A 52-year-old alcoholic with fever and a cough productive of purulent sputum is found to have the opacity on chest film as shown (Fig. 62-15). The following is/are true statement(s):

a. The findings suggest a parapneumonic empyema

b. If pus is found on aspiration of the pleural space, a chest tube should be placed

c. If pus is found on aspiration, bronchoscopy is a necessary part of the patient’s evaluation

The posterior location of the infiltrate and fluid collection is typical of a parapneumonic empyema. The most important test is pleural aspiration which will usually yield frank pus, at which time a chest tube should be placed. Formerly, oily Dionosil was used to perform an empyemagram; this substance is now no longer commercially available. In the case of parapneumonic empyemas, tube drainage alone may be sufficient to allow full expansion of the lung. If this is not the case, a formal rib resection or early decortication should be performed. Decortication or marsupialization is indicated if the lungs fail to expand after 6–8 weeks. Every patient with spontaneous empyema should undergo bronchoscopy to rule out endobronchial obstruction by foreign body or tumor.