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
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
A lung abscess can be treated with antibiotics alone;
however, patients with loculated hydropneumothorax require
chest tube drainage as well as antibiotic therapy.
1. Ueda H. Postoperative pyothorax. Surg Today. 1992;22:115-119.