1. Thoracic Surgery On-Line
Part 5
Pleural space infections

2. Pleural space infections
A pleural effusion which is infected – infected pleural effusion – is managed with drainage and antibiotics.
If the lung expands to fill the chest,after the fluid is drained out,then this may be all that is necessary.

3. Pleural space infections
If patients have a fever and a fluid collection on Chest XRay – needle aspiration of the fluid is necessary for culture.Antibiotics are started empirically.
Drainage of the fluid may require ultrasound guided insertion of a pigtail drain,or insertion of a bigger drain – which is preferable because of the viscosity of the infected fluid.

4. Pleural space infections
CT is often required to identify the extent of the fluid collection and any underlying lung pathology.
It is possible to have a lung abscess eg from aspiration of infected dental particles,with an uninfected pleural effusion – either way the x ray will guide the decision process.

5. Pleural space infections
If the fluid doesn’t drain properly with an aspiration or chest drain,then an open drainage procedure may be required.
VATS procedures consist of inserting the scope into the pleural cavity,breaking down loculi and adhesions and irrigating the cavity,then inserting drains.

6. Pleural space infections
Open procedures
The best procedure to clear up the loculated empyema is a decortication.
A low lateral thoracotomy is performed,and the thickened “cortex” is pealed off the underlying entrapped lung,to allow it to reexpand.

7. Pleural space infections
By allowing the lung to reexpand,the spaces in the pleural cavity for infection to reaccumulate in are reduced,and the lung will bond onto the chest wall,leaving no pleural cavity.
Drains are positioned in an apical and basal position to drain the pleural cavity.

8. Pleural space infections
Drains are removed if the fluid was sterile on culture,and drainage is <100cc/24hrs- as long as there is no continuing air leak.
If fluid was infected,the antibiotics are given according to sensitivities.
Drains are only removed if drainage is stopped,in this circumstance.

9. Pleural space infections
If there is air around the drain on the chest X Ray,this means there is a cavity still,and the drains can’t be removed.
The drains can be cut short,and colostomy bags positioned over them to collect drainage.

10. Pleural space infections
When there is no more air shadow,a sinugram is done up the drains.
If there is no distal or surrounding cavity,the drains are withdrawn an inch every week,to allow the tract to collapse down.Ultimately they will be out altogether.

11. Pleural space infections
Rib resection and drainage.
If the patient is very sick,excising a small piece of the posterior rib over the empyema cavity is done,- even under local anaesthetic.
The pleural cavity is entered and pus drained.The drain is stitched in and covered by a colostomy bag.It is slowly withdrawn as for the drains in infected spaces.

12. Pleural space infections
Fenestration of the empyema cavity.
If it is deemed not a good idea to leave a drain in,which may fall out at a bad time,or in an inaccessible location,one of the safest procedures is to excise the ribs over the cavity and leave the chest wall open,to let the pus drain out,and cover it with dressings.

13. Pleural space infections
Fenestration procedures are very effective,and as the infection subsides,the patients constitutionally improves,and nutritional staus picks up – the hole closes down and tries to close off completely.
It may be necessary from time to time to dilate the opening with Hegar’s dilators