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The British Thoracic Society (BTS) guidelines state that:


Aspiration allows diagnosis of an empyema and differentiation between simple parapneumonic effusions and those requiring drainage.

Investigations to be performed on aspirate:



Thoracic ultrasound (TUS) is a simple bedside investigation that can be used to assess the presence and size of an effusion more accurately than a plain chest radiograph.

Indications for pleural drainage:

TUS improves success and reduces complications of pleural procedures.


Computed tomography (CT) is better able to detect underlying abnormalities such as oesophageal perforation or bronchial carcinoma. It also aids in the differentiation between empyema and lung abscess. The ‘split pleura’ sign, where both parietal and visceral pleura enhance showing their separation, can be present in an empyema. However it is not as accurate as ultrasound in detecting septations and requires transferring the patient.

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