What are the alternatives for breaking clots in a non-draining chest tube due to empyema?

Management of Non-Draining Chest Tubes in Empyema

For a non-draining chest tube due to empyema, intrapleural fibrinolytic agents (urokinase or streptokinase) are the recommended intervention to break clots and improve drainage. 1

Initial Assessment and Management

When a chest tube is not draining properly in empyema:

1. First steps:

   • Flush the tube with 20-50 ml normal saline to ensure patency 2, 1
   • Check for kinks, tube position, or blockage
   • Examine the drainage system to ensure it's positioned below chest level 1

2. Imaging evaluation:

   • Obtain contrast-enhanced CT scan to:
     • Assess for loculations
     • Confirm tube position
     • Identify fibrinous peel
     • Guide further management 2, 1
   • Ultrasound can also be useful to evaluate remaining fluid and loculations 1

Fibrinolytic Therapy Options

Primary Options:

1. Urokinase (preferred option) 1, 3

   • Dosing: 100,000 IU once daily for 3 days 2
   • Administration: Dilute in 100 ml 0.9% saline, instill into chest tube, clamp for 3-6 hours 3
   • Advantages: Non-antigenic, fewer immunological side effects 2

2. Streptokinase 2

   • Dosing: 250,000 IU twice daily for 3 days 2
   • Administration: Dilute in 100 ml 0.9% saline, clamp tube for 3-6 hours 4
   • Caution: May cause immunological reactions (fever, systemic antibody response) 2
   • Note: Patients should receive a streptokinase exposure card and use alternative agents for subsequent indications 2

Efficacy and Safety:

• Success rates of 72-92% have been reported with fibrinolytic therapy 4, 5
• Treatment typically requires multiple instillations (average 3-7) 3, 4
• Complications are rare but may include:
  • Pleural pain
  • Fever
  • Rare instances of local pleural hemorrhage 2

Management Algorithm

1. Initial chest tube management:

   • Flush with saline to ensure patency
   • If drainage improves → continue current management
   • If drainage remains poor → proceed to imaging

2. Imaging assessment:

   • If tube malpositioned → reposition or replace tube
   • If loculations present → initiate fibrinolytic therapy
   • If fibrinous peel without loculations → consider surgical options

3. Fibrinolytic therapy:

   • Urokinase (preferred) or streptokinase as detailed above
   • Continue for 3 days or until adequate drainage achieved
   • Monitor drainage volume and clinical response

4. Reassessment after fibrinolytic therapy:

   • If improved drainage and clinical response → continue medical management
   • If persistent loculations or inadequate drainage after 7 days → consider surgical intervention (VATS or thoracotomy with decortication) 1

Important Considerations and Pitfalls

• Tube selection: Small-bore catheters (10-14 Fr) are recommended as first-line for empyema management 1
• Tube placement: Ultrasound guidance is recommended given the loculated nature of empyema 1
• Antibiotic therapy: Must be continued alongside drainage procedures 1
• Monitoring: Daily assessment of vital signs, drainage output, and inflammatory markers is essential 1
• Pitfall to avoid: Don't delay fibrinolytic therapy in loculated empyema as early administration improves outcomes 4
• Contraindication: Avoid streptokinase in patients with previous exposure due to risk of allergic reactions 2

Remember that while fibrinolytic therapy is effective in most cases (>70%), some patients will ultimately require surgical intervention if medical management fails 1, 3.