Post-Empyema Fibrothorax Management

Pathophysiology and Development

The formation of a thick, inelastic fibrous peel encasing both the visceral and parietal pleural surfaces restricts lung expansion and causes restrictive lung disease, as noted by the British Thoracic Society 1, 2, 3
Fibrinous material deposited during the empyema organizing phase fails to resolve and instead matures into a thick, hard fibrous peel that encases the lung and restricts its ability to expand 1, 2
The process involves both visceral pleural surfaces and parietal pleural surfaces, creating a rigid cage that prevents normal respiratory mechanics 1, 2, 3

Symptomatic patients with organized empyema and thick fibrous peel require formal thoracotomy and decortication to achieve proper lung re-expansion, according to the British Thoracic Society guidelines 1, 2, 3
The decortication procedure requires sharp dissection and excision of both visceral and thick parietal pleural rinds, which carries risks including significant bleeding, lung parenchymal damage with air leaks, and possible nerve injuries 1, 2, 3

CT scanning with intravenous contrast is the most useful imaging modality before surgery to define the thickness of the pleural peel relative to consolidated lung and to check for intralobar pathology such as lung abscesses 1, 2, 3

Early recognition of developing organization is essential to avoid the significant morbidity associated with fibrothorax, as emphasized by the British Thoracic Society 1, 2, 3
The process of rapid evaluation and therapeutic intervention appears to reduce morbidity and mortality 4, 5