Ultrasound-guided pigtail catheters for drainage of various pleural diseases

Reduction of Chest Drain Overuse Through Implementation of a Pleural Drainage Order Set

BACKGROUND AND OBJECTIVES

Small chest drains are used in many centers as the default drainage strategy for various pleural effusions. This can lead to drain overuse, which may be harmful. This study aimed to reduce chest drain overuse.

METHODS

We studied consecutive pleural procedures performed in the radiology department before (August 1, 2015, to July 31, 2016) and after intervention (September 1, 2019, to January 31, 2020). Chest drains were deemed indicated or not based on criteria established by a local interdisciplinary work group. The intervention consisted of a pleural drainage order set embedded in electronic medical records. It included indications for chest drain insertion, prespecified drain sizes for each indication, fluid analyses, and postprocedure radiography orders. Overall chest drain use and proportion of nonindicated drains were the outcomes of interest.

RESULTS

We reviewed a total of 288 procedures (pre-intervention) and 155 procedures (post-intervention) (thoracentesis and drains). Order-set implementation led to a reduction in drain use (86.5% vs 54.8% of all procedures, P < .001) and reduction in drain insertions in the absence of an indication (from 45.4% to 29.4% of drains, P = .01). The need for repeat procedures did not increase after order-set implementation (22.0% pre vs 17.7% post, P = .40). Complication rates and length of hospital stay did not differ significantly after the intervention. More pleural infections were treated with drain sizes of 12Fr and greater (31 vs 70%, P < .001) after order-set deployment, and direct procedural costs were reduced by 27 CAN$ per procedure.

CONCLUSION

Implementation of a pleural drainage order-set reduced chest drain use, improved procedure selection according to clinical needs, and reduced direct procedural costs. In institutions where small chest drains are used as the default drainage strategy for pleural effusions, this order set can reduce chest drain overuse.

Percutaneous management of complicated empyema thoracis using pigtail, report of a case from University Hospital of Nepal: a case report

Empyema thoracis is a condition characterized by the accumulation of pus in the pleural cavity of the lungs. Empyema thoracis is a cause of high mortality in man and its occurrence is increasing in both children and adults. Traditionally, chest tube drainage has been a preferred method of treatment, but recent studies have shown that pigtail catheter drainage is a more effective and less invasive alternative. Image-guided drainage is also preferred over blind drainage, and alternative drainage sites are being explored. These management changes have improved patient outcomes and reduced the risk of complications.

CASE PRESENTATION AND CLINICAL DISCUSSION

A 66-year-old female presented with complaints of cough, fever, and chest pain. A clinical examination was done and relevant investigations were sent. She was then treated in the line of left-sided empyema thoracis. A pigtail catheter was inserted into the loculated empyema via the left 9th intercostal space through a posterolateral approach with ultrasonography guidance.

CONCLUSION

The main aim of this article is to provide an overview of a rare management approach for empyema, a condition characterized by the accumulation of pus in the pleural cavity of the lungs. In this case report, the authors have focused on pigtail catheter drainage over traditionally performed chest tube drainage, and image-guided drainage has been performed over blind drainage ensuring accurate placement and reducing the risk of damage to surrounding tissues. Another notable change in empyema management is the shift in drainage sites from the safety triangle to other sites based on the site of loculations under ultrasonography guidance.

A Primer and Literature Review on Internal and External Retention Mechanisms for Catheter Fixation

Although catheters are commonplace in hospital settings, there is scarce literature discussing the internal and external retention mechanisms used to aid in catheter fixation. Additionally, exact definitions and detailed information on internal and external retention mechanisms are almost non-existent in the literature. This article serves three primary purposes. The first purpose is to define internal and external catheter retention mechanisms, describe how they work, and provide examples of each that are routinely used in healthcare settings. The second goal of this paper is to provide a literature review comparing various aspects of the different types of internal and external catheter retention mechanisms discussed in the paper, including performance variance and the advantages and disadvantages of each. The third aim of this article is to provide a brief overview of catheter dislodgment, including the rates at which this occurs, the problems that can arise, and the best treatment option when this does occur.

Comprehensive Review of Chest Tube Management: A Review

Importance

Thoracostomy, or chest tube placement, is used in a variety of clinical indications and can be lifesaving in certain circumstances. There have been developments and modifications to thoracostomy tubes, or chest tubes, over time, but they continue to be a staple in the thoracic surgeon's toolbox as well as adjacent specialties in medicine. This review will provide the nonexpert clinician a comprehensive understanding of the types of chest tubes, indications for their effective use, and key management details for ideal patient outcomes.

Observations

This review describes the types of chest tubes, indications for use, techniques for placement, common anatomical landmarks that are encountered with placement and management, and an overview of complications that may arise with tube thoracostomy. In addition, the future direction of chest tubes is explored, as well as the management of chest tubes during the COVID-19 pandemic.

Conclusions and Relevance

Chest tube management is subjective, but the compilation of data can inform best practices and safe application to successfully manage the pleural space and ameliorate acquired pleural space disease.

Management of complex pleural disease in the critically ill patient

Disorders of the pleural space are quite common in the critically ill patient. They are generally associated with the underlying illness. It is sometimes difficult to assess for pleural space disorders in the ICU given the instability of some patients. Although the portable chest X-ray remains the primary modality of diagnosis for pleural disorders in the ICU. It can be nonspecific and may miss subtle findings. Ultrasound has become a useful tool to the bedside clinician to aid in diagnosis and management of pleural disease. The majority of pleural space disorders resolve as the patient’s illness improves. There remain a few pleural processes that need specific therapies. While uncomplicated parapneumonic effusions do not have their own treatments. Those that progress to become a complex infected pleural space can have its individual complexity in therapy. Chest tube drainage remains the cornerstone in therapy. The use of intrapleural fibrinolytics has decreased the need for surgical referral. A large hemothorax or pneumothorax in patients admitted to the ICU represent medical emergencies and require emergent action. In this review we focus on the management of commonly encountered complex pleural space disorders in critically ill patients such as complicated pleural space infections, hemothoraces and pneumothoraces.

Overuse of small chest drains for pleural effusions: a retrospective practice review

PURPOSE

Small-bore drains (≤ 16 Fr) are used in many centers to manage all pleural effusions. The goal of this study was to determine the proportion of avoidable chest drains and associated complications when a strategy of routine chest drain insertion is in place.

DESIGN/METHODOLOGY/APPROACH

We retrospectively reviewed consecutive pleural procedures performed in the Radiology Department of the McGill University Health Centre over one year (August 2015-July 2016). Drain insertion was the default drainage strategy. An interdisciplinary workgroup established criteria for drain insertion, namely: pneumothorax, pleural infection (confirmed/highly suspected), massive effusion (more than 2/3 of hemithorax with severe dyspnea /hypoxemia), effusions in ventilated patients and hemothorax. Drains inserted without any of these criteria were deemed potentially avoidable.

FINDINGS

A total of 288 procedures performed in 205 patients were reviewed: 249 (86.5%) drain insertions and 39 (13.5%) thoracenteses. Out of 249 chest drains, 113 (45.4%) were placed in the absence of drain insertion criteria and were deemed potentially avoidable. Of those, 33.6% were inserted for malignant effusions (without subsequent pleurodesis) and 34.5% for transudative effusions (median drainage duration of 2 and 4 days, respectively). Major complications were seen in 21.5% of all procedures. Pneumothorax requiring intervention (2.1%), bleeding (0.7%) and organ puncture or drain misplacement (2%) only occurred with drain insertion. Narcotics were prescribed more frequently following drain insertion vs. thoracentesis (27.1% vs. 9.1%, p = 0.03).

ORIGINALITY/VALUE

Routine use of chest drains for pleural effusions leads to avoidable drain insertions in a large proportion of cases and causes unnecessary harms.

Percutaneous Ultrasound-guided Pigtail Catheter for Pleural Effusions: Efficacy and Safety

Objectives

Small-bore pigtail catheters are now being used more frequently for draining pleural effusions. This study aimed to measure the efficacy, safety, and tolerability of these devices in different clinical conditions.

Methods

We retrospectively collected data from 141 patients with pleural effusions of various etiologies who underwent ultrasound-guided pigtail catheter insertion at Sultan Qaboos University Hospital, Muscat, Oman.

Results

The majority 109 (77.3%) of patients had exudates. The mean age was 50.0±18.6 years in patients with exudates and 67.3±15.5 in patients with transudates (p < 0.001). There was no significant difference (p = 0.232) in the median drainage duration between exudates (6.0 days) and transudates (4.5 days). The incidence of pain requiring regular analgesics, pneumothorax, and blockage were 36.2% (n = 51), 2.8% (n = 4), and 0.7% (n = 1), respectively. The overall success rate of pleural effusion drainage was 90.1%. Among the 109 cases of exudative pleural effusion, 89.0% were successful compared to a 93.8% success rate among patients with transudative effusion (p = 0.737). Short-term success rates were high in all causes of effusions: lung cancer (100%), metastasis (90.0%), pleural infections (83.3%), cardiac failure (94.7%), renal disease (85.7%), and liver disease (100%).

Conclusions

Ultrasound-guided pigtail catheter insertion is an effective, comfortable, and safe method of draining pleural fluid. It should be considered as the first intervention if drainage of a pleural effusion is clinically indicated.

Randomized Clinical Trial of 14-French (14F) Pigtail Catheters versus 28-32F Chest Tubes in the Management of Patients with Traumatic Hemothorax and Hemopneumothorax

Introduction

Traditional management of traumatic hemothorax/hemopneumothorax (HTX/HPTX) has been insertion of large-bore 32–40 French (Fr) chest tubes (CTs). Retrospective studies have shown 14Fr percutaneous pigtail catheters (PCs) are equally effective as CTs. Our aim was to compare effectiveness between PCs and CTs by performing the first randomized controlled trial (RCT). We hypothesize PCs work equally as well as CTs in management of traumatic HTX/HPTX.

Methods

Prospective RCT comparing 14Fr PCs to 28–32Fr CTs for management of traumatic HTX/HPTX from 07/2015 to 01/2018. We excluded patients requiring emergency tube placement or who refused. Primary outcome was failure rate defined as retained HTX or recurrent PTX requiring additional intervention. Secondary outcomes included initial output (IO), tube days and insertion perception experience (IPE) score on a scale of 1–5 (1 = tolerable experience, 5 = worst experience). Unpaired Student’s t-test, chi-square and Wilcoxon rank-sum test were utilized with significance set at P < 0.05.

Results

Forty-three patients were enrolled. Baseline characteristics between PC patients (N = 20) and CT patients (N = 23) were similar. Failure rates (10% PCs vs. 17% CTs, P = 0.49) between cohorts were similar. IO (median, 650 milliliters[ml]; interquartile range[IR], 375–1087; for PCs vs. 400 ml; IR, 240–700; for CTs, P = 0.06), and tube duration was similar, but PC patients reported lower IPE scores (median, 1, “I can tolerate it”; IR, 1–2) than CT patients (median, 3, “It was a bad experience”; IR, 3–4, P = 0.001).

Conclusion

In patients with traumatic HTX/HPTX, 14Fr PCs were equally as effective as 28–32Fr CTs with no significant difference in failure rates. PC patients, however, reported a better insertion experience.

www.ClinicalTrials.gov Registration ID: NCT02553434

Is routine chest radiography necessary after ultrasonography-guided catheter thoracostomy?

INTRODUCTION

Many institutions still perform routine chest radiography (CXR) after tube thoracostomies despite current guidelines suggesting that this is not necessary for simple cases. We aimed to evaluate the usefulness of routine CXR following ultrasonography-guided catheter thoracostomies for the detection of complications of symptomatic pleural effusions in hospitalised patients.

METHODS

This was a retrospective review of 2,032 ultrasonography-guided thoracostomies on hospitalised patients with symptomatic effusions at a single institution from April 2012 to May 2015. The aetiology of effusions was not systemically registered, but patient demographics, procedural details and clinical outcomes were collected. Data was analysed using descriptive statistics and chi-square test. Generalised estimating equation analysis was performed to assess the relationship between CXR findings and complications while controlling for age.

RESULTS

Out of 2,032 CXRs, 92.96% (n = 1,889) were normal, 5.81% (n = 118) showed pneumothorax and 1.23% (n = 25) showed catheter kinking. 99 pneumothoraces and 24 kinked catheters were detected in the first hour post procedure. 97.40% (n = 115) of patients with pneumothorax were stable or had minor complications, such as a vasovagal event. 0.20% (n = 4) of the cases had a serious complication following chest drain insertion, resulting in cardiovascular collapse. There was no significant relationship between CXR results and occurrence of complications (p = 0.244). Amount of fluid drained or side of insertion did not affect the clinical outcome.

CONCLUSION

Routine use of CXR after tube thoracostomy did not significantly change patient management, which was concordant with recent guidelines. Instead, adverse clinical outcomes or procedural factors should guide investigations.

Image-guided catheter drainage in loculated pleural space collections, effectiveness, and complications

INTRODUCTION

Image-guided drainage is an established technique with a multitude of applications. The indications, techniques, and management of image-guided catheter drainage, however, continue to evolve. Image-guided drainage alone is sometimes sufficient for the treatment of a collection, but it can also act as an adjunct or temporizing measure before definitive surgical treatment. Drainage of a symptomatic collection is performed to drain pus from the cavity, working in conjunction with antibiotics. Infected collections accumulate antibiotics to a limited extent, which generally precludes effective treatment with antibiotics alone unless the collection is very small (1-3 cm). There are many indications for image-guided drainage in the chest, including pleural disease, lung parenchymal, pericardial, and mediastinal collections. Pleural collections represent a common clinical problem, for which image-guided drainage is recommended to reduce complications encountered as a result of blind drainage.

AIM AND OBJECTIVE

To evaluate the efficacy and complications of ambulatory catheter drainage system for infective and loculated pleural collection.

MATERIALS AND METHODS

The study was conducted in the department of radiodiagnosis and imaging, Sheri Kashmir Institute of Medical Sciences Srinagar 2016 to 2018. It was prospective in nature. All the patients were referred from in patient department as cases of clinically symptomatic pleural collections with image-based evidence of loculations or septations. All 30 patients referred for drainage were imaged using suitable imaging technique (USG or CT) to quantise and document presence of septations and loculations in pleural collections. Mean attenuation of pleural fluid, presence of internal echo's and associated pleural thickening (>2mm) was noted.

RESULTS

The overall success rate in our study was 77%, with recurrence in 10 % of patients and failure rate of 13 %. The outcome as per etiology was success rate of 100% in parapneumonic effusion, 70 % in TB, 50 % in malignancy and 100% in pleural collection after recent surgical intervention. The common procedure related complications noted in our study were hemothorax (3%), post procedural pain (23 %), pneumothorax (3%).

CONCLUSION

Image guided percutaneous drainage of loculated pleural space collections is an effective and safe procedure.

Efficacy and safety of percutaneous tube drainage in lung abscess: a systematic review and meta-analysis

Objectives: Lung abscess is an infectious lung disease. The main objective of this review was to assess the efficacy and safety of percutaneous tube drainage (PTD) in patients with lung abscess by systematic review and meta-analysis of published data. Methods: We searched all literature published between 1 January 2010, and 6 August 2019, in the PubMed, Cochrane Central Library, EMBASE, Wanfang, Chinese National Knowledge Infrastructure, and Chinese Biomedical Literature databases for relevant reports. The data from these studies were pooled for statistical analysis, and sensitivity analysis and risk-of-bias analysis was performed. Results: Meta-analysis revealed that percutaneous tube drainage (PTD) was superior to conservative treatment in terms of the total effectivity rate (P < 0.01). Moreover, length of hospital stay and number of fever days were reduced for the PTD group than for the group receiving conservative treatment (P < 0.01). There was no significant difference between PTD and conservative treatment in terms of complication rate (P = 0.43). Conclusion: Lung abscess drainage is a safe and effective method for treating lung abscesses. Based on the principle that as much drainage as possible should be performed as treatment of abscess diseases, drainage should be promoted as treatment for lung abscess.

The effectiveness of small-bore intercostal catheters versus large-bore chest tubes in the management of pleural disease with the systematic review of literature

OBJECTIVE

The purpose of this study was to compare the effectiveness of small-bore intercostal catheters (SB ICCs; 10-14 Fr) to large-bore intercostal tubes (LB ICTs; >20 Fr) in the management of pleural diseases.

METHODS

A total of 52 patients (42 males) with a mean age of 55 ± 23 years undergoing pleural intervention were included in the analysis. Twenty-five patients (48.1%) had pneumothorax and rest (51.9%) had pleural effusion. Half of the patients underwent SB ICC (mean age: 63 ± 20 years) and the remaining 26 underwent LB ICT (mean age: 47 ± 25 years).

RESULTS

SB ICCs were predominantly used in patients with primary pleural effusion and LB ICTs in patients presenting with pneumothorax. Failures were in <20% of SB ICC patients (mainly from loculation) and in <30% with LB ICT patients (from persistent airleak) - difference that was not statistically significant. In both groups, no deaths or major complications directly related to the procedure were observed. However, the proportion that needed surgery was significantly different in two cohorts (18.5% OF SB ICC and 42.3% of LB ICT cohorts). The ICC dwell time was less in SB ICC (5 ± 4 days), compared to LB ICT (8 ± 6 days). SB ICCs were associated with less pain and seem to be tolerated better by the patients.

CONCLUSIONS

In well-supervised tertiary hospital setting, SB ICCs are as effective as LB ICTs with better patient tolerance, reduced dwell time, and reduced likelihood for surgical intervention.

Utility of pleural effusion drainage in the ICU: An updated systematic review and META-analysis

PURPOSE

The effects on the respiratory or hemodynamic function of drainage of pleural effusion on critically ill patients are not completely understood. First outcome was to evaluate the PiO₂/FiO₂ (P/F) ratio before and after pleural drainage.

SECONDARY OUTCOMES

evaluation of A-a gradient, End-Expiratory lung volume (EELV), heart rate (HR), mean arterial pressure (mAP), left ventricular end-diastolic volume (LVEDV), stroke volume (SV), cardiac output (CO), ejection fraction (EF), and E/A waves ratio (E/A). A tertiary outcome: evaluation of pneumothorax and hemothorax complications.

MATERIALS AND METHODS

Searches were performed on MEDLINE, EMBASE, COCHRANE LIBRARY, SCOPUS and WEB OF SCIENCE databases from inception to June 2018 (PROSPERO CRD42018105794).

RESULTS

We included 31 studies (2265 patients). Pleural drainage improved the P/F ratio (SMD: -0.668; CI: -0.947-0.389; p < .001), EELV (SMD: -0.615; CI: -1.102-0.219; p = .013), but not A-a gradient (SMD: 0.218; CI: -0.273-0.710; p = .384). HR, mAP, LVEDV, SV, CO, E/A and EF were not affected. The risks of pneumothorax (proportion: 0.008; CI: 0.002-0.014; p = .138) and hemothorax (proportion: 0.006; CI: 0.001-0.011; p = .962) were negligible.

CONCLUSIONS

Pleural effusion drainage improves oxygenation of critically ill patients. It is a safe procedure. Further studies are needed to assess the hemodynamic effects of pleural drainage.

A Prospective Study of 7-Year Experience Using Percutaneous 14-French Pigtail Catheters for Traumatic Hemothorax/Hemopneumothorax at a Level-1 Trauma Center: Size Still Does Not Matter

BACKGROUND

The effectiveness of 14-French (14F) pigtail catheters (PCs) compared to 32-40F chest tubes (CTs) in patients with traumatic hemothorax (HTX) and hemopneumothorax (HPTX) is becoming more well known but still lacking. The aim of our study was to analyze our cumulative experience and outcomes with PCs in patients with traumatic HTX/HPTX. We hypothesized that PCs would be as effective as CTs.

METHODS

Using our PC database, we analyzed all trauma patients who required chest drainage for HTX/HPTX from 2008 to 2014. Primary outcomes of interest, comparing PCs to CTs, included initial drainage output in milliliters (mL), tube insertion-related complications, and failure rate. For our statistical analysis, we used the unpaired Student's t test, Chi-square test, and Wilcoxon rank-sum test. We defined statistical significance as P < 0.05.

RESULTS

During the 7-year period, 496 trauma patients required chest drainage for traumatic HTX/HPTX: 307 by CTs and 189 by PCs. PC patients were older (52 ± 21 vs. 42 ± 19, P < 0.001), demonstrated a significantly higher occurrence of blunt trauma (86 vs. 55%, P ≤ 0.001), and had tubes placed in a non-emergent fashion (Day 1 [interquartile range (IQR) 1-3 days] for PC placement vs. Day 0 [IQR 0-1 days] for CT placement, P < 0.001). All primary outcomes of interest were similar, except that the initial drainage output for PCs was higher (425 mL [IQR 200-800 mL] vs. 300 mL [IQR 150-500], P < 0.001). Findings for subgroup analysis among emergent and non-emergent PC placement were also similar to CT placement.

CONCLUSION

PCs had similar outcomes to CTs in terms of failure rate and tube insertion-related complications, and the initial drainage output from PCs was not inferior to that of CTs. The usage of PCs was, however, selective. A future multi-center study is needed to provide additional support and information for PC usage in traumatic HTX/HPTX.

Comparison of closed-chest drainage with rib resection closed drainage for treatment of chronic tuberculous empyema

Background

This study aimed to compare the efficacy of closed-chest drainage with rib resection closed drainage of chronic tuberculous empyema.

Methods

This retrospective study reviewed 86 patients with tuberculous empyema in Shanghai Pulmonary Hospital from August 2010 to November 2015. Among these included patients, 22 patients received closed-chest drainage, and 64 patients received rib resection closed drainage.

Results

The results showed that after intercostal chest closed drain treatment, 2 (9.09%) patients were recovery, 13 (59.09%) patients had significantly curative effect, 6 (27.27%) patients had partly curative effect, and 1 (4.55%) patient had negative effect. After treatment of rib resection closed drainage, 9 (14.06%) patients were successfully recovery, 31 (48.44%) patients had significantly curative effect, 19 (29.69%) patients had partly curative effect, and 5 (7.81%) patients had negative effect. There was no significant difference in the curative effect (P>0.05), while the average catheterization time of rib resection closed drainage (130.05±13.12 days) was significant longer than that (126.14±36.84 days) in course of intercostal chest closed drain (P<0.05).

Conclusions

This study had demonstrated that closed-chest drainage was an effective procedure for treating empyema in young patients. It was less invasive than rib resection closed drainage and was associated with less severe pain. We advocated closed-chest drainage for the majority of young patients with empyema, except for those with other diseases.

When size matters: changing opinion in the management of pleural space-the rise of small-bore pleural catheters

Tube thoracostomy is usually the first step to treat several thoracic/pleural conditions such as pneumothorax, pleural effusions, haemothorax, haemo-pneumothorax and empyema. Today, a wide range of drains is available, ranging from small to large bore ones. Indications for an appropriate selection remains yet matter of debate, especially regarding the use of small bore catheters. Through this paper, we aimed to retrace the improvements of drains through the years and to review the current clinical indications for chest drain placement in pleural/thoracic diseases, comparing the effectiveness of small-bore drains vs. large-bore ones.

Pigtail Catheter: A Less Invasive Option for Pleural Drainage in Egyptian Patients with Recurrent Hepatic Hydrothorax

Background and Aims. Treatment of hepatic hydrothorax is a clinical challenge. Chest tube insertion for hepatic hydrothorax is associated with high complication rates. We assessed the use of pigtail catheter as a safe and practical method for treatment of recurrent hepatic hydrothorax as it had not been assessed before in a large series of patients. Methods. This study was conducted on 60 patients admitted to Tanta University Hospital, Egypt, suffering from recurrent hepatic hydrothorax. The site of pigtail catheter insertion was determined by ultrasound guidance under complete aseptic measures and proper local anesthesia. Insertion was done by pushing the trocar and catheter until reaching the pleural cavity and then the trocar was withdrawn gradually while inserting the catheter which was then connected to a collecting bag via a triple way valve. Results. The use of pigtail catheter was successful in pleural drainage in 48 (80%) patients with hepatic hydrothorax. Complications were few and included pain at the site of insertion in 12 (20%) patients, blockage of the catheter in only 2 (3.3%) patients, and rapid reaccumulation of fluid in 12 (20%) patients. Pleurodesis was performed on 38 patients with no recurrence of fluid within three months of observation. Conclusions. Pigtail catheter insertion is a practical method for treatment of recurrent hepatic hydrothorax with a low rate of complications. This trial is registered with ClinicalTrials.gov Identifier: NCT02119169.

Lung abscess-etiology, diagnostic and treatment options

Lung abscess is a type of liquefactive necrosis of the lung tissue and formation of cavities (more than 2 cm) containing necrotic debris or fluid caused by microbial infection. It can be caused by aspiration, which may occur during altered consciousness and it usually causes a pus-filled cavity. Moreover, alcoholism is the most common condition predisposing to lung abscesses. Lung abscess is considered primary (60%) when it results from existing lung parenchymal process and is termed secondary when it complicates another process, e.g., vascular emboli or follows rupture of extrapulmonary abscess into lung. There are several imaging techniques which can identify the material inside the thorax such as computerized tomography (CT) scan of the thorax and ultrasound of the thorax. Broad spectrum antibiotic to cover mixed flora is the mainstay of treatment. Pulmonary physiotherapy and postural drainage are also important. Surgical procedures are required in selective patients for drainage or pulmonary resection. In the current review we will present all current information from diagnosis to treatment.

Pleural procedural complications: prevention and management

Pleural disease is common with a rising case frequency. Many of these patients will be symptomatic and require diagnostic and/or therapeutic procedures. Patients with pleural disease present to a number of different medical specialties, and an equally broad range of clinicians are therefore required to have practical knowledge of these procedures. There is often underestimation of the morbidity and mortality associated with pleural interventions, even those regarded as being relatively straightforward, with potentially significant implications for processes relating to patient safety and informed consent. The advent of thoracic ultrasound (TUS) has had a major influence on patient safety and the number of physicians with the necessary skill set to perform pleural procedures. As the variety and complexity of pleural interventions increases, there is increasing recognition that early specialist input can reduce the risk of complications and number of procedures a patient requires. This review looks at the means by which complications of pleural procedures arise, along with how they can be managed or ideally prevented.

Pleural Disorders

This chapter provides an overview of both benign and malignant pleural disorders, starting with the relevant anatomy and physiology. The focus is on the management of pneumothoraces and pleural effusions—conditions that are commonly encountered on a general thoracic surgery service. The pleural cavity is lined by parietal and visceral pleura, which are smooth membranes that are continuous with one another at the hilum and pulmonary ligaments. Parietal Pleura: innermost chest wall layer, divided into cervical, costal, mediastinal and diaphragmatic pleura.

Percutaneous pigtail catheter in the treatment of pneumothorax in major burns: the best alternative? Case report and review of literature

Multiple factors place burn patients at a high risk of pneumothorax development. Currently, no specific recommendations for the management of pneumothorax in large total body surface area (TBSA) burn patients exist. We present a case of a major burn patient who developed pneumothorax after central line insertion. After the traditional large bore (24 Fr) chest tube failed to resolve the pneumothorax, the pneumothorax was ultimately managed by a percutaneous placed pigtail catheter thoracostomy placement and resulted in its complete resolution. We will review the current recommendations of pneumothorax treatment and will highlight on the use of pigtail catheters in pneumothorax management in burn patients.

Advances in pleural disease management including updated procedural coding

Over 1.5 million pleural effusions occur in the United States every year as a consequence of a variety of inflammatory, infectious, and malignant conditions. Although rarely fatal in isolation, pleural effusions are often a marker of a serious underlying medical condition and contribute to significant patient morbidity, quality-of-life reduction, and mortality. Pleural effusion management centers on pleural fluid drainage to relieve symptoms and to investigate pleural fluid accumulation etiology. Many recent studies have demonstrated important advances in pleural disease management approaches for a variety of pleural fluid etiologies, including malignant pleural effusion, complicated parapneumonic effusion and empyema, and chest tube size. The last decade has seen greater implementation of real-time imaging assistance for pleural effusion management and increasing use of smaller bore percutaneous chest tubes. This article will briefly review recent pleural effusion management literature and update the latest changes in common procedural terminology billing codes as reflected in the changing landscape of imaging use and percutaneous approaches to pleural disease management.

Role of interventional pulmonology in the management of complicated parapneumonic pleural effusions and empyema

Pleural infection is a major problem that affects 80,000 cases per year in the UK and USA. It is increasing in incidence, and in an ageing population, it presents a complex challenge that requires a combination of medical therapies and may lead to the need for surgery. This article focuses on the role of the interventional pulmonologist in the diagnosis and management of pleural infection. In particular, we examine the role of pleural ultrasound in diagnostics, thoracocentesis and real-time guided procedures, and the current management strategies, including the controversial role of medical thoracoscopy.

Use of ultrasound to diagnose and manage a five-liter empyema in a rural clinic in sierra leone

We report the case of a dyspneic patient with a five-liter pleural empyema that was diagnosed and managed in a resource-limited clinic in a rural part of Sierra Leone. The diagnosis and management of this condition are usually guided by imaging modalities such as X-rays or CT scans. However, these resources may not be available in austere settings in developing countries. Because emergency physicians work in a variety of clinical settings, they should be well versed in the use of portable ultrasound machines to diagnose, treat, and manage many different conditions.

Advanced ultrasound procedures

Ultrasound guidance has become the standard of care for many bedside procedures, owing to its portability, ease of use, and significant reduction in complications. This article serves as an introduction to the use of ultrasonography in several advanced procedures, including pericardiocentesis, thoracentesis, paracentesis, lumbar puncture, regional anesthesia, and peritonsillar abscess drainage.

Percutaneous pigtail catheter versus tube thoracostomy for pediatric empyema: A comparison of outcomes

PURPOSE

Randomized trials have shown no benefit to thoracoscopic decortication over pleural drainage with fibrinolytic installation for pediatric empyema. However, the optimal method of pleural drainage has not been defined. The present study compares outcomes of 8.5-Fr soft pigtail catheters (PC) placed via Seldinger technique with larger caliber, stiff chest tubes (12- to 24-Fr) placed via tube thoracostomy (TT).

METHODS

A retrospective review of all pediatric patients treated for empyema during a 5-year period (2006-2011) was conducted. Clinical, therapeutic, and outcomes data from patients treated by PC were compared with those treated by TT. Treatment failure, the primary outcome, was defined as need for an additional invasive thoracic procedure (second tube or catheter or thoracoscopic decortication).

RESULTS

We treated 43 patients, 21 by PC and 22 by TT. Fibrinolytics were used in 71% of the PC and 64% of the TT groups. Baseline clinical parameters were not different between the 2 groups. Treatment failure was significantly higher in the PC group (43% vs 14%; P = .045). When the analysis was limited to patients who received fibrinolytics, the failure rate was greater in the PC group (40% vs 14%; P = .129), and duration of illness was shorter (18.3 ± 1.0 vs 25.6 ± 3.5 days; P = .048).

CONCLUSION

Soft PCs are associated with higher failure rates but shorter total duration of illness in the treatment of pediatric empyema. The ideal method for draining pediatric empyema may be a small-caliber, stiff chest tube placed percutaneously.

Large-bore and small-bore chest tubes: types, function, and placement

Chest tubes are placed in the pleural space, either surgically or percutaneously to evacuate abnormal fluid and air. Indications for chest tubes include therapeutic drainage of pleural conditions such as pneumothorax, hemothorax, empyema, chylothorax, and malignant effusions, as well as prophylaxis drainage of air, blood, and other fluids after chest surgery. This article characterizes the types of chest tubes, reviews the basic techniques for insertion, and describes the comparative effectiveness between large-bore and small-bore chest tubes.

Epidemiology of pleural infections in Taiwan from 1997 through 2008

BACKGROUND AND OBJECTIVE

Population-based data on pleural infections are limited. This study describes the temporal trends in the incidence, management and outcomes of pleural infections in Taiwan.

METHODS

The Taiwan National Health Insurance Research Database was used to analyse data on 26,385 patients with a first episode of pleural infection between 1997 and 2008.

RESULTS

During the study period, the median age of the patients increased from 60 to 65 years. The majority of patients were men (75%); this proportion remained constant over time. The standardized annual incidence of pleural infection increased from 5.2 per 100,000 in 1997 and reached a plateau of 8.4 to 9.6 per 100,000 between 2002 and 2008. Over time, there was an increase in the use of computed tomography (from 47.3% in 1997-1998 to 59.4% in 2007-2008), pigtail catheters (from 1.5% to 18.9%), fibrinolytics (from 0.9% to 9.3%) and surgery (from 27.7% to 33.6%), to treat pleural infections. Furthermore, the use of life-support resources, including haemodialysis, mechanical ventilation and intensive care, also increased by 3.1%, 11.0% and 12.8%, respectively. Median hospital charges per patient increased by 63.6% over the 12 years. Although the proportion of patients with organ dysfunction (i.e. severe sepsis) increased from 26.5% to 47.7%, 30-day mortality decreased from 15.0% to 13.1% (P-value for trend = 0.001).

CONCLUSIONS

These findings suggest that advances in the management of pleural infections and subsequent severe sepsis may have led to a reduction in the risk of short-term mortality in Taiwan.

Treatment of complicated pleural effusions in 2013

The incidence of pleural infection seems to be increasing worldwide. Despite continued advances in the management of this condition, morbidity and mortality have essentially remained static over the past decade. This article summarizes the current evidence and opinions on the epidemiology, etiology, and management of complicated pleural effusions caused by infection, including empyema. Although many parallels may be drawn between children and adults in such cases, most trials, guidelines, and series regard pediatric patient groups and those more than 18 years of age as separate entities. This review focuses mainly on the treatment of adult disease.

Ultrasound for the Detection of Pleural Effusions and Guidance of the Thoracentesis Procedure

Objective. To review the use of ultrasound for the detection of pleural effusions and guidance of the thoracentesis procedure. Methods. Two clinical cases will be presented in which ultrasound proved beneficial in guiding the diagnosis and management of patients with pleural effusions and respiratory distress. The ultrasound techniques for the evaluation of pleural effusions and performance of the thoracentesis procedure are discussed. A review of the most current literature follows to present the known diagnostic and safety benefits of ultrasound guidance for thoracentesis. Conclusions. Ultrasound improves the diagnostic accuracy for the detection of pleural effusions over standard chest radiographs. Ultrasound can also diagnose a complicated pleural effusion that may be at higher risk for an adverse outcome during a thoracentesis. Optimally, thoracentesis should be performed under direct ultrasound guidance to decrease the complication rate and improve patient safety.

[Lung ultrasound: clinical applications and perspectives in intensive care unit]

OBJECTIVE

To describe the use of lung ultrasound in clinical practice and the new opportunities offered by this technology in intensive care unit (ICU) patients.

METHOD

Review of signs identified by lung ultrasound and systematic analysis of data published within the last 5 years on its use in ICU. The literature has been extracted from the database Pubmed™. Specific keywords were used to select relevant publications. Clinical studies published in French and English languages were assessed.

RESULTS

Lung ultrasound serves to diagnose, quantify, drain and monitor pleural effusions. In patients with acute respiratory failure, lung ultrasound participates to the diagnosis, the implementation of treatments and their follow-up. It helps to manage patients with pneumonia and acute lung injury. Finally, the investigation of the interstitial edema brings information about hemodynamics that can serve to manage our patients.

CONCLUSION

Lung ultrasound is an easy, non-invasive, and non-irradiant technology. It brings lot of useful information at the patient's bedside.

Tube thoracostomy: a review for the interventional radiologist

Small-caliber tube thoracostomy is a valuable treatment for various pathologic conditions of the pleural space. Smaller caliber tubes placed under image guidance are becoming increasingly useful in numerous situations, are less painful than larger surgical tubes, and provide more accurate positioning when compared with tubes placed without image guidance. Basic anatomy and physiology of the pleural space, indications, and contraindications of small caliber tube thoracostomy, techniques for image-guided placement, complications and management of tube thoracostomy, and fundamental principles of pleurodesis are discussed in this review.

Management of pleural effusion, empyema, and lung abscess

Pleural effusion is an accumulation of fluid in the pleural space that is classified as transudate or exudate according to its composition and underlying pathophysiology. Empyema is defined by purulent fluid collection in the pleural space, which is most commonly caused by pneumonia. A lung abscess, on the other hand, is a parenchymal necrosis with confined cavitation that results from a pulmonary infection. Pleural effusion, empyema, and lung abscess are commonly encountered clinical problems that increase mortality. These conditions have traditionally been managed by antibiotics or surgical placement of a large drainage tube. However, as the efficacy of minimally invasive interventional procedures has been well established, image-guided small percutaneous drainage tubes have been considered as the mainstay of treatment for patients with pleural fluid collections or a lung abscess. In this article, the technical aspects of image-guided interventions, indications, expected benefits, and complications are discussed and the published literature is reviewed.

Current evidence for the management of paediatric parapneumonic effusions

BACKGROUND

Parapneumonic effusions (PPE) and empyema, secondary to bacterial pneumonia, are relatively uncommon but their prevalence is increasing lately. Even if their prognosis is generally good, they may still cause significant morbidity. The traditional treatment of PPE has been intravenous antibiotics and, when necessary, chest tube drainage. Open thoracotomy with decortication has usually been applied in case of failure of the traditional approach. Lately, the use of fibrinolysis and/or video-assisted thoracoscopic surgery (VATS) are utilized in the management of PPE; however, there is still little consensus on the most effective primary treatment.

SCOPE

In this article our goal was to summarize, based on up-to-date evidence, all the management options for PPE available to physicians and weigh the benefits and risks of the most popular ones, in an effort to figure out which one is superior as a first-line approach in children.

FINDINGS

A literature search of randomized and retrospective studies that pinpoint methods of evaluation and treatment of PPE was carried out in Medline and Scopus databases. Chest X-ray, ultrasound as well as microbiology and biochemical characteristics of the pleural fluid will facilitate decision-making. Small uncomplicated effusions resolve with antibiotics alone, larger ones require small-bore chest tube drainage and in case of complicated loculated PPE, fibrinolysis or VATS should be considered. Both methods promote faster drainage, reduce hospital stay and obviate the need for further interventions when used as first-line approach. However, primary treatment with VATS is not advised by the majority of studies as a first choice intervention, unless medical treatment has failed.

CONCLUSION

The main steps in treatment are diagnostic thoracocentesis and imaging, small percutaneous drainage, and considering fibrinolysis in complicated PPE. In case of failure, VATS should be the surgical method to be applied.

Pigtail Catheter Use for Draining Pleural Effusions of Various Etiologies

Background. Use of small-bore pigtail catheter is a less invasive way for draining pleural effusions than chest tube thoracostomy. Methods. Prospectively, we evaluated efficacy and safety of pigtail catheter (8.5–14 French) insertion in 51 cases of pleural effusion of various etiologies. Malignant effusion cases had pleurodesis done through the catheter. Results. Duration of drainage of pleural fluid was 3–14 days. Complications included pain (23 patients), pneumothorax (10 patients), catheter blockage (two patients), and infection (one patient). Overall success rate was 82.35% (85.71% for transudative, 83.33% for tuberculous, 81.81% for malignant, and 80% for parapneumonic effusion). Nine cases had procedure failure, five due to loculated effusions, and four due to rapid reaccumulation of fluid after catheter removal. Only two empyema cases (out of six) had a successful procedure. Conclusion. Pigtail catheter insertion is an effective and safe method of draining pleural fluid. We encourage its use for all cases of pleural effusion requiring chest drain except for empyema and other loculated effusions that yielded low success rate.