Key Points

• The principles behind using decortication to improve lung function and expansion date back more than 100 years.
• In selected patients, early decortication prevents the development of fibrothoraces.
• Early and complete drainage of the pleural space is the best way to prevent a fibrothorax and to prevent decortication.
• Video-assisted thoracoscopy (VATS) is a reasonable alternative to open thoracotomy for deloculation of early stage empyema.

Under normal conditions, the pleural space is a virtual cavity interposed between the chest wall and the lung. The visceral and parietal linings of this cavity are 1 to 2 mm thick and serve as permeable membranes for transport of cells and fluid. Under pathologic conditions, these relationships may be altered, leading to the development of chronic infections, trapped lung, and severely impaired respiration. Although infrequently encountered, these pathologic conditions must be well understood, not only because they are of historical interest but also because they present challenging management problems.