Empyema and Bronchopleural Fistula

Daniel L. Miller

Historical Note

Empyema of the pleural cavity was recognized approximately 2400 years ago when Hippocrates made the distinction between empyema and hydrothorax.[1] Prior to his description, the terms were used interchangeably; and before the principles of asepsis were defined by Semmelweis and Lister, infection from unsterilized instruments (used to evacuate fluid) occurred often in the treatment of serous pleural effusions. Hippocrates diagnosed empyema based on its clinical presentation. Fever was constant but mild during the day and increased at night. Patients’ coughs were nonproductive. Eyes were hollow, and cheeks showed red spots. When the patient was shaken by the shoulders, splash succussion sounds could be heard from the thorax, depending on the presence of air and fluid. In his book on chest auscultation, Laënnec translated Hippocrates’ description that distinguished hydrothorax from empyema: “When applying the ear on the ribs, during a certain time you hear a noise like boiling wine gar, which suggests that the chest contains water and no pus.”[2]Sometimes, the noises were not heard, depending on the quantity and physical characteristics of the intrathoracic liquid.

Hippocrates is also credited with the first drainage operation for empyema by using the cautery or doing the trephination of a rib. As reported by Paget, Hippocrates opened the chest where the pain and swelling were most evident.[3] He packed the wound with a strip of linen cloth, which was changed every day. He observed that this packing allowed fluid to escape around the strip but prevented air into the space. Daily irrigations with “warm wine and oil” cleaned the lung surfaces, and when the empyema had healed, metal rods were used to close the wound. He clearly understood the natural history of undrained empyemas when he wrote in a treatise on pleurisy and peripneumonia: “Patients with pleurisy who, from the beginning, have sputum of different colors or consistencies die on the third or the fifth day, or they become suppurative by the eleventh day.”[4] Hippocrates also wrote: “When empyemas are opened by the cautery or by the knife, and the pus flows pale and white, the patient survives, but if it is mixed with blood, muddy, and foul smelling, he will die.”

In the 19th century, aspiration of acute pleural effusions was introduced. Wyman and his colleague Bowditch are credited with establishing this procedure.[5],[6] Wyman described the first therapeutic thoracentesis in a letter addressed to Sir William Osler: “With Dr. Homans’ advice and assistance, the chest was punctured with an exploring trocar and cannula between the sixth and seventh ribs about six inches from the spine, and twenty ounces of straw colored serum drawn off slowly with great relief of the symptoms.” Needles used for pleural aspiration, cannulas, devices preventing the entry of air, and suctioning systems were developed during the 19th century.[7]

Thoracentesis was modified by the description of closed-tube thoracostomy by Playfair[8] (Figure 1) and Hewitt,[9] who performed drainage with a trocar, placing a rubber tube through the cannula into the pleural space. The rubber drain was connected to a glass tube that went through a cork into a bottle with a sealing level of antiseptic solution. It acted like a unidirectional valve, allowing the liquid to leave the thoracic cavity but keeping air from entering the space. The sealing level could be adjusted depending on the type and amount of fluid being drained. This system constituted a true siphon drainage system that also allowed pleural irrigation. In 1891, Von Bulau popularized the underwater drainage system throughout Europe. His name is still associated with this “no suction” method of pleural drainage.[10]

Figure 1 
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Water seal drainage of the pleural space as described by Playfair in 1875. “The end of the tube was placed in a vessel of water under the bed.” This system was used mostly for children with empyema. (FROM HOCHBERG LA: THORACIC SURGERY BEFORE THE 20TH CENTURY. NEW YORK, VANTAGE PRESS, 1960, P 244.)

The consequences of open pneumothorax and the importance of closed-tube drainage were not truly appreciated until a clear understanding of the pathogenesis of pleural infection was provided by Graham and Bell.[11] They were members of the U.S. Army Medical Corp (USAMC) and of the World War I Empyema Commission, and most of their work was done in Europe during the severe influenza epidemic due to hemolytic Streptococcus. Prior to their report, acute empyemas were managed by rib resection and open drainage; unfortunately, mortality rates averaged 30%. Death frequently occurred within 30 minutes of the procedure and was attributed to the open pneumothorax and mediastinal instability rather than to the empyema itself. Soon after Graham and Bell recommended closed rather than open drainage to treat early empyemas, the mortality rates decreased from 30% to 5% to 10%.[12],[13] The principles of empyema management as described by Graham and Bell include (1) careful avoidance of open pneumothorax during the acute stage; (2) prevention of chronicity by rapid sterilization and obliteration of the space; and (3) careful attention to the patient’s nutritional status. Open drainage is indicated only when fibrotic changes have occurred within the space. In 1935, Eloesser (Figure 2) described a tissue flap for the treatment of acute pleural tuberculosis. This flap was constructed as a one-way valve, allowing the exit of pus but preventing the entry of air (Figure 3).[14]

Figure 2 
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Dr. Leo Eloesser.
Figure 3 
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The original Eloesser flap.

As thoracic surgery evolved rapidly during the end of the 19th century, procedures such as thoracoplasty[15],[16] and decortication[17],[18],[19] were introduced. These procedures described the obliteration of space either by collapsing it over the lung or by attempting to re-expand the lung itself. The results were not always good but, in 1901, Fowler stated that decortication was applicable to all patients with nontuberculous empyemas who could tolerate the procedure.[18] He even said that “decortication could be used instead of Estlander’s operation in most cases and should replace the Schede’s thoracoplasty in all.” In 1923, Eggers reported on 146 patients who submitted to decortication, and he described in full details the procedure as it is still used today.[20]

At the end of the 20th century, another modality was introduced for the diagnosis and treatment of empyema: thoracoscopy or video-assisted thoracoscopic surgery (VATS). Wakabayashi first used thoracoscopy for the drainage of an empyema.[21] Today VATS is the modality of choice for the diagnosis and treatment of early empyema.[22]

With the onset of the antibiotics era, the incidence of pneumococcal and streptococcal empyemas fell sharply and the mortality rate also declined dramatically. Subsequently, the increasing significance of anaerobic infection and the development of new generations of drug-resistant organisms led to a new spectrum of problems. In addition, the increasing frequency of the acquired immunodeficiency syndrome (AIDS) and of patients undergoing active chemotherapy has somewhat modified the natural history of the disease because patients are no longer able to produce the inflammatory reaction that is so important to localize the empyema and obliterate the space.[23]

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Last updated: June 6, 2020