Management options for the complicated pleural space

Abstract

Clinicians frequently encounter patients with malignant and benign diseases involving the pleural space.Complications from these disease processes pose clinical challenges that often require a multi-disciplinary management approach. Here we discuss therapeutic options available for complicated diseases of the pleural space, including loculated malignant effusions, complicated pleural infections, hemothorax, nonexpanding lung, pleural thickening, and persistent bronchopleural fistulas. Our objective is to review current literature on management of these complex issues.

A clinical review of the pathophysiology, diagnosis, and treatment of pyothorax in dogs and cats

“…As there are currently no guidelines in veterinary medicine, the decision to place unilateral versus bilateral thoracostomy tubes should be made based on the volume and distribution of pleural fluid . Traditionally, large‐bore trocar tubes have been recommended due to the belief that smaller tubes would become obstructed by thick exudate and fibrin and fail to completely drain effusion . The reported complication rate of large‐bore chest tube insertion in people varies between 5% and 35% .…”

“…Use of small‐bore (14 Fr) wire‐guided chest tubes has been reported in the treatment of dogs and cats with pyothorax (Figure ) . Proponents of small‐bore chest tubes advocate their use because they are easier and less traumatic to insert, they can often be placed under sedation, are better tolerated once in place, and they may be associated with fewer placement‐related complications . Regular flushing of small‐bore chest tubes has been recommended to avoid catheter blockage, but there is no evidence to support this practice.…”

“…While studies have provided useful information on possible etiologies, risk factors, treatment strategies, and patient outcome, prospective studies evaluating the efficiency of different therapeutic options are lacking. Despite a lack of evidence‐based guidelines, there appears to be general consensus that antimicrobial therapy in combination with thoracic drainage should be the mainstay of therapy . Treatment of pyothorax has classically been divided into medical or surgical therapy and may include administration of antimicrobials, intermittent or continuous thoracic drainage, thoracic lavage, intrapleural fibrinolytic therapy, video‐assisted thoracic surgery (VATS), and traditional thoracostomy.…”

“…Parapneumonic effusion and empyema are relatively rare in pediatric patients with reported mortality rates of <3% . In order to facilitate establishment of treatment guidelines, the American Thoracic Society divides pleural infections into three stages based on chronicity: an exudative stage, fibropurulent stage, and organizational stage characterized by formation of a pleural peel (scar tissue) . Pleural infection occurs most commonly in pediatric and elderly human patients and risk factors mirror those for pneumonia, including immunosuppression, gastro‐esophageal reflux, aspiration, poor oral hygiene, diabetes mellitus, alcohol, and intravenous (IV) drug abuse …”

Treating Recurrent Pleural Disease: A Review of Indications and Technique for Chemical Pleurodesis for the Interventional Radiologist

“…37,39 VATS does offer benefits of direct visual inspection and lysis of adhesions/ decortication. 40…”