Effective Treatment of Empyema With Fistula Using Saline Irrigation Through Tube Thoracostomy: A Case Report

Empyema with fistula formation represents a particularly challenging clinical entity, as the presence of an abnormal connection between the pleural cavity and the bronchial tree or lung parenchyma often exacerbates infection, hinders effective drainage, and complicates treatment. We report the case of a 66-year-old man who developed a massive pulmonary embolism, complicated by hemothorax and subsequent empyema with fistula formation, manifested by pneumothorax and purulent drainage. Despite the administration of anticoagulation and broad-spectrum antibiotics, the infection persisted, and surgical intervention was deemed too risky due to ongoing cardiopulmonary instability and residual pulmonary vascular obstruction. Given the high surgical risk, we initiated intrathoracic saline irrigation via a double-lumen irrigation suction tube as a conservative alternative. This strategy led to a prompt resolution of high fever and notable improvements in inflammatory markers. Saline lavage was administered over approximately one month, with progressive volume escalation and close clinical monitoring, ultimately resulting in radiological and clinical resolution of the empyema and closure of the fistula without serious complications. This case highlights the potential utility of intrapleural saline irrigation as a safe and effective therapeutic option in patients with fistulous empyema who are not suitable candidates for surgery. Careful patient selection and multidisciplinary collaboration are essential to ensure favorable outcomes in such complex scenarios.