Background
Open pleural drainage is an uncommon modality in the current era of appropriate antibiotic coverage and multiple means of closed pleural drainage. It is usually reserved for very ill patients for whom thoracoscopy or thoracotomy would be too morbid. [1, 2] In its extreme form, open pleural drainage results in a thoracoplasty [3] by removing ribs from the chest wall, which brings the chest wall to the lung and achieves obliteration of an empty space.
In the preantibiotic era, pleural infections were a challenging entity, with many complications and difficult management. At that time, open pleural drainage was an important treatment of chronic empyemas. Because of advances in medical technology, including radiographic imaging and antibiotics, today most pleural infections are successfully treated with closed suction drainage or video-assisted thoracoscopy. [4, 5] However, in view of the historical importance of open pleural drainage, it is worthwhile to review the indications for and techniques of this operation.
Indications
Most patients presenting with pleural space infections initially undergo less invasive procedures, such as repeat aspiration thoracocentesis, radiography-guided catheterization, and tube thoracostomy. [6] In the case of failure of those less invasive modalities, or in the presence of multiloculated chronic collections and entrapped lung, surgical decortication is indicated. However, some patients are debilitated enough to rule out such an procedure, and open pleural drainage remains an alternative approach in this particular setting.
The main current indications for open chest drainage are as follows:
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Patients who failed an initial approach with closed suction drainage and have a low physiologic reserve to tolerate more aggressive surgical interventions, such as decortication
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Patients who need a period of medical rehabilitation or correction of nutritional abnormalities before more radical and definitive procedures
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Anticipation of long-term drainage
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Postpneumonectomy empyema with or without bronchopleural fistula [7]
Fibrinolysis (eg, with tissue plasminogen activator [tPA] or urokinase) may improve fluid drainage in patients with pleural infection and thereby reduce the need for surgery. [8]
Contraindications
Contraindications include the following:
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No proper adherence of surrounding lung tissue to the chest wall, which could lead to complications of open pneumothorax
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Patients with good functional status who otherwise could tolerate a more invasive and definitive treatment, such as surgical decortication
Technical Considerations
Best practices
Generally, closed drainage techniques (ranging, in order of escalating invasiveness, from needle thoracocentesis to 12-French pigtail placement to tube thoracostomy to video-assisted thoracoscopy [9] ) are preferred to open drainage techniques. However, open pleural drainage may be indicated for very ill patients or, more commonly, patients with postpneumonectomy empyema with or without bronchopleural fistula. In the latter, open drainage is the first step in a staged, definitive closure.
Procedural planning
Computed tomography (CT) and chest radiography prior to the procedure are recommended to better define the extent of disease, determine the presence of loculations, and assess the site of incision. It is helpful to review the CT scan not only in axial but also in sagittal and coronal views so as to gain a better idea of where to place the incision.
