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Empyema is a collection of infected, pus-filled fluid in the pleural space — the thin space between the lung and the chest wall. It usually develops as a complication of pneumonia, when infection spreads from the lung into the surrounding fluid. Empyema needs both antibiotics and drainage of the infected fluid, usually with a chest drain, and recovery can take weeks. This page explains what empyema is, how it develops, how it is treated, and where physiotherapy fits in.
Definition
Empyema is the presence of frank pus, or heavily infected fluid, in the pleural space — the thin cavity between the lung and the chest wall. It represents the most advanced stage of a parapneumonic effusion, the fluid that can accumulate alongside pneumonia, and is distinguished from a simple pleural effusion by the degree of infection and by the fact that antibiotics alone will not resolve it. Pus in a body cavity requires drainage, and that principle governs everything that follows.
Pathophysiology
Parapneumonic effusions evolve through three recognised stages, and the stage at presentation determines the treatment.
Stage 1: exudative
Inflammation in the adjacent lung increases capillary permeability, and sterile, free-flowing fluid collects in the pleural space. At this point the fluid drains easily and antibiotics with simple drainage are usually sufficient.
Stage 2: fibrinopurulent
Bacteria invade the fluid. Neutrophils accumulate, the fluid becomes turbid and then frankly purulent, and fibrin is deposited in strands across the cavity. Those strands divide the space into loculations — separate pockets that a single drain cannot reach. This is the stage at which fibrinolytic therapy becomes relevant.
Stage 3: organising
Fibroblasts convert the fibrin into a thick, inelastic fibrous peel over the visceral pleura, trapping the lung and preventing it re-expanding. No amount of drainage or breathing exercise will reverse an established peel; it requires surgical removal. The whole progression can occur within one to two weeks, which is why delay in drainage is the single most consequential error in managing this condition.
Co-morbidities
Empyema is more common and more severe in people with pre-existing lung disease — COPD, bronchiectasis — and with diabetes, alcohol-use disorder, malnutrition, immunosuppression, poor dentition and chronic kidney or liver disease. Aspiration risk from swallowing difficulty, reduced consciousness or neurological disease predisposes to the aspiration pneumonia that progresses to empyema, and the same patients often have the weak cough and limited mobility that slow recovery afterwards. Chest trauma and thoracic surgery are the other principal routes in.
Prevalence
Empyema complicates a small but significant proportion of pneumonia admissions — of the order of 5–10% of hospitalised pneumonia develops a parapneumonic effusion, and a minority of those progress to frank empyema. Incidence has risen in several countries over the past two decades, particularly in children and in older adults with co-morbidity. It carries a substantially prolonged hospital stay, commonly two to three weeks, and appreciable mortality in frail patients when drainage is delayed.
Causes and risk factors
- Bacterial pneumonia — the commonest cause by a wide margin, with infection tracking from the lung into an existing effusion.
- Aspiration — particularly with poor dental hygiene, which introduces anaerobic organisms.
- Thoracic surgery or chest trauma, including retained haemothorax, which is an excellent culture medium.
- Ruptured lung abscess or, less commonly, spread of infection from below the diaphragm.
- Iatrogenic — after chest drain insertion or pleural procedures.
- Organisms — Streptococcus species (notably the Streptococcus anginosus group), Staphylococcus aureus including MRSA, and anaerobes; Gram-negative organisms in hospital-acquired and post-surgical cases; and tuberculosis in the appropriate epidemiological context.
Symptoms
Typical features
Persisting or worsening fever, pleuritic chest pain, breathlessness and productive cough despite antibiotic treatment for pneumonia. That failure to improve as expected is the clinical clue that should prompt imaging, and it is more reliable than any single symptom.
Chronic empyema
Where the diagnosis is delayed, the picture becomes indolent: weight loss, anaemia, night sweats, clubbing, low-grade fever and a chronically unwell patient, sometimes with a discharging sinus through the chest wall. Restriction of chest expansion on the affected side is often visible.
Warning signs
Diagnosis
Why diagnosis matters
The distinction between a simple parapneumonic effusion and an empyema decides whether the patient needs antibiotics alone or antibiotics plus a drain, and every day of delay moves the disease towards the organising stage and surgery. Any pneumonia not responding as expected warrants imaging of the pleural space rather than a change of antibiotic.1
How is it diagnosed?
Diagnosis requires demonstrating infected fluid, which means sampling it. Imaging identifies and localises the collection; aspiration characterises it. Clinical severity is scored formally — the RAPID score (renal, age, purulence, infection source, dietary/albumin) stratifies risk at presentation and helps identify patients who will do badly with conservative management.2
Radiology
Chest X-ray shows an effusion, often with a shape that does not simply layer with gravity. Thoracic ultrasound is the key bedside test: it distinguishes fluid from consolidation, detects septations and loculation that CT can miss, estimates volume and guides safe aspiration. CT chest with contrast defines loculation, shows pleural enhancement and thickening (the split pleura sign), demonstrates any underlying lung pathology, and is essential when surgery is being considered.
Pleural fluid analysis
Diagnostic aspiration is essential and should not be deferred. Frank pus is diagnostic in itself. Otherwise, a fluid pH below 7.2, glucose below 3.3 mmol/L or lactate dehydrogenase above three times the serum upper limit indicate a complicated effusion requiring drainage. Light's criteria confirm the exudative nature. The pH sample must be handled in a blood gas syringe and analysed promptly, as delay and air exposure both distort it.
Microbiology
Fluid is sent for Gram stain, aerobic and anaerobic culture, and inoculation into blood culture bottles improves yield. Cultures are negative in a substantial minority, particularly after antibiotics have been started, so a negative culture does not exclude empyema. Blood cultures, sputum culture and, where relevant, testing for tuberculosis are taken in parallel.
Investigations for related conditions
Bloods track the inflammatory response, renal function and albumin (both components of the RAPID score) and screen for diabetes and immunosuppression. Where the pneumonia was unexplained or recovery is atypical, bronchoscopy or follow-up CT looks for an obstructing lung cancer. A swallow assessment is warranted where aspiration is suspected.
Management
Management and goals
The goals are to sterilise the pleural space, drain it completely, re-expand the lung fully, and prevent a residual fibrous peel and permanent restriction. Success is judged by clinical improvement, falling inflammatory markers and radiological re-expansion — not by drain output alone. Management is a joint respiratory, radiology and thoracic surgical decision, and involving surgery early is better than involving them late.
Antibiotics
Broad-spectrum cover is started immediately, including anaerobic cover, then narrowed to culture results. Courses are long — typically two to six weeks, often with an oral step-down after discharge — because antibiotic penetration into a walled-off purulent collection is poor. Antibiotics are necessary but never sufficient.
Chest drainage
An intercostal chest drain is inserted under ultrasound guidance. Small-bore drains are as effective as large-bore for most pleural infection and considerably more comfortable, provided they are flushed regularly to prevent blockage. Ongoing drain care, patency and position are checked daily.
Intrapleural fibrinolytic therapy
Where fluid is loculated, agents instilled into the pleural space break down fibrin. Streptokinase alone did not improve mortality or the need for surgery in a large randomised trial,3 but the combination of tissue plasminogen activator with DNase significantly improved fluid drainage and reduced both hospital stay and referral for surgery, while neither agent alone was effective.4 That combination is now standard where loculation limits drainage.
Surgery
Surgical intervention — usually video-assisted thoracoscopic surgery (VATS) with debridement, progressing to open decortication where a peel is established — is indicated when medical drainage fails to control sepsis, when the lung remains trapped, or in chronic organising empyema. In children, thoracoscopic decortication and drainage with fibrinolysis produce comparable outcomes, so the choice turns on local expertise and the child's condition.5 In adults, earlier surgical drainage has been shown to shorten hospital stay compared with tube thoracostomy alone,6 and contemporary practice favours early surgical referral rather than prolonged failed medical management.7
Identifying deterioration
Persisting fever, a static or rising inflammatory response, a drain that stops swinging or draining, increasing oxygen requirement, or a chest X-ray showing an unchanged or enlarging collection all indicate the current approach is not working. The response is a repeat ultrasound or CT and a surgical opinion — not another week of antibiotics.
Medications
Medications for empyema
Antibiotics are the pharmacological mainstay, chosen for anaerobic and Gram-positive cover initially and adjusted to culture and to whether infection was community- or hospital-acquired. Intrapleural tissue plasminogen activator and DNase are used as described above. Nutritional supplementation is frequently needed, as hypoalbuminaemia is both a marker of severity and a barrier to healing.
Correct use of medications
The long antibiotic course is completed even though the patient feels well well before the end — early cessation is a recognised route to recurrence. Oral step-down requires an agent with adequate tissue penetration, and adherence is checked at follow-up along with liver and renal function where prolonged courses are used.
Analgesia and breathing
Pleuritic pain and a chest drain both cause splinting, shallow breathing and an ineffective cough, which directly prevent lung re-expansion. Adequate, regularly reviewed analgesia is therefore a respiratory intervention, not a comfort measure, and should be timed so that physiotherapy sessions fall within its peak effect.
Living with empyema
Recovery takes longer than expected
Recovery is considerably slower than for uncomplicated pneumonia — commonly six to twelve weeks to feel normal, longer after surgery. Fatigue persists well after the infection is controlled, and patients who expect a two-week illness become discouraged. Saying this clearly at discharge prevents a great deal of unnecessary worry.
Nutrition
Weight loss and low albumin are near-universal, and both predict poorer outcome. Energy- and protein-dense intake, with dietetic input where loss has been marked, supports both healing and the strength needed for rehabilitation.
Wound, drain and scar care
Drain sites and surgical wounds are kept clean and dry, with any redness, discharge or fever reported. After thoracic surgery, scar mobility and the sensory changes around the incision are normal but benefit from explanation and gentle desensitisation.
Activity and return to work
Activity is rebuilt gradually, guided by breathlessness and fatigue rather than a calendar. Return to physical work or heavy lifting is usually deferred for six weeks or more after surgery, and driving until pain no longer limits an emergency stop.
Follow-up
Follow-up imaging confirms resolution and full re-expansion, and detects the residual pleural thickening that occasionally causes lasting restriction. Persisting breathlessness, fever or chest pain after treatment warrants review rather than watchful waiting.
Prognosis
Most people recover fully with timely antibiotics and drainage, though full recovery of lung function and exercise capacity can take weeks to months, particularly after surgery. Around one in five adults requires surgical intervention, and mortality is appreciable in older, frailer patients with high RAPID scores — a reminder that this is a serious illness and not simply a complicated chest infection. A degree of residual pleural thickening is common but usually functionally silent; established untreated peel causes permanent restrictive impairment. Delay to drainage is the strongest modifiable determinant of all of these outcomes.
Role of the physiotherapist
Physiotherapy begins once the infection is being actively treated and drainage is established — not before, since expansion techniques against an undrained, loculated collection achieve nothing and cause pain. From that point the contribution is substantial.
Lung re-expansion is the central task: thoracic expansion exercises, sustained maximal inspiration and incentive spirometry, using the active cycle of breathing technique for lung expansion, with positioning to favour the affected side. Where secretions are retained, airway clearance and supported cough are added. All of it depends on analgesia being adequate first, and negotiating that is part of the job.
Mobilisation and reconditioning counter the marked deconditioning of a prolonged septic illness. Enhanced recovery pathways after lung surgery place early mobilisation and structured respiratory physiotherapy at the centre of postoperative care,8 and incentive spirometry is used as one component of that rather than in isolation.9 Where surgery is planned rather than emergent, a single preoperative physiotherapy education session substantially reduces postoperative pulmonary complications and is worth arranging.10
Shoulder and thoracic mobility on the affected side is addressed after prolonged drainage or thoracotomy, where guarding readily produces a stiff, painful shoulder and an asymmetrical posture that outlasts the infection. Progress is tracked with exercise tolerance, oxygen saturation and chest expansion, and handed over to a home programme at discharge.
Part 1 · References
- Roberts ME, Rahman NM, Maskell NA, et al. British Thoracic Society guideline for pleural disease. Thorax 2023;78(Suppl 3):s1–s42.
- Rahman NM, Kahan BC, Miller RF, Gleeson FV, Nunn AJ, Maskell NA. A clinical score (RAPID) to identify those at risk for poor outcome at presentation in patients with pleural infection. Chest 2014;145(4):848–855.
- Maskell NA, Davies CWH, Nunn AJ, et al. UK controlled trial of intrapleural streptokinase for pleural infection (MIST1). N Engl J Med 2005;352(9):865–874.
- Rahman NM, Maskell NA, West A, et al. Intrapleural use of tissue plasminogen activator and DNase in pleural infection (MIST2). N Engl J Med 2011;365(6):518–526.
- St Peter SD, Tsao K, Spilde TL, et al. Thoracoscopic decortication vs tube thoracostomy with fibrinolysis for empyema in children: a prospective, randomized trial. J Pediatr Surg 2009;44(1):106–111.
- Wait MA, Sharma S, Hohn J, Dal Nogare A. A randomized trial of empyema therapy. Chest 1997;111(6):1548–1551.
- Semenkovich TR, Olsen MA, Puri V, Meyers BF, Kozower BD. Current state of empyema management. Ann Thorac Surg 2018;105(6):1589–1596.
- Batchelor TJP, Rasburn NJ, Abdelnour-Berchtold E, et al. Guidelines for enhanced recovery after lung surgery: recommendations of the Enhanced Recovery After Surgery Society and the European Society of Thoracic Surgeons. Eur J Cardiothorac Surg 2019;55(1):91–115.
- Restrepo RD, Wettstein R, Wittnebel L, Tracy M. Incentive spirometry: 2011. Respir Care 2011;56(10):1600–1604.
- Boden I, Skinner EH, Browning L, et al. Preoperative physiotherapy for the prevention of respiratory complications after upper abdominal surgery (LIPPSMAck-POP): pragmatic, double blinded, multicentre randomised controlled trial. BMJ 2018;360:j5916.
References are numbered in citation order (Vancouver/BMJ style) and were current at the time of writing. Guidelines are living documents — verify against the latest version before clinical use.
Supervised exercise, breathing technique and self-management education are the mainstay of cardiorespiratory physiotherapy for this condition.
Clinical evidence
Part 1 covers the same condition without the technical detail. What follows is the evidence base behind it, written for clinicians — the literature, the reasoning and the gaps.
For clinicians: this summary supports clinical reasoning and is not a protocol. Check current guidelines and local policy before applying it, and read it alongside the key references and guidelines directory.
Framing. Empyema is a drainage and antibiotic problem, not a physiotherapy one. Management follows the pleural-infection pathway — sampling, intercostal drainage, prolonged antibiotics, intrapleural agents where drainage fails, and surgery for the rest — and there is no evidence that any chest physiotherapy technique clears pus from the pleural space.1 The physiotherapy contribution lies on the other side of that: preserving thoracic mobility, mobilising a patient tethered to a drain, restoring lung expansion and function, and picking up the restrictive deficit that follows.
Drainage and intrapleural therapy
- MIST1 showed intrapleural streptokinase alone did not reduce mortality or the need for surgery, ending single-agent fibrinolysis.2
- MIST2 showed combined tissue plasminogen activator and DNase improved radiographic drainage and reduced the need for surgical referral and hospital stay; neither agent alone was effective — the combination is now standard where drainage fails.3
- Surgical decortication (usually VATS) is indicated for failed drainage or established organisation, and earlier referral shortens stay compared with prolonged conservative attempts.1
- Risk stratification with the RAPID score (renal, age, purulence, infection source, dietary factors) identifies patients at high risk of poor outcome who warrant earlier escalation.4
- In children, fibrinolytic therapy and primary VATS give broadly comparable outcomes, with fibrinolysis usually first-line on cost and invasiveness grounds.5
Rehabilitation evidence
- Early mobilisation with an intercostal catheter in situ is safe and is recommended in thoracic ERAS guidance; drains should not be a reason for bed rest, provided the drainage system is managed correctly.6
- Lung-expansion therapy after thoracic procedures has no single superior modality — deep breathing, incentive spirometry, positive expiratory pressure and CPAP perform similarly, so choose on tolerance and cost.7
- Prophylactic physiotherapy reduces postoperative pulmonary complications in major surgery, and a single preoperative education session halved complications in LIPPSMAck-POP, a trial conducted before major upper abdominal surgery rather than thoracic surgery — applied to the patient facing decortication by analogy, not as an effect measured in this population.8
- Residual restriction is common but usually improves: most patients regain substantial lung function over three to six months, with a minority left with pleural thickening and a persistent restrictive defect.9,10
Physiotherapy implications
- Do not attempt to drain the pleural space with technique. Percussion, vibration and postural drainage do not clear pus and waste a session; concentrate on ventilation, mobility and function.1
- Mobilise with the drain, keeping the drainage system below the insertion site and upright, never clamping a bubbling drain, and coordinating with nursing before and after activity.6
- Restore the hemithorax: thoracic expansion exercises with an end-inspiratory hold on the affected side, side-flexion and rotation to counter splinting, and full shoulder-girdle range — a frozen shoulder on the drain side is a preventable complication.
- Get pain control right first. Splinted, shallow breathing is usually analgesia failure; time treatment to analgesia and escalate to the medical team rather than working around the pain.
- Treat concurrent sputum retention on its own merits — many patients have an underlying pneumonia, aspiration risk or COPD, and that is a legitimate clearance indication.
- Escalate sudden increased air leak or surgical emphysema, drain dislodgement, rising oxygen requirement, or new fever and pain suggesting inadequate drainage.
- Refer to rehabilitation at discharge: these patients are typically deconditioned by weeks of illness and prolonged antibiotics, and this is where the measurable gains are.9
Clinical reasoning
- Persistent fever and inflammatory markers on adequate antibiotics means undrained pleural fluid — a radiology and surgical question, not a physiotherapy intensity question.
- Distinguish a restrictive pleural problem (reduced expansion, dull percussion, reduced breath sounds) from an airway problem; only the second responds to clearance.
- Look for the cause: aspiration risk, dental sepsis, alcohol use, immunosuppression, malignancy and intravenous drug use all change follow-up.
- Slow functional recovery after discharge is usually deconditioning plus deconditioned respiratory mechanics, both trainable.
Evidence gaps
- No randomised trial has tested any physiotherapy intervention specifically in pleural infection; practice is extrapolated from thoracic surgery and pneumonia populations.7,8
- Optimal timing, dose and content of thoracic mobility work during and after drainage is unknown.
- Which patients develop persistent pleural thickening and restriction, and whether early rehabilitation alters that, has not been studied.10
- Long-term functional and quality-of-life outcomes after empyema are poorly described.
References for the clinical evidence summary
- Roberts ME, Rahman NM, Maskell NA, et al. British Thoracic Society guideline for pleural disease. Thorax 2023;78(Suppl 3):s1–s42.
- Maskell NA, Davies CWH, Nunn AJ, et al. UK controlled trial of intrapleural streptokinase for pleural infection (MIST1). N Engl J Med 2005;352(9):865–874.
- Rahman NM, Maskell NA, West A, et al. Intrapleural use of tissue plasminogen activator and DNase in pleural infection (MIST2). N Engl J Med 2011;365(6):518–526.
- Rahman NM, Kahan BC, Miller RF, Gleeson FV, Nunn AJ, Maskell NA. A clinical score (RAPID) to identify those at risk for poor outcome at presentation in patients with pleural infection. Chest 2014;145(4):848–855.
- St Peter SD, Tsao K, Spilde TL, et al. Thoracoscopic decortication vs tube thoracostomy with fibrinolysis for empyema in children: a prospective, randomized trial. J Pediatr Surg 2009;44(1):106–111.
- Batchelor TJP, Rasburn NJ, Abdelnour-Berchtold E, et al. Guidelines for enhanced recovery after lung surgery: recommendations of the Enhanced Recovery After Surgery Society and the European Society of Thoracic Surgeons. Eur J Cardiothorac Surg 2019;55(1):91–115.
- Restrepo RD, Wettstein R, Wittnebel L, Tracy M. Incentive spirometry: 2011. Respir Care 2011;56(10):1600–1604.
- Boden I, Skinner EH, Browning L, et al. Preoperative physiotherapy for the prevention of respiratory complications after upper abdominal surgery (LIPPSMAck-POP): pragmatic, double blinded, multicentre randomised controlled trial. BMJ 2018;360:j5916.
- Semenkovich TR, Olsen MA, Puri V, Meyers BF, Kozower BD. Current state of empyema management. Ann Thorac Surg 2018;105(6):1589–1596.
- Wait MA, Sharma S, Hohn J, Dal Nogare A. A randomized trial of empyema therapy. Chest 1997;111(6):1548–1551.
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