema, but VATS
was associated with lower perioperative morbidity and mortality rates. 17 This
suggests that VATS is a preferable initial intervention for selected patients,
particularly those with Stage II empyema, when clinically feasible.
This study has several strengths, including its prospective design, which allowed
for systematic data collection and minimized recall bias. The comprehensive
analysis provided a holistic view of the factors influencing treatment outcomes.
However, the relatively small sample size may limit the generalizability of the
findings, and the single-center nature of the study means that the results may not
be applicable to other settings. Additionally, the lack of randomization in the
assignment of treatment interventions may have introduced confounding factors.
The findings emphasize the importance of early and appropriate intervention,
particularly in the later stages of empyema. Less invasive procedures, such as
thoracostomy drainage tubes and VATS, are effective for early-stage empyema,
whereas more advanced stages may require aggressive surgical interventions like
thoracotomy with decortication. Effective management of postoperative
complications, including chest infections and bronchopleural fistula, is crucial.
Establishing protocols for the early identification and treatment of these
complications can reduce morbidity and mortality.
Future research should focus on larger multicenter studies to validate these
findings and improve the generalizability of the findings. Additional studies are
needed to explore the development of standardized treatment protocols and
identify further predictors of treatment success. Investigating the role of new,
minimally invasive techniques and their long-term outcomes is also beneficial.

4.1 Limitation of Study

 The study was conducted at a 2 center, which may not represent broader trends or
practices in other regions or healthcare systems.

 Loss of some patients in long term follow up.

31
CHAPTER VI

CONCLUSIONS
 CHAPTER VII: CONCLUSIONS

CHAPTER VI

CONCLUSIONS

6.1 Conclusions

 A higher percentage of males compared to females.

 Smoking history is a significant negative predictor of success.

 The stage of empyema significantly affects the success rate, with early stages showing
better outcomes.

 Early and appropriate intervention, particularly in later stages, is crucial for better
outcomes.

 Effective management of postoperative complications, such as chest infections,

bronchopleural fistula, and surgical site infections, is vital. Protocols should be
established for early identification and treatment of these complications to reduce
morbidity and mortality.

31
CHAPTER VII

RECOMMENDATIONS
 CHAPTER VIII: RECOMMENDATIONS

CHAPTER VII

RECOMMENDATIONS

7.1 Recommendations

 Prompt diagnosis and timely intervention are crucial, especially for patients in the
early stages of empyema. Stage I patients should receive immediate attention to
improve their success rates.
 Smoking cessation programs should be strongly encouraged and integrated into the
treatment plans for empyema patients.
 Implementing a multidisciplinary approach involving pulmonologists, thoracic
surgeons, radiologists, and other healthcare professionals can lead to more
comprehensive care and better patient outcomes.
 Regular monitoring of pleural fluid pH and other laboratory parameters can provide
valuable insights into the patient's condition and the effectiveness of the treatment.
Special attention should be given to maintaining an optimal pleural fluid ph.
 Further research is needed to explore the long-term outcomes of different intervention
strategies, the impact of various comorbidities, and the potential benefits of novel
treatment modalities. Additionally, larger studies with diverse populations can
provide more generalizable data

32
CHAPTER VIII

REFERENCES
 CHAPTER IX: REFERENCES

CHAPTER VIII

REFERENCES

8.1 REFERENCES

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immune inflammation index as a predictor of lethal outcome in patients with thoracic
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[2] V. Garvia and M. Paul, “Empyema,” in StatPearls [internet], StatPearls Publishing, 2023.
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[4] L. Huang, H. Kehlet, B. L. Holbek, T. K. Jensen, and R. H. Petersen, “Efficacy and safety of
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[5] D. Subotic, D. Lardinois, and A. Hojski, “Minimally invasive thoracic surgery for
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[6] D. Shore and J. W. Toth, “Empyema Thoracis,” in Interventions in Pulmonary Medicine,
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[7] E. M. DeBiasi and D. Feller-Kopman, “Anatomy and applied physiology of the pleural
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[8] A. Lehtomäki, R. Nevalainen, M. Ukkonen, J. Nieminen, J. Laurikka, and J. Khan, “Trends
in the incidence, etiology, treatment, and outcomes of pleural infections in adults over a
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[10] M. Hassan, S. Patel, A. S. Sadaka, E. O. Bedawi, J. P. Corcoran, and J. M. Porcel,
“Recent insights into the management of pleural infection,” Int. J. Gen. Med., pp. 3415–
3429, 2021.

34
 CHAPTER IX: REFERENCES

[11] R. Nayak, S. B. Brogly, K. Lajkosz, M. D. Lougheed, and D. Petsikas, “Two decades of

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[13] S. Petrusevska-Marinkovic, I. Kondova-Topuzovska, Z. Milenkovic, G. Kondov, and A.
Anastasovska, “Clinical, laboratory and radiographic features of patients with pneumonia
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[14] R. Zablockis, R. Petruskeviciene, and R. V. Nargela, “Causes and risk factors of pleural
empyema and complicated parapneumonic pleural effusion,” Med. Kaunas Lith., vol. 46, no.
2, pp. 113–119, 2010.
[15] L. McCauley and N. Dean, “Pneumonia and empyema: causal, casual or unknown,” J.
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[16] H. E. Davies, R. J. Davies, and C. W. Davies, “Management of pleural infection in
adults: British Thoracic Society pleural disease guideline 2010,” Thorax, vol. 65, no. Suppl
2, pp. ii41–ii53, 2010.
[17] B. Moffett et al., “Computed tomography measurements of parapneumonic effusion
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[18] S. M. Menzies et al., “Blood culture bottle culture of pleural fluid in pleural infection,”
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[19] A. A. Liou et al., “The role of the RAPID score in surgical planning for empyema,” J.
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[20] R. Bhatnagar, V. S. Skouras, N. M. Rahman, and I. Psallidas, “Antibiotics for pleural
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[21] H. Tamiya et al., “Reduction in the need for surgery and mortality after early
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[22] J. M. Porcel, “Minimally invasive treatment of complicated parapneumonic effusions and
empyemas in adults,” Clin. Respir. J., vol. 12, no. 4, pp. 1361–1366, 2018.
[23] Y. Jiang, Z. Su, H. Liang, J. Liu, W. Liang, and J. He, “Video-assisted thoracoscopy for
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[24] R. Gupta, P. Mathur, and A. Bhandari, “Muscle-Sparing Skin Crease Incision

Posterolateral Thoracotomies in Pediatric Patients: Our Experience,” J. Indian Assoc.
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[25] J. Jolliffe, B. Dunne, J. Eckhaus, and P. Antippa, “Long‐term outcomes in surgically
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[26] P. Pérez and A. Bello, “Management of chronic pleural tuberculosis and non-tuberculous
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[27] M. Di Mitri et al., “The role of the early video-assisted thoracoscopic surgery in children
with pleural empyema,” Pediatr. Surg. Int., vol. 40, no. 1, p. 134, 2024.
[28] S.-S. Tong et al., “Comparison of outcome between sole operation and operation after
tube thoracostomy in late phase empyema,” 2023.
[29] N. Santana-Rodríguez et al., “Surgical management of parapneumonic empyema,”
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[30] M. S. Godfrey, K. T. Bramley, and F. Detterbeck, “Medical and surgical management of
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“Outcomes associated with type of intervention and timing in complex pediatric empyema,”
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[34] A. K. Mandal, H. Thadepalli, A. K. Mandal, and U. Chettipally, “Outcome of primary
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36
 QUESTIONER

QUESTIONER
Patient Information:
Patient Information
Name: …………………………; Age: ……..; Gender:……..; Occupation: ……...
Patient file number: …………; - Smoke cigarette……….
Medical History
Do you have any chronic illnesses (Diabetes, hypertension, TB, Respiratory
disease)? ( )Yes ( ) No
If yes …………………………………………..

Pre-Surgery Assessment:
What is the Site, size and location of the defect?
Site________________________________
Size:______________________________________
Location:_________________________________
Pleural fluid analysis result
1-LDH
2-WBC
3-PH level
4-glucose
5-gram stain
Radiologic Finding:
CT fining :
Surgery Details:
 Date of Surgery: ________________
 Type of 1st Intervention Surgery ________________________
 Duration of the Procedure: ________________
 Were There Any Intraoperative Complications?
o ( ) Yes? written ________________________________
o ( ) No
Post-Surgery Follow-Up:
 Outcome of first intervention: Treatment success rates:
- Clinically improvement.
- Full lung expansion on radiography.
- No additional drain

Treatment _______
Outcome:
Success Rates ,
Required other surgical intervention
Mortality

37