Postpneumonectomy Empyema

A 64-year-old man underwent a right pneumonectomy for squamous cell carcinoma of the right lung. He was discharged from the hospital on the fifth day after surgery.

Three weeks later, the patient presented with fever, chills, and rigors. He was diaphoretic. Blood pressure was 90/40 mm Hg; pulse rate, 126 beats per minute; and respiration rate, 28 breaths per minute. Lung examination revealed no air entry on the right side. The chest films demonstrated an air-fluid level, or hydropneumothorax, in the right pleural space (A and B). Culture of the pleural fluid obtained during a thoracentesis grew Staphylococcus aureus, which confirmed the clinical suspicion of empyema.

A chest tube was inserted for drainage, and intravenous vancomycin( was given. The patient’s condition improved markedly; he was discharged from the hospital 4 weeks after admission.

Postpneumonectomy empyema occurs in about 2% of all pneumonectomies and usually causes significant morbidity or death. Empyema generally develops within 4 weeks of surgery; symptoms include fever and toxemia, expectoration of a large amount of pleural fluid or drainage of fluid from the surgical site, and the presence of an air-fluid level in the pneumonectomy space. Since nearly 40% of cases are associated with bronchopleural fistula or esophagopleural complications, consider a barium swallow and a bronchoscopic examination for all patients with this condition.¹

A CT scan can help distinguish a loculated hydropneumothorax from a lung abscess, which also presents with an air-fluid level on a chest film. The scan can demonstrate whether the air-fluid level is located in the pleural space or in the lung, as seen in another patient (C).

S aureus is the most commonly isolated organism; chest tube drainage and antibiotics are the standard therapies. If nonsurgical treatment fails, decortication may be required.

A lung abscess can be treated with antibiotics alone; however, patients with loculated hydropneumothorax require chest tube drainage as well as antibiotic therapy.