Treatment of Complicated Pleural Fluid Collections With Image-Guided Drainage and Intracavitary Urokinase

doi:10.1378/chest.108.5.1252

Chest

Volume 108, Issue 5, November 1995, Pages 1252-1259

https://doi.org/10.1378/chest.108.5.1252 Get rights and content

Study objective

We report the results of image-guided catheter drainage with adjunctive enzymatic pleural debridment in the treatment of empyemas and other complicated pleural fluid collections.

Design

Retrospective review.

Patients

One hundred eighteen patients with complicated pleural fluid collections were treated with image-guided drainage. There were 79 empyemas, 27 sterile loculated parapneumonic effusions, 10 sterile hemothoraces, and 2 sterile postoperative exudative effusions. Forty-one patients had failed prior large-bore thoracostomy drainage. The estimated age of the effusions at the time of image-guided drainage ranged from 1 to 175 days with a mean estimated age of 13 days.

Interventions

Patients were treated with image-guided placement of one or more 12F to 16F chest drains. Adjunctive urokinase instillation was used in 98 cases. Urokinase (100,000 to 250,000 U/mL) was instilled in 20 to 240-mL aliquots and reaspirated in 1 to 4 h. One to four instillations were performed per day until drainage was complete.

Measurements and results

Drainage was successful in 111 cases (94%). Two patients died of sepsis with incomplete drainage. Five patients underwent decortication (three recovered and two died postoperatively). Fifty-three patients (45%) required placement of more than one drain. The mean duration of drainage was 6.3 days. Patients treated with pleurolysis required a mean of five instillations of urokinase. The mean total dose of urokinase used per case was 466,000 U. There were no complications.

Conclusion

Image-guided drainage with adjunctive pleural urokinase therapy is a safe and effective method of closed thoracostomy drainage of complicated pleural fluid collections and can obviate surgery in most cases.

Section snippets

Materials and Methods

We reviewed the records of 118 consecutive patients undergoing image-guided drainage of complicated pleural fluid collections at two Denver community hospitals between 1988 and 1994. The etiology of the fluid collections is summarized in Table 1. Malignant effusions were excluded from the review. The average age of the patients was 50 years (range, 9 to 95 years). There were 82 male and 36 female patients. The initial clinical presentation was multiple trauma in 17 patients and pneumonia with

Results

Resolution was complete with full clinical recovery and no further interventional or surgical therapy was needed in 111 patients (94%). The mean age of the effusions at the time of drainage in these patients was 11.2 days (range, 1 to 54 days). The effusion was estimated to be greater than 20 days old at the time of drainage in 16 of these patients and greater than 30 days old in 6 patients.

There were two deaths due to sepsis during treatment. Both cases involved parapneumonic empyemas in

Discussion

The evolution of complex exudative pleural fluid collections is divided into three stages.¹ The first stage is a thin free-flowing exudative effusion with a minimal cellular component and pliable underlying pleura and lung. The second or fibrinopurulent stage is characterized by increased cellularity and protein content. The high protein content promotes the formation of fibrin nets within the fluid, deposition of fibrin sheets along the pleural surfaces, and pleural loculations. Atelectasis of

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Chest

Clinical Investigations: The PleuraTreatment of Complicated Pleural Fluid Collections With Image-Guided Drainage and Intracavitary Urokinase

Study objective

Design

Patients

Interventions

Measurements and results

Conclusion

Section snippets

Materials and Methods

Results

Discussion

Clin Chest Med

Am J Surg

Ann Thorac Surg

Ann Thorac Surg

Chest

Chest

Nontuberculous bacterial empyema in patients with and without underlying disease

JAMA

Percutaneous catheter drainage of pleural effusion and empyema

AJR

Thoracic empyema: management with image-guided catheter drainage

Radiology

Radiographically guided percutaneous catheter drainage of pleural fluid collections

AJR

Clinical Investigations: The Pleura
Treatment of Complicated Pleural Fluid Collections With Image-Guided Drainage and Intracavitary Urokinase