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PubMed This is a summary of 17 peer-reviewed journal articles Updated
Pulmonology

Understanding Pleural Empyema: Stages and Recovery

At a Glance

Pleural empyema is a treatable collection of pus in the space between the lungs and chest wall, usually caused by pneumonia. It progresses through three stages, from thin fluid to thick scar tissue. Prompt drainage via a chest tube or VATS surgery, paired with antibiotics, is the main treatment.

Finding out you have pleural empyema can feel overwhelming, but it is a well-understood medical condition with a clear roadmap for treatment. At its simplest, an empyema is a collection of pus that has gathered in the pleural space—the narrow area between your lungs and your chest wall [1][2].

It is important to remember that an empyema is almost always a “secondary” problem. It usually starts as a complication of something else, most commonly a severe case of pneumonia [3]. It can also occur after chest surgery or a traumatic injury to the chest [4][5]. While it is a serious infection, modern medicine has highly effective ways to drain the fluid and clear the bacteria.

The Three Stages of Empyema

Doctors categorize empyema into three stages. Knowing which stage you are in is the most important piece of information you can have, because the stage dictates how your care team will treat you [6].

  • Stage I: The Exudative Stage (Early)
    In this beginning phase, the fluid in the pleural space is thin and moves freely, like water [7]. The body is just starting to respond to the nearby infection. Because the fluid is “free-flowing,” it is usually the easiest to drain using a simple needle or a small chest tube (a thin plastic tube inserted between the ribs) [6].
  • Stage II: The Fibrinopurulent Stage (Middle)
    As the infection progresses, the fluid becomes thicker and full of white blood cells and debris (pus). A protein called fibrin begins to form “walls” or “strands” within the fluid, creating small pockets called loculations [7]. These pockets make it harder to drain the fluid with a standard tube. At this stage, doctors often use special medications called fibrinolytics (like tPA/DNase) delivered through the chest tube to “melt” those walls and allow the fluid to escape [8][9].
  • Stage III: The Organizing Stage (Late)
    If the infection persists, the fibrin strands toughen into a thick, leathery layer called a pleural peel [7]. This peel can act like a “shrink-wrap” around the lung, preventing it from expanding fully when you breathe [6]. At this stage, medications often cannot dissolve the peel, and a surgical procedure called decortication is typically needed to manually remove the peel and free the lung [10][11].

Stabilizing Facts for Your Journey

  • It is treatable: Even advanced (Stage III) empyemas can be successfully treated with surgery, and most patients recover well once the fluid is gone and the infection is cleared [10].
  • You are being monitored: Doctors use tools like Ultrasound and CT scans (see Diagnosing Empyema) to see exactly where the fluid is and which stage you are in [6]. They also track blood markers, like C-reactive protein (CRP), to make sure the infection is shrinking [12].
  • Draining is the priority: The “gold standard” of treatment is getting the infected fluid out of your body as soon as possible [13]. Whether it’s through a tube or surgery, the goal is “source control”—removing the source of the infection so your antibiotics can do their job [14].
  • Tailored antibiotics: Your team will likely test the fluid to find the specific bacteria causing the trouble, ensuring you get the most effective antibiotic for your specific case [15][16].

Looking Ahead

Your recovery depends on how quickly the infection is addressed and how your body responds to drainage. While Stage I and II can often be handled with tubes and medicine, Stage III often requires Video-Assisted Thoracoscopic Surgery (VATS), a minimally invasive surgical approach that uses small incisions and a camera to clean the pleural space [10][17]. To understand exactly how these treatments work, see Treatment Strategies.

Common questions in this guide

What is a pleural empyema?
A pleural empyema is a collection of pus that gathers in the pleural space, which is the narrow area between your lungs and chest wall. It almost always occurs as a complication of another issue, most commonly a severe case of pneumonia.
What are the three stages of empyema?
Empyema progresses through three stages: the exudative stage (early, thin fluid), the fibrinopurulent stage (middle, thicker fluid with pockets), and the organizing stage (late, where a thick scar tissue peel forms). Knowing your stage helps doctors decide the best treatment.
How is a pleural empyema treated?
The most important part of treatment is draining the infected fluid from your body. Depending on the stage, this is done using a chest tube, sometimes with special medicines to dissolve thick fluid, or through a minimally invasive surgery called VATS. You will also receive targeted antibiotics.
What is a pleural peel?
A pleural peel is a thick, leathery layer of tissue that forms around the lung during the late stage of an empyema. It can act like shrink-wrap and prevent your lung from expanding fully when you breathe, which often requires surgery to remove.
Why do doctors monitor my CRP levels?
Doctors measure C-reactive protein (CRP) in your blood to check the level of inflammation in your body. Tracking your CRP levels helps your care team confirm that the antibiotics and drainage are working and the infection is shrinking.

Questions to Ask Your Doctor

Curated prompts to bring to your next appointment.

  1. 1.What stage is my empyema in—exudative, fibrinopurulent, or organizing?
  2. 2.What did the cultures or testing of my pleural fluid reveal about the bacteria causing the infection?
  3. 3.Given the stage of my empyema, are we starting with a chest tube and medication, or is surgery like VATS necessary now?
  4. 4.How will you monitor if the treatment is working? Will we be using serial C-reactive protein (CRP) blood tests?
  5. 5.What is my RAPID score, and what does it tell us about my expected recovery?

Questions For You

Tap a prompt to share your answer — we'll use it plus this page's context to start a tailored conversation.

References

References (17)
  1. 1

    Management of Empyema Thoracis in Low-Resource Settings.

    Bekele A, Alayande BT

    Thoracic surgery clinics 2022; (32(3)):361-372 doi:10.1016/j.thorsurg.2022.02.004.

    PMID: 35961744
  2. 2

    Clinico-radiological profile of the patients with empyema thoracis: A prospective analytical study.

    Shekhar H, Sharma N, Singh SK, et al.

    The Indian journal of tuberculosis 2021; (68(4)):491-496 doi:10.1016/j.ijtb.2021.03.007.

    PMID: 34752319
  3. 3

    16S rRNA is a valuable tool in finding bacterial aetiology of community-acquired pleural empyema-a population-based observational study in South Sweden.

    Hjertman J, Bläckberg J, Ljungquist O

    Infectious diseases (London, England) 2022; (54(3)):163-169 doi:10.1080/23744235.2021.1985165.

    PMID: 34606399
  4. 4

    Epidemiology, Etiology and Prevention of Postpneumonectomy Pleural Empyema.

    Petrov DB, Subotic D, Yankov GS, et al.

    Folia medica 2019; (61(3)):352-357 doi:10.3897/folmed.61.e39120.

    PMID: 32337920
  5. 5

    Open window thoracostomy for a chronic calcified pleural empyema in the setting of a closed chest trauma.

    Harmouchi H, Hamraoui Y, Lakranbi M, et al.

    SAGE open medical case reports 2021; (9()):2050313X211025437 doi:10.1177/2050313X211025437.

    PMID: 34178354
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    Pleural empyema in children - benefits of primary thoracoscopic treatment.

    Barglik R, Grabowski A, Korlacki W, et al.

    Wideochirurgia i inne techniki maloinwazyjne = Videosurgery and other miniinvasive techniques 2021; (16(1)):264-272 doi:10.5114/wiitm.2020.97443.

    PMID: 33786143
  7. 7

    Video-assisted thoracoscopic decortication for the management of late stage pleural empyema, is it feasible?

    Hajjar WM, Ahmed I, Al-Nassar SA, et al.

    Annals of thoracic medicine 2016; (11(1)):71-8 doi:10.4103/1817-1737.165293.

    PMID: 26933461
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    Role of Medical Interventions in Complicated Parapneumonic Pleural Effusion and Empyema.

    Dawadi A, Dhungana A, Shrestha DK, et al.

    Journal of Nepal Health Research Council 2025; (23(2)):404-410 doi:10.33314/jnhrc.v23i02.4926.

    PMID: 41319060
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    Choice of intrapleural fibrinolytic agents in the treatment of adult complicated parapneumonic effusion and empyema: Network meta-analysis.

    Yokoyama Y, Kuno T, Takagi H, Burfeind W

    Asian cardiovascular & thoracic annals 2023; (31(5)):451-458 doi:10.1177/02184923231180990.

    PMID: 37287257
  10. 10

    Early Thoracotomy and Decortication in Pleural Empyema.

    Kohli A, Bhende VV, Chaudhary A, et al.

    Cureus 2025; (17(10)):e93879 doi:10.7759/cureus.93879.

    PMID: 41054428
  11. 11

    Two case reports of two interventional radiology techniques for the treatment of stage II empyema: Hydrodissection and guidewire-dissection.

    Yoshikawa S, Nakamura M, Ueda T

    Radiology case reports 2023; (18(8)):2711-2716 doi:10.1016/j.radcr.2023.04.061.

    PMID: 37304312
  12. 12

    Association between serial changes in serum C-reactive protein levels and mortality among patients with pleural empyema: a database research.

    Shiroshita A, Takeshita M, Nishiuma T, et al.

    BMC pulmonary medicine 2025; (25(1)):337 doi:10.1186/s12890-025-03799-3.

    PMID: 40652250
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    Evaluation and management of pleural sepsis.

    Lui JK, Billatos E, Schembri F

    Respiratory medicine 2021; (187()):106553 doi:10.1016/j.rmed.2021.106553.

    PMID: 34340174
  14. 14

    More isn't always better: antibiotic duration after surgical decortication in pleural empyema.

    Freudenberger DC, Scheese D, Wolfe LG, et al.

    Journal of thoracic disease 2024; (16(6)):3873-3881 doi:10.21037/jtd-24-61.

    PMID: 38983133
  15. 15

    Microbiological profile and antibiotic resistance pattern of empyema thoracis in Calabar, Nigeria.

    Nwagboso CI, Ekeng BE, Etiuma AU, et al.

    Tropical doctor 2021; (51(4)):523-526 doi:10.1177/00494755211032844.

    PMID: 34459297
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    Severe pneumonia with empyema due to multiple anaerobic infections: case report and literature review.

    Yu F, Zhang X, Li Y, et al.

    Frontiers in medicine 2024; (11()):1435823 doi:10.3389/fmed.2024.1435823.

    PMID: 39206173
  17. 17

    A review of the management of complex para-pneumonic effusion in adults.

    Koppurapu V, Meena N

    Journal of thoracic disease 2017; (9(7)):2135-2141 doi:10.21037/jtd.2017.06.21.

    PMID: 28840015

This page provides educational information about pleural empyema stages and treatments. It is not intended to replace professional medical advice, diagnosis, or treatment from your pulmonologist or thoracic surgeon.

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