ABSTRACT
For nonpost-resection empyema, i.e., that empyema arising most commonly as a result of a lung abscess or pneumonia, thoracentesis is the procedure done first (Table 13.2). Either clear water fluid or pus is produced. For clear watery fluid, cultures and chemistries are obtained. If there is a positive culture, a chest tube is placed. For negative culture, and if it is a transudate by chemistry evalua tion, then the patient only will require a repeat thoracentesis if the effusion reac cumulates. If, however, it is an exudate by chemistries (i.e., if the specific gravity is greater than 1.02, the white blood count greater than 500 per cubic millimeter, the protein greater than 2.5 grams/dl, the pH less than 7.00, the glucose less than 40 mg/dl, or the LDH greater than 1000, then a chest tube is placed. If pus is ob tained from the initial thoracentesis, then a chest tube is placed and this chest tube is applied to suction drainage. After about 10 days, this is converted to open drainage via an empyema tube. A sinogram is then obtained. If no cavity is present, then the chest tube can be slowly withdrawn over a period of several days to weeks. If a small cavity is found and if the chest tube is draining well, then again the tube may be slowly withdrawn. If the cavity is not well-drained by the chest tube, a new chest tube is placed or a rib is resected to facilitate drainage. If there is a large cavity which appears to be well-drained, then the tube is slowly withdrawn. If the lung does not re-expand fully, then decortication is indicated between 6 weeks to 8 weeks later. If there is a large cavity which is not well-drained, rib resection is indicated to facilitate drainage or a Clagett window or Eloesser flap is performed. A Clagett window involves resection of several ribs and marsupialization of the skin such that the skin is tacked down to the intercostal muscles permitting good drainage. The physician/nurse and ultimately the patient can irrigate and pack
• Is there adequate drainage? • Is there a space problem? • Is there a bronchopleural fistula? • Is this postop? • Is this acute or chronic? Drainage procedures • Chest tube • Rib resection • Clagett window/Eloesser flap Airspace filling procedures • Thoracoplasty • Fill space with muscle and omentum Bronchopleural fistula after surgery • Early reoperation • Transpericardial approach to close fistula • Muscle flap over fistula
J NO CAVITY
this wound. The Eloesser flap is a specific form of drainage in which a tube of skin is literally laid down into the cavity to facilitate drainage. It is probably considered less and less in this day and age, since rib resection and Clagett window have served so well. At the time of drainage of the empyema a decortication of the lung is also performed.
