What is the next step for a chest tube that is not draining for empyema (empyema is a condition of pus in the pleural space)?

Management of Non-Draining Chest Tube in Empyema

When a chest tube is not draining for empyema, the first step should be to flush the tube with 20-50 ml of normal saline to ensure its patency. 1

Initial Assessment and Management

Check for Mechanical Issues

• Examine the tube for:
  • Kinking (especially at skin exit site with smaller drains)
  • Tube position (may have migrated)
  • Blockage by thick pus
  • Proper positioning of drainage system (must be kept below chest level)

Tube Flushing Protocol

• Flush with 20-50 ml normal saline 1
• For pediatric patients, smaller volumes are appropriate 1
• Never clamp a bubbling chest drain 2
• Ensure the drainage system remains below the level of insertion site

If Poor Drainage Persists After Flushing

Imaging Assessment

• Obtain contrast-enhanced CT scan (most useful imaging modality) 1
  • Provides anatomical detail of locules
  • Confirms accurate chest tube placement
  • Identifies fibrinous peel that may prevent lung re-expansion
• Ultrasound can also be useful to assess:
  • Remaining fluid volume
  • Loculations
  • Tube position

Management Options Based on Imaging Findings

1. If tube is malpositioned or permanently blocked:

   • Remove the chest tube
   • Insert a new chest tube if significant fluid remains 1
   • Consider ultrasound or CT guidance for placement 2, 3

2. If loculations are present:

   • Administer intrapleural fibrinolytic drugs:
     • Streptokinase 250,000 IU twice daily for 3 days OR
     • Urokinase 100,000 IU once daily for 3 days 1
     • For children: urokinase is recommended (40,000 units in 40 ml 0.9% saline for ≥10 kg; 10,000 units in 10 ml 0.9% saline for <10 kg) 2

3. If fibrinous peel is present:

   • Consider surgical intervention if medical management fails
   • Options include video-assisted thoracoscopic surgery (VATS) or thoracotomy with decortication 2, 4

Important Considerations

Monitoring Response

• Daily assessment of:
  • Vital signs
  • Pain levels
  • Laboratory markers (WBC, CRP)
  • Drainage output and characteristics 2

Antibiotic Therapy

• Continue appropriate antibiotic therapy
• For community-acquired empyema:
  • Cefuroxime + metronidazole OR
  • Amoxicillin + clavulanic acid 2
• For hospital-acquired empyema:
  • Piperacillin/tazobactam (4.5g four times daily IV) 2
• Avoid aminoglycosides (poor pleural penetration) 2

When to Consider Surgical Intervention

• No improvement after 7 days of appropriate antibiotics and drainage 2
• Organized empyema with significant respiratory compromise 4
• Failed medical management with persistent sepsis 1, 2

Common Pitfalls to Avoid

• Delaying drainage when indicated
• Inappropriate clamping of chest drains
• Failure to recognize when medical therapy is failing
• Overlooking potential underlying conditions predisposing to empyema 2

By following this algorithmic approach to non-draining chest tubes in empyema, you can systematically address the issue and improve patient outcomes while reducing the need for more invasive surgical interventions.