Open Pleural Drainage 

Updated: Feb 19, 2020
Author: Doraid Jarrar, MD; Chief Editor: Zab Mosenifar, MD, FACP, FCCP 

Overview

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] In its extreme form, open pleural drainage results in a thoracoplasty[2] 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.[3] 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, radiographic-guided catheterization, and tube thoracostomy.[4]  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 undergo an extensive surgical procedure. Open pleural drainage remains an alternative approach in this particular setting.

The main current indications for open chest drainage are as follows:

  • 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
  • Patients who need a period of medical rehabilitation or correction of nutritional abnormalities before more radical and definitive procedures
  • Anticipation of long-term drainage
  • Postpneumonectomy empyema with or without  bronchopleural fistula [5]

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.[6]  

Contraindications

Contraindications include the following:

  • No proper adherence of surrounding lung tissue to the chest wall, which could lead to complications of open pneumothorax
  • 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[7] ) 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.

 

Periprocedural Care

Patient Education and Consent

Some patients live with a thoracic window for years or for the rest of their lives. They need to understand the importance of daily dressing changes and adjusting their lifestyle for this new routine. Good family support is also important because many spouses actively participate in the management of these patients.

Equipment

A major thoracotomy tray with various-sized rib spreaders should be available. In addition, periosteal elevators, such as the Matson, Coryllos, and Alexander, and various-sized rib cutters should be available.

Monitoring & Follow-up

The wound must be regularly inspected to ensure adequate drainage of the pleural space. Thoracic window obliteration should also be observed.

 

Technique

Approach Considerations

Thoracic and extrathoracic (ie, abdominal) procedures and complications can lead to a pleural empyema. Thoracic causes include the following:

  • Postresectional factors (eg, after  lobectomy, [8] lung biopsy, or  pneumonectomy [9] )
  • Esophageal disease (eg, perforation or complications of esophageal surgery)

Moreover, pulmonary infections without prior resection can lead to an empyema of the pleural space with possible need for closed or open drainage.

In addition, surgery in the abdomen can lead to pleural effusions with subsequent seeding of bacteria and an empyema. Examples include the following:

Several factors promote the progression of pleural effusions into a pleural empyema, as follows:

  • Improper or delayed use of antibiotics
  • Delay in diagnosis
  • Inadequate initial drainage with residual fluid collections
  • Malnourishment
  • Foreign body in the pleural space
  • Presence of a bronchopleural fistula

The chest cavity and the pleural space present a greater challenge to the drainage of empyemas than the abdomen does. Because of the rigid structure of the chest wall, infections within the thorax are more difficult to eradicate. Moreover, a space problem can occur when the lung is trapped and no pleural-to-pleural apposition can be reached. This sometimes necessitates open pleural drainage or additional measures, such as the interposition of healthy, well-perfused tissue (eg, muscle flaps or omentum).

Open Drainage of Pleural Space

In 1915, Robinson identified adequate drainage and obliteration of the pleural space as the two basic principles of managing chronic empyema.[10] He suggested a technique of open drainage and partial obliteration of the pleural cavity with muscle, which probably influenced some of the subsequent procedures of chest drainage.

In 1935, Eloesser described a technique of open drainage without extensive thoracoplasty, which became known as the Eloesser flap.[11] The flap was designed to act as tubeless one-way valve to drain chronic pleural effusions without the need of indwelling catheters.

In 1963, Clagett and Geraci described a procedure for the treatment of postpneumonectomy empyema, now known as the Clagett procedure.[12] It consists of the resection of a posterolateral lower ribs and formation of an open window in the lateral aspect of the chest to allow continuous drainage and irrigation of the cavity with antibiotic solutions. In the final step, when the chest cavity showed signs of granulation tissue, it was filled with antibiotic solution and closed. Clagett's partners at the Mayo Clinic subsequently modified this procedure to address the issue of a stump leak.

In current practice, as a consequence of advances in antibiotic therapy and early recognition of infectious processes, these operations are rarely used. No major procedural modifications have been described for open chest drainage.

The procedure for an Eloesser flap originally consisted of making a U-shaped skin incision that was 2 in. (5 cm) wide by 2.5 in. (6.25 cm) long. A segment of rib over the most dependent portion of the infected pleural space was removed, and the skin flaps were then sutured to the pleura and the remaining edges of skin sutured together. As a result, the one-way valve provided drainage of purulent material and air and prevented the formation of pneumothorax.

The only aspect of the original technique that still applies today, however, is the concept of draining an empyema cavity with an epithelialized stoma.[13]

Different skin incisions have been described, including U-shaped, inverted U-shaped, and H-shaped.[13] Whichever type is chosen, the incision must be long enough to provide adequate drainage, prevent premature closure, and facilitate dressing changes. Suturing the skin flaps to the parietal pleural edge will “marsupialize” the open drainage site. Over time, the infected pleural space will be replaced by epithelialized tissue, and the thoracic window will slowly obliterate, leaving only an indentation on the chest wall.[14]

Complications

Open chest drainage is usually well tolerated by patients. The main complications include the following:

  • Failure to create the one-way valve, which leads to pneumothorax
  • Premature closure of the window, which leads to inadequate empyema drainage

Irritation of the surrounding skin also may be a source of pain or discomfort for the patient.