Definitive surgical treatment for empyema entails drainage of the infected pleural fluid. A chest tube may be inserted, often using ultrasound guidance. Intravenous antibiotics are given. If this is insufficient, surgical debridement of the pleural space may be required.^[1][2][3]Management strategies of Empyema necessitans with pulmonary involvement and lung abscess may involve thoracotomy with pulmonary resection in addition to extended duration antimicrobial therapy.^[4][5]

Treatment of empyema focuses on the following:^[1]

• Controlling the infectious focus
• Drainage of fluid and pus
• Re-expansion of the lung

Surgery should be considered without delay in the following patients:^[6][7]

• who fail to improve with antibiotics and chest tube drainage,
• who have persistent infective symptoms, fever, leukocytosis and raised inflammatory markers.

Contrary to popular belief, radiological clearance of pleural collection is not a good indicator of disease progress.

Definitive surgical treatment for empyema entails drainage of the infected pleural fluid. A chest tube may be inserted, often using ultrasound guidance. Intravenous antibiotics are given. If this is insufficient, surgical debridement of the pleural space may be required.^[1][2][3]

• Least invasive
• Preferred for unilocuated effusions and free-flowing fluid.
• For solitary lesions a CT scan or ultrasound is used to guide the tube.
• For lesions more than one multiple small catheters are used to drain.
• When draining empyema fluid, thoracostomy tubes are typically placed using either an ultrasound or CT-guided approach. When multiple loculations are present, we typically place small-bore catheters, as multiple tubes may be needed to drain the multiloculated pleural space.
• A trial showed no difference between different sizes of thoracostomy tube. Smaller tubes were preferred due to decreased pain.^[8][9]
• British thoracic society recommends flushing the tube every 6 hrs to remain patent.^[10]. Smaller tubes are more prone to failure due to blockage.^[11]. Chest tubes are placed atleast till the cavity closes or drainage falls below 50 ml/day.
• Confirm correct placement of the tube using CT scans and checking drainage .

An incision is made through the chest wall to aid drainage at the inferior border of the cavity . A chest tube is inserted and left to drain the remaining cavity . This process is time consuming and requires at least 2-3 months. However a few side effects of anesthesia and chest tube infection still remain.

Management strategies of Empyema necessitans with pulmonary involvement and lung abscess may involve thoracotomy with pulmonary resection in addition to extended duration antimicrobial therapy.^[4][5]