Surgical management of pleural space infections

Adequate drainage of pleural space infections is generally required to achieve resolution of the infection and full expansion of the underlying lung. An understanding of the normal pathologic evolution of pleural infection is necessary to choose the optimal method of pleural drainage. The timing of surgical drainage and the choice of drainage procedure in each case should be based upon the duration of the infection, the characteristics of the pleural fluid, the presence of loculations within the pleural space, and the overall condition of the patient. Thoracentesis should be performed to confirm a suspected diagnosis of pleural empyema. The diagnostic information from thoracentesis may be augmented by imaging techniques such as computed tomography, ultrasound, or empyemagrams. Such radiographic studies are important in the planning of either closed or open drainage. Repeated thoracentesis are rarely adequate for drainage of an established empyema. Closed tube thoracostomy requires careful placement and is very effective if instituted in the early stage of pleural infection. Open drainage with rib resection for chest tube placement is probably the most versatile form of pleural drainage. Decortication is promptly curative and should be employed in the latter stages of empyema in patients who can tolerate the procedure. Chronic open flap drainage is reserved for debilitated patients or patients with destroyed underlying lung.