Thoracostomy drainage

The use of chest tubes has been the standard modality once it has been decided to drain the pleural fluid. It can be effective for drainage of parapneumonic effusions, particularly if it is done early in the course of the disease process. Once loculations and viscous fluid have developed in the pleural space, the efficacy of chest tube drainage decreases and the likelihood that the lung becomes trapped or develops an empyema increases ( Sahn 1993).

Barring inadequate chest tube positioning, the most common reason for failed chest tube drainage is tube obstruction by organized empyema with multiple loculations

(Sahn 1993). The use of chest-tube-instilled fibrinolytics, such as urokinase, may improve drainage of such effusions if utilized early in the disease process before significant collagen is laid down within the pleural space (,S.a..hnJ.993).

In those instances where the effusion is not free flowing on lateral decubitus radiographs, a CT scan may be helpful in defining the nature of the effusion and whether it will be amenable to chest tube drainage. A single loculus with minimal pleural enhancement may be adequately drained via chest tube insertion as opposed to empyectomy with decortication.

Those patients who present with malignant pleural effusions can also be drained with a tube thoracostomy. If the lung re-expands to fill the chest cavity, then pleurodesis may be attempted with one of a number of agents. However, when the lung does not re-expand, pleurodesis is doomed to failure and the clinician must consider other alternatives, depending on the patient's condition ( KeNerJā€˛993.).

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