accurate assessment of the size of the effusion and, where necessary, loculations using ultrasound or CT scanning
early diagnostic pleural aspiration, to assess fluid appearance, bacteriology and biochemistry
antibiotic therapy - depends on the bacteriology of the aspirated fluid; often requires metronidazole because organisms may not be revealed by culture
pleural fluid is drained - if this is not possible then surgery is indicated (surgical evacuation and lung decortication so that it may be fully expanded and so obliterate the pleural space)
consider the possibility of tuberculosis
Reference:
Shen KR, Bribriesco A, Crabtree T, et al. The American Association for Thoracic Surgery consensus guidelines for the management of empyema. J Thorac Cardiovasc Surg. 2017 Jun;153(6):e129-46.
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